Inspection on 07/06/07 for Alexander Lodge

This inspection was carried out on 7th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Alexander Lodge 12/11/08

Alexander Lodge 12/11/07

Alexander Lodge 28/11/06

Alexander Lodge 03/08/06

Alexander Lodge 28/11/05

Alexander Lodge 12/04/05

Alexander Lodge 11/10/04

Alexander Lodge 12/07/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Alexander Lodge Alexander Lodge 41 Skinners Lane Ashtead Surrey KT21 2NN Lead Inspector Sandra Holland Unannounced Inspection 7th June 2007 10:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Alexander Lodge DS0000013548.V339494.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Alexander Lodge DS0000013548.V339494.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alexander Lodge Address Alexander Lodge 41 Skinners Lane Ashtead Surrey KT21 2NN 01372 276052 01372 813293 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Izette Aeon Davis Mrs. Desline May Davis Mr Izette Aeon Davis Care Home 16 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (16), of places Physical disability over 65 years of age (2) Alexander Lodge DS0000013548.V339494.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Out of the 16 (sixteen) service users accommodated, 4 (four) may fall within the condition of DE(E) The age/age range of the persons to be accommodated will be: OVER 65 YEARS Out of the 16 (sixteen) service users accommodated, 2 (two) may fall within the category of PD(E) 28th November 2006 Date of last inspection Brief Description of the Service: Alexander Lodge is a large detached house, situated close to the local amenities of Ashtead. The home provides accommodation and personal care for up to sixteen service users in the category of older people, four of whom may have dementia and two of whom may have a physical disability. The accommodation currently consists of twelve single bedrooms, two double bedrooms, dining room, a lounge with a conservatory, and appropriate laundry and kitchen facilities. A small garden is situated to the rear of the home and parking for approximately four vehicles is available to the front of the property. The fees at this service range from £385.00 to £550.00 per week. Alexander Lodge DS0000013548.V339494.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out by the Commission for Social Care Inspection (CSCI) under the Inspecting for Better Lives process. Mrs Sandra Holland, Regulation Inspector carried out the inspection over six and a half hours. Mr Izette Davis, Registered Provider and Registered Manager was present representing the service. For clarity, Mr Davis will be referred to throughout this report as the manager. A number of documents and records were sampled, including care plans, medication administration record (MAR) charts, staff files and records. A tour of the premises was undertaken and all seven residents, two staff, and three visiting healthcare professionals were spoken with during the course of the inspection. A pre-inspection questionnaire was supplied to the home and this was completed and returned. Information from the questionnaire will be referred to in this report. A number of CSCI feedback cards was also supplied to the home for distribution to residents, healthcare professionals and relatives and visitors. The people living at the home prefer to be known as residents and that is the term that will be used throughout this report. The inspector would like to thank the residents, staff and management for their time and assistance. What the service does well: Residents spoke of the kindness of the staff at the home. The needs of residents were assessed before they moved into the home. The healthcare needs of residents are well met. Meals served at the time of inspection were being enjoyed by residents. Almost all areas of the home were clean and freshly aired. The provider/manager is in day-to-day involvement in the home and is accessible to residents, visitors and staff. Alexander Lodge DS0000013548.V339494.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Although there are good outcomes for residents in some areas this is compromised by the lack of robust management and shortfalls in the areas of medication and staffing. Five requirements made following the last inspection have not been met and CSCI will determine what action will be taken to secure compliance. Assessments of any risks to residents should include any actions which can be taken to minimise the risks. An immediate requirement was made at the time of the inspection, that the amount of medication held in the home must accurately match the record held, that the administration of medication to residents must be supervised and that the record of administration of medication must not be completed until the resident has actually taken the medication. Arrangements must be made to enable residents to take part in community activities. All areas of the premises must be maintained in a good state of repair and be reasonably decorated. Staffing in the home must be reviewed to ensure there are enough staff to meet residents’ needs at all times. An immediate requirement was made at the time of the inspection that persons must not be employed to work at the home until all the specified documents and information have been obtained. Alexander Lodge DS0000013548.V339494.R01.S.doc Version 5.2 Page 7 The manager and staff must receive updated training in the safeguarding of adults. Other training must also be undertaken to ensure residents are safeguarded, including first aid, moving and handling and health and safety. The home must be managed more effectively and the manager must undertake training to enable him to carry out his role. The results of the recent resident survey into the quality of the service provided should be reviewed and provided to residents. The staff rota must be an accurate record of who is working in the home and the hours which are actually worked. The temperature of the hot water supply must be regularly tested and recorded to safeguard residents and staff from scalding. