Inspection on 01/05/07 for Alexandra Lodge

This inspection was carried out on 1st May 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 Lodge 26/04/06

Alexandra Lodge 12/04/05

Alexandra Lodge 14/01/05

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Alexandra Lodge Alexandra Lodge Wyllie Road Hilsea Portsmouth Hampshire PO2 9NA Lead Inspector Michael Gough Unannounced Inspection 1st May 2007 10:00 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 Alexandra Lodge DS0000044121.V336123.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. Alexandra Lodge DS0000044121.V336123.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alexandra Lodge Address Alexandra Lodge Wyllie Road Hilsea Portsmouth Hampshire PO2 9NA 023 9266 0551 023 9265 1046 deidre.mills@portsmouthcc.gov.uk www.portsmouthcc.gov.uk Portsmouth City Council 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) Mrs Deirdre Mills Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50) of places Alexandra Lodge DS0000044121.V336123.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th April 2006 Brief Description of the Service: Alexandra Lodge is a purpose built residential home providing care and accommodation for up to fifty older people. The home is situated in Hilsea, a residential area of Portsmouth. The home is owned and run by Portsmouth City Council Social Services Department and managed by Mrs Deirdre Mills. The home is arranged into four living units each with its own lounge/diner, a kitchen area, bedrooms, bathrooms and toilets. All bedrooms are for single occupancy and equipped with a wash hand basin. There is a shaft lift to the upper floor. Externally the home has pleasant gardens which are accessible to service users and adequate car parking to the front of the home. Fees at the home range from £98.60 to £434 per week and service users are responsible for paying for their own toiletries, hairdressing, chiropody and items of a personal or luxury nature. Alexandra Lodge DS0000044121.V336123.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report details the evaluation of the quality of the service provided at Alexandra Lodge and takes into account the accumulated evidence of the activity at the home since the last inspection, which was carried out on 26 April 2006. An unannounced site visit to the home took place on the 1 May 2007. During the site visit the inspector had the opportunity to tour the home, read and inspect records and also observe the interaction between staff and service users. The inspector also had the opportunity to speak with the homes manager, 6 members of staff, 5 visitors to the home and 14 service users who were able to comment on how they felt the home was meeting their needs. An Annual Quality Assurance Assessment Questionnaire was sent to the home, however the date for its return was after the site visit to the home. The home is registered to provide support for 50 service users but at the time of the inspection there were 44 service users living at the home. What the service does well: All service users spoken to during the inspection had positive comments about the service provided at Alexandra Lodge. The inspector was told that staff were very kind and helpful and that they were happy living at the home. Relatives felt that the home was well run and that there was a nice atmosphere in the home. Staff at the home treats service users with dignity and respect and service users have access to a full range of healthcare support. Meals in the home are good and offer a choice at meal times and there is a varied diet, which includes vegetarian options at all meals. Visitors to the home are made welcome and there is a flexible visiting routine. Service users are offered choice as much as possible and are encouraged to make their own decisions about how they spend their time. There is a range of varied activities and staff offers support to enable service users to take part. The home was commended for supporting staff to obtain recognised qualifications and all of the staff employed by the home have either achieved or are working towards National Vocational Qualifications. They are committed to their role and work well together as a team. Alexandra Lodge DS0000044121.V336123.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The inspection report will make 2 requirements to the home, which will help improve the service provided for residents. To ensure clear information is available for staff on the care needs of each service user, the manager needs to review the care planning process as at present there is not always clear information for staff on what care is required and care plans did not always give staff clear guidance on how care should be delivered. The home has information on service users needs but these are recorded in different areas and it would be beneficial for service users and staff for all of this information to be in one place. The monthly review of care plans did not provide any information on how the care plans were working for the service user and they require more information and evaluation and they should provide information on any progress of lack of it as the case may be. The home must consult with the district nurse so that there is clear information for staff on the normal blood glucose range of the service user for whom staff monitor the blood glucose levels. Currently there is no clear information for staff on what the normal safe blood glucose level is for the service user and there is no information on what action staff should take should blood glucose levels be unusually high or low and this could put the service user at risk. Medication administration was generally sound, although in some instances where instruction on the medication administration record sheet stated 1 or 2 tablets to be given there was no information recorded on how many tablets had been given each time they were administered, this issue was discussed with the homes manager who will be consulting with the GP’s concerned to get a definitive number of tablets prescribed. Alexandra Lodge DS0000044121.V336123.R01.S.doc Version 5.2 Page 7 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 Lodge DS0000044121.V336123.