Inspection on 13/11/07 for Alexandra House and The Lodge

This inspection was carried out on 13th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Alexandra House and The Lodge 25/02/09

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Alexandra House and The Lodge Main Road Alresford Colchester Essex CO7 8AP Lead Inspector Ray Finney Key Unannounced Inspection 13th November 2007 09:30 Alexandra House and The Lodge DS0000070230.V354798.R01.S.doc Version 5.2 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 Alexandra House and The Lodge DS0000070230.V354798.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 Adults 18-65. 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. Alexandra House and The Lodge DS0000070230.V354798.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alexandra House and The Lodge Address Main Road Alresford Colchester Essex CO7 8AP 01206 826009 01206 231106 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) Minster Pathways Limited vacant post Care Home 14 Category(ies) of Learning disability (14), Learning disability over registration, with number 65 years of age (14) of places Alexandra House and The Lodge DS0000070230.V354798.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 14 persons) Persons of either sex, aged 65 years and over, who require care by reason of a learning disability (not to exceed 14 persons) The total number of service users accommodated in the home must not exceed 14 persons 18th May 2007 Date of last inspection Brief Description of the Service: Alexandra House and The Lodge are two self-contained units within a detached property, situated in a semi-rural location between Colchester and Clacton-onSea. The home provides care and accommodation for thirteen adults with learning disabilities, some of who are over the age of sixty-five. Both units are on two floors. There are two double bedrooms and nine single. None of the rooms are en-suite but they do have hand basins. Alexandra House has a kitchen-dining room with separate lounge. The Lodge has a lounge-dining room with separate kitchen. There is an upstairs activities room in The Lodge but, as neither unit has a lift, this is only accessible to mobile service users. To the front of the property is a paved area, separated from a small lay-by, and the road, by a large sliding iron gate. The home charges between £457.39 and £908.21 a week for the service they provide. This information was given to us in November 2007. Information about the home can be obtained by contacting the manager. Inspection reports are available from the home and from the CSCI website www.csci.org.uk Alexandra House and The Lodge DS0000070230.V354798.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A range of evidence was looked at when compiling this report. Documentary evidence was examined, such as menus, staff rotas, care plans and staff files. An Annual Quality Assurance Assessment (AQAA) with information about the home was completed earlier in the year and the information was considered at the time of the last inspection. A further AQAA was not requested before this inspection. We sent surveys out to people living in the home, relatives, health & social care professionals and members of staff and a total of 11 were completed and returned. All questionnaires contained positive responses about the home. Two visits to the home took place, the first on 13th November 2007 and the second on 21st November 2007. The visits included a tour of the premises, discussions with people living in the home, the manager, members of staff and a visiting relative. Observations of how members of staff interact and communicate with people living there have also been taken into account. On both of the inspector’s visits the atmosphere in the home was relaxed and the inspector was given every assistance from the manager and the staff team. What the service does well: Alexandra House and the Lodge provides a service that values the individuality of people who live there. Interactions between staff and people in the home are good. Staff are able to provide support for people in a way that meets their needs and wishes. They ensure the personal and healthcare needs of people living in the home are met and relevant healthcare professionals are consulted where appropriate. Work has been done to develop skills and independence by encouraging people to be involved in daily chores at the home. Alexandra House and the Lodge provides a comfortable environment for people with ample communal areas and bedrooms that reflect individual tastes. Visitors are made welcome and people are encouraged to maintain contact with families and friends. A relative said there is “Always a welcome to visitors”. Alexandra House and The Lodge DS0000070230.V354798.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: 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. Alexandra House and The Lodge DS0000070230.V354798.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Alexandra House and The Lodge DS0000070230.V354798.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People choosing to live at Alexandra House and the Lodge receive sufficient information about the home and may be confident their needs will be assessed before admission. EVIDENCE: The Service User Guide has been updated since the last inspection. Records examined confirm that copies of the updated Service User Guide and Statement of Purpose are in people’s individual files. The Service User Guide is also prominently displayed on the notice board. There have been no new admissions to Alexandra House and the Lodge since the last inspection. The process for assessing whether they could meet people’s needs was discussed with the acting manager, who was able to demonstrate a good awareness of the importance of a sound assessment process. The acting manager said that any new admissions would be considered by the new manager who has been recruited and is soon to be in post. Individual files examined contain statements of terms and conditions. People living in the home have complex needs associated with learning disabilities and Alexandra House and The Lodge DS0000070230.V354798.R01.S.doc Version 5.2 Page 9 some also have additional needs relating to the aging process. No one living there has the capacity to read or understand contracts, therefore relatives act on their behalf. Alexandra House and The Lodge DS0000070230.V354798.