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Alexander Lodge DS0000013548.V339494.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Alexander Lodge DS0000013548.V339494.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of prospective residents are assessed before they move into the home. EVIDENCE: The files of a number of residents were seen including those of recently admitted residents. The manager stated that the needs of the residents had been assessed before admission to the home took place and the assessment forms were seen on file. These were comprehensive and covered a wide range of information to enable the manager to assess whether the home could meet the needs of the prospective residents. The manager advised that the needs of some of the recently admitted residents had been assessed at the hospitals where the prospective residents had been patients. The manager stated that intermediate care is not provided at the home. Alexander Lodge DS0000013548.V339494.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Plans of care are available to guide staff to meet the needs of residents. Assessments of risks to residents need to be more detailed. The management of medication in the home needs to be more robust to ensure residents receive their medication as prescribed and to ensure they are safeguarded. EVIDENCE: A plan of care has been drawn up for each resident, using the information gathered from the pre-admission assessment as a base, the manager stated. The plans are used to guide staff to the care and support needs of residents and include daily notes to record how these needs have been met. The care plans were seen to include assessments of risks to residents including the risks associated with mobility, falling, self-neglect, moving and handling and medication. It was noted that the assessments were not detailed and gave minimal information to advise staff of control measures which could be used to minimise the risks. It is recommended that these are reviewed, to include the control measures which may help to minimise the risks. Alexander Lodge DS0000013548.V339494.R01.S.doc Version 5.2 Page 11 It was clear from the records seen that the healthcare needs of residents are appropriately met. Entries in residents’ care plans recorded the involvement of a number of healthcare professionals, including general practitioners (GPs), community nurses and a chiropodist. Three visiting healthcare professionals were spoken with during the course of the inspection. The administration of medication still needs to be managed more effectively and robustly to ensure that residents are safeguarded and they receive their medication as prescribed. An immediate requirement was made at the two previous inspections that the standard of medication administration must be improved. The manager provided an improvement plan to CSCI which stated that the requirement had been met, but shortfalls in the required standard were noted again at this inspection. The quantities of a number of individual medications were checked and two of these did not accurately match the record held. A medication had been left in a resident’s bedroom, so it would not be possible to know whether the resident had taken the medication as prescribed. Staff were observed to sign the medication administration record (MAR) chart to show that the resident had received the medication, before the medication had been administered to the resident. An immediate requirement was again made at the time of the inspection, that the amount of medication held in the home must accurately match the record held, that the administration of medication to residents must be supervised and that the record of administration of medication must not be completed until the resident has actually taken the medication. Staff were observed to speak to residents in a friendly and informal but appropriate manner. Residents were prompted to receive assistance with personal care in a sensitive manner, and in a way that respected residents’ privacy. Alexander Lodge DS0000013548.V339494.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities are carried out in the home, but there are few activities outside the home. Residents are offered a well balanced diet. EVIDENCE: Musical and other activities were taking place on the morning of inspection, led by the care staff on duty. Residents and staff said they played skittles and indoor bowls and enjoyed a selection of songs. A daily record of the activity planned is written on the notice board in the central hall, between the dining room and lounge, to enable residents to know what is taking place. Opportunities for activities outside the home are to be more limited, although staff mentioned these take place occasionally. One resident had stated on the home’s quality assurance form which was titled “What are you thinking”, that they “would like to get out more”. The manager also stated that another resident enjoyed going out and would take up every opportunity to do so. Another resident advised that they frequently go out with their family. Visitors from a local church attend the home on a regular basis and feedback indicated that a homely atmosphere is provided, the home was welcoming and Alexander Lodge DS0000013548.V339494.R01.S.doc Version 5.2 Page 13 that staff are helpful and caring. Feedback from the relatives of residents also indicated that they were made welcome in the home. Residents were spoken to during the lunchtime meal that