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 Alexandra Lodge DS0000044121.V336123.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): 1, 3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a statement of purpose and service users guide available to all SU and no service users move into the home without having their needs assessed. The home does not provide intermediate care. EVIDENCE: The inspector saw the homes Statement or Purpose and there were some minor changes required to provide clear information about the services provided at the home. A copy of the service users guide was available to all service users and this contained all the required information. The manager stated that Portsmouth City Council is looking to produce a corporate service users guide and this would include service specific information about Alexandra Lodge. Alexandra Lodge DS0000044121.V336123.R01.S.doc Version 5.2 Page 10 The home carries out an individual needs assessment prior to service users moving into the home and there is a clear admission process and assessments were on file at the home and were looked at for the 4 service users case tracked. Assessments were made using a needs assessment form and service users were visited before they moved into the home. Care management assessments were also on file. Intermediate care is not provided at the home. Alexandra Lodge DS0000044121.V336123.R01.S.doc Version 5.2 Page 11 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 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning procedures in the home do not always give staff clear guidance on the care needs of individuals or how care should be delivered. Medication procedures are generally sound and protect service users. The health care needs of service users are met and service users at the home are treated with dignity and respect. EVIDENCE: Care plans were inspected for 4 service users and each plan gave information on: Personal history, physical needs, mental behaviour, nutrition, pressure areas, religion and culture, social and emotional needs and there was also a pen portrait which gave information on night time routines, preferred times of going to bed and getting up and also food preferences. However none of the care plans had any information on Personal Care needs, the inspector was informed that these service users were all capable of taking care of their own personal care, however there was no information for staff and care plans did not always give staff clear guidance on how care should be delivered. Care plans were reviewed monthly but review notes did not provide any information on how the care plans were working for the service user and they require more Alexandra Lodge DS0000044121.V336123.R01.S.doc Version 5.2 Page 12 information and evaluation and they should provide information on any progress of lack of it as the case may be. There were risk assessments in place and these were geared to the individual. Care Planning was discussed with the homes manager and also the duty manager, it was clear that the home had good information on service users needs but these were not always contained in the service users plan. Information to staff was given verbally at the start of each shift by the duty manager and staff did not use the care plans as a working document on a day to day basis. The home should ensure that all the relevant information for each service user is contained within their plan of care and this plan should give clear information and guidance to staff on the care and support that is needed by each service user and should show how this care is to be given. Service users spoken to were aware that they had a plan of care but said that they were not involved in its compilation. Relatives and service users stated that they were very happy with the care provided at the home, service users said all they had to do was ask and staff would help. Service users at the home are registered with a number of different GP surgeries and they may keep heir own GP if possible. The home has support from district nurses and other health care professionals services are arranged through GP’s & district nurse referrals. Dental care is arranged through service users own dentist or if required by a local NHS dentist. Service users own optician or a visiting optician who calls once per year provides sight tests. The home also has 2 visiting chiropodists who call on a regular basis. Service users spoken to all stated that they were well cared for and that staff were aware of their needs. Visitors were very happy with the services provided by the home and said that the home deals with any health issues quickly and that they had no concerns. Medication procedures at the home have been reviewed and all staff who are authorised to administer medication receive appropriate training. The home has dealt with the issue of a resident who is diabetic and this person now administers her own insulin via a pen injection system. The inspector was informed that staff monitor the service users blood glucose levels, however there is no clear information for staff on what the normal safe level is for the service user and there is no information on what action staff should take should blood glucose levels be unusually high or low. This issue was discussed with the homes manager and the district nurse will be consulted so that clear guidelines and instructions can be given to staff. The home uses a monitored dose system provided by a local pharmacist and there are clear routines in place for the receipt storage and disposal of medication. Medication administration recording was inspected and these were generally sound, although in some instances where instruction on the medication administration record sheet stated 1 or 2 tablets to be given, there was no information recorded