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in Alexandra House and the Lodge have care plans and risk assessments in place that are continuing to be developed. They are supported to make decisions about their lives and to take risks within their capacity to understand. EVIDENCE: The acting manager and senior staff have worked hard on people’s care plans to meet the requirement that was left at the previous inspection. The current care plans that are in place have an appropriate format that identifies the background to the particular need, the aims and objectives that they are trying to achieve for the person and the actions that are to be taken to meet the identified objectives. Although there is a well established staff team who know the people living in the home well, the details in current care plans are quite general and could contain greater detail to ensure that all staff are doing things in a consistent Alexandra House and The Lodge DS0000070230.V354798.R01.S.doc Version 5.2 Page 11 manner. The care plans could be further improved if there are more details around identifying specific needs and the actions to be taken. There is a new format for care plans that covers a wide range of healthcare needs including general health, eye testing, dentist, chiropodist, blood pressure, G.P. appointments, physiotherapy, diabetes, mental health, hospital appointments and medication. The acting manager and senior staff are continuing to collate details for the new format care plans and are looking at further improving them. The acting manager and care staff spoken with are able to demonstrate a sound knowledge of people’s needs. Observations on both visits confirm that people are receiving a good standard of care and further development of care plans will provide better evidence of this. Although people have complex needs and some have communication difficulties, staff at Alexandra House and the Lodge know people well and have developed skills in understanding and communicating with individuals living there. A completed survey from a healthcare professional stated, “The care team are always endeavouring to advocate for service users rights and choice”. At both inspection visits staff were observed to ask people what they would like to drink and preferences around food. There is a residents’ meeting every four to six weeks where they discuss things like menus and those who are able can express their opinions. Minutes of these meetings are available. A meeting was held before the second inspection visit where healthy eating was discussed and as a result menus were revised to try to incorporate more healthy options. Staff spoken with confirm that people also have one to one meetings with their keyworkers and make decisions about things like Christmas shopping. Where people’s complex needs present difficulties in decision making, relatives are involved. One relative spoken with on the day of the inspection visit was helping decide about buying new clothes for their relative. Three people have input from advocacy services. Records show that advocacy support helped one person continue in a day services placement that was at risk of being ended. Records examined confirm that risk assessments are in place. These identify specific risks and have a management plan as to how to support the person around the identified risk. Although the risk assessments are clear and relevant to individuals, they could be further improved if there is greater detail in the section on actions to be taken to reduce the risks. Alexandra House and The Lodge DS0000070230.V354798.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in Alexandra House and the Lodge have opportunities to participate in activities that are appropriate to their needs and they are supported to access facilities in the local community and are able to build and maintain relationships. People have varied diet that they enjoy. EVIDENCE: The daily recording sheets examined are completed briefly on a daily basis giving an overview of what each individual is doing, such as doing ‘etch-asketch’, going to college, helping staff around the house. Daily recording sheets are completed individually, but are all stored in one file so that they can be completed easily. The file also contained health recording sheets, telephone contact numbers, menus, some health records and staff rotas. After a discussion with the acting manager and senior staff, any records relating to health or confidential areas of care were removed an put in the individual’s file. Alexandra House and The Lodge DS0000070230.V354798.R01.S.doc Version 5.2 Page 13 Staff spoken with said that people are supported to take part in social activities where they can meet people and develop friendships. Activities records show that people go to local clubs and social gatherings such as discos. A local church has been running the Causeway Club for many years and people enjoy going there. Although many of the people living in Alexandra House and the Lodge have complex needs, those who are able to do so are encouraged to take an active part in the day to day running of the home. One person gets involved in household chores such as dusting and drying up dishes. Menus examined covering a six-weekly period show that a variety of food is available. At the first visit there appeared to be quite a lot of chips, pies and processed foods used; crisps, cakes and chocolate bars also featured heavily and were enjoyed by people living in the home. However, plenty of fresh fruit was also seen to be available and people have a roast dinner on Sundays. Guidelines around healthy eating that include a minimum of 5-a-day portions of fruit and vegetables would improve outcomes for people living in the home. Although it was obvious from the well-stocked fruit bowl and observations that people eat fruit between meals, there could be more use of a greater variety of vegetables. After the first inspection visit, menus were discussed at a residents’ meeting where people said they like the food. After discussions new menus were agreed that give a greater balance and include the foods people enjoy whilst introducing other healthy options. Alexandra House and The Lodge DS0000070230.V354798.