was served and which residents said they had enjoyed. The meal looked appetising and well balanced. Staff provided sensitive support to those residents requiring it and small adaptations, such as providing different shaped dishes, had been made to assist residents to manage their meal independently. As the meal of the day was not suited to a resident for religious reasons, an alternative meal was provided. The manager stated that a dietician has reviewed the meals at the home and an information folder titled “Dietician on the shelf” has been provided. This is to support the management and staff at the home in meeting the dietary needs of the residents. A four weekly menu is displayed in the dining room and the meal served on the day of inspection reflected the menu. The menu for the day was also written on the notice board outside the lounge and dining room and was more easily accessible to residents. The cook stated that three residents had specific dietary requirements either for health or religious reasons, and these are accommodated. Alexander Lodge DS0000013548.V339494.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A complaints procedure is available in the home, but no complaints have been received. Staff are aware of their responsibilities in the safeguarding of residents. EVIDENCE: The manager stated that the complaints procedure had been reviewed to meet a requirement made following the last inspection. The procedure was seen to include the appropriate information and included timescales by which responses would be made. The complaints procedure is made available on the main notice board in the hall, for all who may wish to use it. It was noted that the procedure still offered the option of making a complaint to the home or referring the complaint directly to CSCI or the Ombudsman. This was discussed with the manager, as it is the responsibility of the home’s management to address complaints made about the home, and the manager stated he would amend the procedure. Staff in the home have received training in the safeguarding of adults (formerly the Protection of Vulnerable Adults), although this needs to be updated for a number of staff and the manager. The manager stated that the home would follow the Surrey Multi-Agency Procedure for the Protection of Vulnerable Adults in the event of an incident or Alexander Lodge DS0000013548.V339494.R01.S.doc Version 5.2 Page 15 an allegation of abuse. An up to date copy of this procedure has been obtained and is held in the home for staff to refer to. The manager stated that he had undertaken Surrey County Council training in safeguarding adults in 2003 and another training by an independent trainer in 2005. It is recommended that the manager undertakes updated training in the Surrey Multi-Agency procedure, to ensure that he is aware of recent changes and should advise his staff of these. Staff spoken to stated that they would report any concerns to the manager or person in charge. Staff were advised that concerns could also be raised outside the home if required. Alexander Lodge DS0000013548.V339494.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements have been made to the standard of the premises. The home was clean and freshly aired in most areas. EVIDENCE: As required following the last inspection, improvements have been made to a number of areas of the home. The central hall, stairs and landings have been re-carpeted and a number of vanity units in residents’ bedrooms have been replaced. The surround of the upstairs bath has been resealed but it was noted that other aspects of this bathroom still need to be improved to make it a pleasant place in which to bathe. A small area of trimming near the fitted hoist has broken and presents a rough edge, which needs to be repaired. The small window ledge beside the bath is in a poor condition and needs repainting and the small blind at the window is very worn and in need of replacement. The Alexander Lodge DS0000013548.V339494.R01.S.doc Version 5.2 Page 17 fabric towel hanging on the rail in the bathroom was also worn and discoloured. An area of “boxing in” below the basin in the bathroom is very marked and needs to be painted. Most of the home, with the exception of one resident bedroom, was freshly aired with adequate odour control. Liquid soap and paper towels have now been supplied in all toilets, bathrooms and the kitchen, to maintain effective standards of hygiene and prevent infection, or the spread of infection. Alexander Lodge DS0000013548.V339494.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents are supported and cared for by a very small team of staff. Recruitment must be carried out more thoroughly to safeguard residents. EVIDENCE: From the information contained in the pre-inspection questionnaire and staff rota, it was clear that residents are supported by a very small team of staff. The majority of staff are carers and they carry out laundry tasks in addition to care and activities. A cook is employed to work at the home for six days each week on average and a domestic assistant is employed to work for four hours on three days each week. The manager is listed on the staff rota to work seven days each week. It was noted that the manager is recorded on the rota to work a waking night shift each week, which is immediately followed by either a full 12 hour day shift or a morning shift. The manager stated that although scheduled on the rota to work a waking night shift, he sometimes did an on-call shift, in which he slept in the home, to be available to assist the member of staff on the waking night shift. He was reminded that the rota must be a true and accurate record of the staff who are working and the actual hours that are worked. Other members of staff are also recorded to