on how many tablets had been given each time they were administered, this issue was discussed with the homes manager who will be Alexandra Lodge DS0000044121.V336123.R01.S.doc Version 5.2 Page 13 consulting with the GP’s concerned to get a definitive number of tablets prescribed. Staff were observed interacting with service users appropriately and they were seen to treat service users with dignity and respect. Staff were heard to use service users preferred form of address when talking to service users and staff were seen to knock on service users doors before entering. Alexandra Lodge DS0000044121.V336123.R01.S.doc Version 5.2 Page 14 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 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a range of activities for service users, which meets their expectations. Service users are able to maintain contact with family and friends and visitors are welcome at any time. Service users are supported to exercise choice and control over their lives as much as possible and they are provided with a balanced diet in pleasant surroundings at a time convenient to them. EVIDENCE: The home arranges for regular activities and the programme is displayed on the notice board with activities take place each day. The home has an activities co-ordinator who is employed for twenty hours per week on a permanent contract. Discussions with service users during the inspection indicated that they were happy with the activities organised and said that they were free to participate if they wished or if they chose they did not have to be involved and they were able to spend their time as they wished. The activities organiser maintains her own file for documenting activities and who has attended. She stated that it is often the same people who attend planned group activities although she tries to encourage other people to join in. Alexandra Lodge DS0000044121.V336123.R01.S.doc Version 5.2 Page 15 Service users are encouraged to participate around the home, with several being very involved in the home’s gardens. The home’s manager stated that the home organises trips out using the mini-bus linked to the adjacent day service, she said that it is often quite difficult to get different people to go out on these trips but more outings are being planned for the warmer weather The home has a clear visitors policy and there are no set times, visitors sign in at the home and the visitors book is kept in the hallway, the inspector checked the visitors book and there is a regular stream of visitors to the home. The inspector also had the opportunity to speak with 6 visitors to the home who all stated that they were made welcome. The inspector observed staff supporting service users and it was clear that service users were able to make informed choices and are able to control their own lives as much as possible. A number of service users had bought some of their own possessions into the home and most bedrooms had been personalised. Service users spoken with were very happy with the food provided at the home and menus seen indicated that a varied nutritious menu with choices available is provided. Between meals service users are provided with snacks and hot and cold drinks. However, the homes recent service user surveys indicated that some service users were not always happy with the choices at meals times and the manager has arranged for 3 monthly meetings with service users and the cooks to discuss menus and choices. Service users are encouraged to eat their meals in one of the 4 dining areas but may eat elsewhere if they prefer. Alexandra Lodge DS0000044121.V336123.R01.S.doc Version 5.2 Page 16 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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is an accessible complaints procedure, which includes timescales for the process and any complaints are responded to appropriately. The homes policies and procedures protect service users from any form of abuse. EVIDENCE: There have been no complaints since the last inspection. The inspector discussed the issue of complaints with the homes manager and she stated that although formal written complaints go directly to the council’s complaints department and investigated independently from the home, the manager is kept fully informed of the nature of the complaint and the outcomes of any investigation. Service users spoken to stated that they were confident that if they had any concerns they would be dealt with by the home, they said that they would report any concerns to a member of staff or to the homes manager. They were aware of the homes complaints procedure. They were also able to comment on the running of the home at regular service user meetings but said that they would not wait until the next meeting if they had any concerns and they would speak to staff to sort out any issues. Relatives spoken to were aware of how to make a complaint and stated that when they had any concerns they would speak to staff and issues were resolved quickly and to their satisfaction. One relative was not entirely happy with the response she had received when she had spoken with the manager. She felt that she had not received a satisfactory explanation. However she has not raised a complaint with the home or with Portsmouth City Council. Staff members spoken to were aware of the complaints procedure and said that Alexandra Lodge DS0000044121.V336123.R01.S.doc Version 5.2 Page 17 they would support any service user to make a complaint if they wished to do so. Staff have received training on adult protection as part of the induction process and also cover this as part of their NVQ training, additional training and updates are also provided. Staff spoken to were aware of their responsibilities in this area and knew what to do should they suspect any form of abuse had taken place they said that they would report any concerns to the duty manager. The inspector spoke to 2 of the duty managers and also the homes manager who were aware of what action they should