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service receive personal and healthcare support that meets their needs. Alexandra House and the Lodge has systems in place to ensure the safe administration of medication and the protection of people living there. EVIDENCE: As at last inspection people continue to be well supported with their personal care needs. Observations on both days that the inspection was carried out showed good practices being followed by members of staff when supporting people with their care needs. Positive comments about the home were received in a completed survey from a community nurse, including “Always see clients addressed with respect and given privacy where needed”. Since the last inspection visit there have been improvements in record keeping around people’s health care needs. Records examined confirm that people access services from the optician, dentist and chiropodist. There are health recording sheets in place relating to people’s needs around diabetes. A completed survey from a community nurse said that if they have any queries in matters relating to a persons health the staff team “Will seek information Alexandra House and The Lodge DS0000070230.V354798.R01.S.doc Version 5.2 Page 15 actively and always check if in doubt”. The health care professional also confirmed that “All health checks are done and a proactive approach made by the manager and team. Any advice is always followed” and “All client information is kept confidential”. Another healthcare professional said, “The senior staff will contact me to seek advice where necessary and will ensure I am updated as appropriate in regard to healthcare needs”. There is a monitored dose system in place for medication. No-one living in the home has the capacity to self medicate, although one person takes their daytime medication with them when they go to work and there is a risk assessment in place around this. Storage of medication was examined on a tour of the premises. Medication is securely stored in lockable two-drawer metal cabinets. However, the monitored dose ‘bubble packs’ take up a lot of space, consequently all other prescribed medications including tablets, liquids and topical creams are stored together in the second drawer. Creams and other medication that is applied externally should not be stored next to medicines taken orally. The acting manager confirmed that two new medicine cabinets are to be installed and have been ordered. On the day of the second site visit a senior member of staff bought storage containers to ensure individual’s medication could be organised separately with their names and this improved the current system for storing medication. Medication Administration Record (MAR) sheets examined are all correctly completed. Staff spoken with said that they have taken photographs to be printed out and put in the MAR file, which will improve recording and reduce the risk of errors in administering medication. Staff spoken with are aware of good practices around supporting people with medication and have received training. There are no controlled drugs in use at present but a senior member of staff spoken with was able to demonstrate a good awareness of the correct storage, recording and handling of controlled drugs. A survey from a health care professional said that “Medication is always managed safely and effectively. Any queries are addressed” Alexandra House and The Lodge DS0000070230.V354798.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have access to an effective and understandable complaints procedure that ensures that they are listened to. There are procedures in place to protect the people who live there. EVIDENCE: Since the last inspection improvements have been made to the complaints procedure to make it more accessible to the people living in Alexandra House and the Lodge. However, the complex needs of some of the people using the service means they would not have the capacity to use a complaints process independently. Records confirm that people have access to advocacy services who can act on their behalf when necessary. A relative spoken with has no complaints about the service provided but is aware of how to raise concerns. The relative is very complimentary about the way the acting manager runs the home and staff spoken with are also confident that they can raise any concerns. Since the last inspection staff have all received Protection of Vulnerable Adults (POVA) training and all have been provided with a booklet with guidelines on safeguarding issues. Records examined confirm that staff have signed to say they have received and understand the POVA information. There is a Whistleblowing policy and procedure in place so that staff may be confident that they can safely raise any concerns they may have about poor Alexandra House and The Lodge DS0000070230.V354798.R01.S.doc Version 5.2 Page 17 practices. Records examined contain a signed record that staff have read and understand this policy. Staff spoken with have a good awareness of their responsibilities around safeguarding vulnerable people. Alexandra House and The Lodge DS0000070230.V354798.