work night shifts, either before or after another shift. One member of staff was recorded on the rota in April, as Alexander Lodge DS0000013548.V339494.R01.S.doc Version 5.2 Page 19 working for 23 hours in a row and another member of staff was recorded on the rota in June, as working 32 hours within a 41 hour period. The manager stated that these shifts had been necessary due to unexpected, short notice changes in staffing. It was noted however, that these additional shifts were recorded on the rota in April, May and June. The European Working Time Directive specifies that there should be an eleven hour interval between staff shifts. Sufficient time off must be allowed to ensure staff are rested enough to provide a safe standard of care and support to residents, and to safeguard the health of staff. It was required following the last inspection that staffing in the home must be reviewed to ensure that there are sufficient staff working at the home at all times to meet the needs of residents, whilst safeguarding staff or management from working excessive hours. The manager stated in an improvement plan supplied to CSCI, that staffing levels are reviewed with increased levels of resident occupancy, but this requirement has not been met. Information from the pre-inspection questionnaire indicates that three of the seven care staff employed have achieved a National Vocational Qualification (NVQ) to level 2 or above, which is just under the recommended target of 50 trained staff. From the records seen, it was clear that the standard of recruitment processes in the home must still be more robust and thorough to ensure that residents are safeguarded. From the records seen, it was noted that for one member of staff, no references had been obtained or were held on file. For this member of staff, no record of their induction or any training was available. It is required that induction records are maintained and retained in the home, to be available for inspection. An immediate requirement was made following the last inspection, that people must not be employed until the specified information and documents have been obtained, but this has not been met. The manager stated in the improvement plan that he supplied to CSCI, that subsequent documentation will comply with requirements, but this has not been adhered to. Individual staff training records are maintained and these were seen. Most of the staff have recently undertaken training in food safety and fire safety, but gaps were noted in the frequency of other training courses. The majority of staff have received moving and handling, but have not had annual updates to this as required. For some staff, the last training received in moving and handling, was in 2004. Alexander Lodge DS0000013548.V339494.R01.S.doc Version 5.2 Page 20 Only one member of staff has received recent training (within the last year), in Safeguarding Adults, only one member of staff has received training in health and safety, which was in 2002, and only one member of staff has completed medication training. It was also noted that only three care staff have received first aid training, so it would not be possible to ensure that there is a first aid trained member of staff available on every shift. The manager stated that first aid training has been booked to be carried out in July 2007 and health and safety training has been booked for September 2007. The majority of residents are of British background so do not reflect the cultural and racial diversity of the staff team. The resident group is predominantly male, whilst the staff group is predominantly female. A further immediate requirement was made at the time of this inspection, that persons must not be employed to work at the home until all the specified documents and information have been obtained. A requirement has been made regarding Standard 30, that staff must receive training appropriate to the work they are to perform. Alexander Lodge DS0000013548.V339494.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The management of the home needs to be more robust and effective to ensure the safety of residents and to ensure that the required standards are met. EVIDENCE: Although there are good outcomes for residents in some areas, this is compromised by the lack of robust management and shortfalls in the areas of medication and staffing. Five requirements made following the last inspection have not been met and CSCI will determine what action will be taken to secure compliance. The management of the care home needs to be more robust, and effective monitoring needs to be carried out to ensure that residents are safeguarded Alexander Lodge DS0000013548.V339494.R01.S.doc Version 5.2 Page 22 and a quality service is provided. More thorough medication procedures, recruitment procedures and a review of staffing levels are required. It is of serious concern that two of the immediate requirements made at the last inspection have not been met. Written details of the shortfalls were left at the home at the time of the inspection and were followed by a letter of serious concern. The manager supplied a written improvement plan to confirm that the immediate requirements made at the inspection had been complied with, but once again this was not evident at this inspection. A requirement was made following the last inspection that the manager must manage and carry on the home with sufficient care, competence and skill. He must also undertake from time to time such training as is appropriate to ensure he has the knowledge and skills necessary for managing the care home. At the last inspection, the manager stated that he had undertaken statutory training courses within the last two years, but did not have the certificates available at the home. The manager presented a number of training certificates at this inspection, but fire safety was the only training undertaken within the past year. It was noted that the manager’s first aid certificate had expired in 2005. The majority of other training courses that the manager had undertaken dated from 2001 to 2002, although moving and handling was undertaken in 2005. The manager needs to receive updated training in the safeguarding of adults, as noted at Standard 18 which relates to protection. The manager also stated that he has not undertaken a care or management qualification to NVQ Level 4, as recommended by the National Minimum Standards for Older People. Residents’ monies are not held for safekeeping the manager advised. Any additional expenses on residents’ behalf are paid for by the home and invoiced to the resident or their representative. A requirement was made following the last inspection that a review of the quality of the service must be carried out, and a summary of the responses received must be made available to residents and a copy forwarded to CSCI. The manager stated that surveys have been supplied to residents and four of these which had been returned were seen. The majority of responses were positive and included responses such as “the food is nice” and “the staff are friendly”. A relative responded that their perception of the home was one of safety, kindness and consideration. The manager stated that the responses had not been fully analysed or supplied to residents, because he had noted the mainly positive responses. As one Alexander Lodge DS0000013548.V339494.R01.S.doc Version 5.2 Page 23 resident had indicated that they found it difficult to remember the day or the date, the home had introduced a notice board in the hall to provide this daily information and had included which staff were on duty and a note regarding current news headlines. Four CSCI feedback cards were received from relatives or visitors and their responses included that they were made welcome in the home, staff were helpful and caring, their relatives’ needs were met and any concerns raised had been addressed. Two other responses were received from health and social care professionals who visit the home. One indicated positive responses and one indicated that improvements are needed to the standard of care provided. A requirement was made at the last inspection, that equipment in the home must be serviced appropriately as the bath hoist had not been serviced for over a year. The manager stated that this had been carried out but written confirmation was not available. During the inspection, the manager telephoned the company contracted to carry out the servicing, to receive verbal confirmation of the date of the servicing. The manager stated that regular tests of the temperature of the hot water supply have been carried out, but a review of the record showed that this had not been carried out for a number of weeks. It is required that the temperature of the hot water supply is tested and recorded, in order to safeguard residents and staff from scalding. The home’s insurance policy and Safety at Work poster were displayed as required. Alexander Lodge DS0000013548.V339494.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 1 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 X X 2 Alexander Lodge DS0000013548.V339494.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP13 Regulation 16 (2) (m) 13 (6) Requirement Arrangements must be made to enable residents to engage in local, social and community activities. Arrangements must be made by training management and staff, to prevent residents being harmed or suffering abuse, or being placed at risk of harm or abuse. The premises must be maintained in a good state of repair and all parts of the home must be kept clean and reasonably decorated. Timescale of 02/03/07 not met. Staffing at the home must be reviewed to ensure that sufficient staff are working at the care home to meet the needs of residents. Timescale of 23/02/07 not met. A record of staff induction must be maintained and retained in the care home. Timescale of 28/11/06 not met. DS0000013548.V339494.R01.S.doc Timescale for action 06/09/07 2 OP18 06/09/07 3 OP19 23 (2) (b & d) 06/09/07 4 OP27 18(1) (a) 05/07/07 5 OP30 17 and 18 05/07/07 Alexander Lodge Version 5.2 Page 26 6 OP30 18 7 OP31 10 8 OP37 17 9 OP38 13 (4) (a) Staff employed to work at the home must receive training appropriate to the work they are to perform. The registered provider/manager must manage and carry on the care home with sufficient care, competence and skill. He must also undertake from time to time such training as is appropriate to ensure he has the experience and skills necessary for managing the care home. Timescale of 02/03/07 not met. The records specified in Schedule 4 must be maintained in the home and must be kept up to date. Specifically, the staff rota must record the staff working in the home and the hours actually worked. Timescale of 28/11/06 not met. All parts of the home to which residents have access must be free from hazards to their safety. The temperature of the hot water supply must be tested and a record maintained. Timescale of 28/11/06 not met. 06/09/07 06/09/07 21/06/07 21/06/07 Alexander Lodge DS0000013548.V339494.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP33 Good Practice Recommendations Assessments of any risks to residents should include any actions which can be taken to minimise the risks. The outcomes of the resident surveys regarding the quality of the service provided should be reviewed and a summary supplied to residents. Alexander Lodge DS0000013548.V339494.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Alexander Lodge DS0000013548.V339494.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!