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall, people living in Alexandra House and the Lodge benefit from a comfortable environment that is well maintained and clean. EVIDENCE: A tour of the premises confirmed that the home is kept in good decorative order. The premises are homely and comfortable with furnishings that are domestic and well maintained. All bedrooms are decorated individually to the taste of the person using the room. All rooms examined contain ample evidence of people’s individual, personal possessions. The acting manager is planning to decorate throughout and had already started this at the time of the second inspection visit. The acting manager said that improvements due to be carried out include a new back door and a new patio door, which are on order. Alexandra House and The Lodge DS0000070230.V354798.R01.S.doc Version 5.2 Page 19 Some improvements could be made to the shower room. Although the area is clean and odour free, the tiling is old and there is some damage. Improvements needed include replacing the shower door and improving the tiling. The acting manager said that this has been identified as part of their maintenance plan. The bathing experience for all those living in Alexandra House and the Lodge would be better if the shower room is refurbished. The laundry is suitable for the size of the home and the number of people living there and has appropriate flooring and facilities for hand washing. There is a good standard of cleanliness throughout the premises and there are no unpleasant odours. Alexandra House and The Lodge DS0000070230.V354798.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in Alexandra House and the Lodge benefit from a competent, well trained staff team who receive appropriate supervision. The recruitment procedure in the home provides the safeguards that ensure appropriate staff are employed. EVIDENCE: Out of a total of eleven care staff, four have achieved a National Vocational Qualification (NVQ) at level 2 or above. A further three people are working on the award and another two are about to commence. The management team and the providers should continue to support these staff to achieve the award to ensure the recommended minimum 50 of care staff have an NVQ qualification. Rotas examined confirm that most days there are three members of staff per shift and sometimes four, although some shifts only have two staff. Staff are used flexibly according to the activities and when people need to go out. Alexandra House and The Lodge DS0000070230.V354798.R01.S.doc Version 5.2 Page 21 There are two sleep-in staff at night, one in each unit. It was observed on both inspection visits that there are sufficient staff on duty to ensure people receive the support they require. People were being supported to take part in activities at home and were also going out. A sample of two staff files examined had all the required documentation in place including contracts, proof of identity, Criminal Record Bureau (CRB) checks and two written references. A person was being interviewed on the first inspection visit and a senior member of staff was able to demonstrate an awareness of good recruitment procedures, including involving people who live in Alexandra House and the Lodge in the inspection process. The training files of the new Minster Pathways induction process that has been introduced were examined and all staff are receiving this induction. Staff training records confirm that staff have received training including Moving & Handling, First Aid, Fire Safety, Health & Safety, Basic Food Hygiene, Managing Challenging Behaviour and Diabetes Awareness. Staff have completed a comprehensive package of Infection Control training. Personnel records examined contain evidence that staff receive appropriate supervisions. Staff spoken with feel well supported. Alexandra House and The Lodge DS0000070230.V354798.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is competently managed and run in the best interests of the people who live there. The health and safety of individuals living and working in the home is promoted and protected. EVIDENCE: The new providers of Alexander House and the Lodge are currently recruiting to the post of manager. In the interim period until a new manager is in post the acting manager, supported by the staff team, has worked very hard to ensure that requirements that were made after the last inspection have been addressed. There are significant improvements in record keeping and credit should be given to the acting manager and the staff team for their hard work. There has been further development of the Quality Assurance system and records examined show that people living in the home and their relatives are Alexandra House and The Lodge DS0000070230.V354798.R01.S.doc Version 5.2 Page 23 consulted about how the service is delivered. There are minutes of meetings with people living there and a relative spoken with was complimentary about how they are consulted in any matter relating to their relative. Discussion with the acting manager confirms that they are aware that this is an ongoing process and will continue to look at ways of improving the Quality Assurance process. As at the last inspection, all Health & Safety records examined were found to be in good order and up to date. Alexandra House and The Lodge DS0000070230.V354798.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 Adults 18-65 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 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Alexandra House and The Lodge DS0000070230.V354798.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 YA9 YA20 Good Practice Recommendations The management team should continue to develop the risk assessments that are in place so that they contain greater detail to ensure all risks are fully identified. The providers and management team should ensure that cabinets for the storage of medication are installed so that there is adequate space to store all the medicines and other preparations separately. The providers should continue to support staff to achieve NVQ qualifications. 3. YA32 Alexandra House and The Lodge DS0000070230.V354798.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Alexandra House and The Lodge DS0000070230.V354798.R01.S.doc Version 5.2 Page 27 - 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. 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