take. Alexandra Lodge DS0000044121.V336123.R01.S.doc Version 5.2 Page 18 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, 22 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a safe and well-maintained environment and have access to comfortable indoor and outdoor facilities. Service users are provided with the specialist equipment they require and bedrooms are safe and comfortable. There are suitable laundry facilities and the home was clean, pleasant and hygienic and free from offensive odours. EVIDENCE: The inspector toured the building and this included all communal areas of the home including bathrooms, toilets and lounges. Many of the home’s bedrooms had been personalised and service users spoken with said that they were happy with their rooms. All areas of the home were clean and tidy and furniture was in a good state of repair. The manager informed the inspector that a lot of work has been carried out to improve the appearance and fabric of the home and all of the upstairs windows have been replaced and bathrooms have been decorated. Alexandra Lodge DS0000044121.V336123.R01.S.doc Version 5.2 Page 19 The home has also been able to increase the number of profiling beds from 1 to 4 and the manager stated that these beds support both service users and staff caring for people who have reduced mobility. The majority of the service users living at the home are mobile and can move around the home independently. There is a shaft lift to provide access to the first floor and shared space is provided in four lounge/dining rooms, two on each floor of the home. There is also a large lounge on the ground floor of the home that can be used for activities groups or meetings. Service users were seen using the communal areas throughout the inspection. The home has a large garden with wheelchair access and service users were seen enjoying the garden in the warm weather. The home has a call bell system in use within the home and they are available in all service users rooms as well as bathrooms and WC’s, there are also pendant buzzers for the home’s call bell system that can be used by service users who are enjoying the gardens. Calls are relayed to a bleeper, which all staff holds on their person, when someone calls the bleeper sounds until it is cancelled at the point on which it was called. The manager stated that there are sufficient personal bleepers for all staff and there is a system in place for staff to sign for bleepers as they come on and go off duty so that they can be accounted for at all times. Infection control procedures were observed to be followed and staff carried antiseptic gel. The laundry at the home contains 2 industrial washing machines and 2 industrial tumble driers and the home employs dedicated laundry and domestic staff and suitable protective equipment is provided. The home was clean pleasant and hygienic with no unpleasant odours. Alexandra Lodge DS0000044121.V336123.R01.S.doc Version 5.2 Page 20 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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing numbers and the mix of staff currently meets the needs of service users. Staff morale was good and there was a good rapport between service users and staff. Service users are protected by the homes recruitment procedures and the home provides training for staff to enable staff to support service users effectively. EVIDENCE: The homes staff rota was examined and this showed that the home provides 1 duty manager plus 6 carers between 0730 – 2130 and between 2130 – 0730 there is 1 duty manager who sleeps in between 2230 & 0700 and 3 other care staff members awake throughout the night. In addition to the care staff, domestic and catering staff are also employed at the home. Staffing numbers were discussed with the homes manager who felt that staffing levels were sufficient. Service users spoken to said that they felt that there were always staff around. Relatives said that staff were very good although one visitor felt that although 3 members of staff are on duty on the first floor she said that she did not see them very often. The inspector observed staff on both floors supporting service users appropriately throughout the day and there was a good rapport between service users and staff. The home employs a total of 39 staff, and of these 39, 33 already hold National Vocational Qualifications and the home was commended for supporting staff to obtain recognised qualifications. Alexandra Lodge DS0000044121.V336123.R01.S.doc Version 5.2 Page 21 The home has policies and procedures in place with regard to recruitment and staff recruitment records were inspected for 2 staff members and records contained all of the required information. The inspector discussed staff training with the manager and all new staff complete a full 6 day induction, which takes place over the first 12 weeks of employment. Mandatory training is carried out in heath & safety, infection control, Adult Protection, fire safety & moving and handling. Portsmouth City Council has a training co-ordinator and there is a rolling programme of training that is available for staff and this includes: Deaf awareness, communication skills, bereavement, falls prevention, medication, 1st aid, food hygiene and care practices. Senior staff undertake medication training and complete a full four day first aid course. In addition to this training all staff are supported to undertake National Vocational Training after completing 6 months at the home. Alexandra Lodge DS0000044121.V336123.R01.S.doc Version 5.2 Page 22 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 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management arrangements in place at the home are satisfactory and the health and safety of service users and staff are promoted and protected. Quality assurance procedures are in place and service users financial interests are safeguarded by the homes policies and procedures EVIDENCE: The home’s manager was registered with the Commission in March 2005 and has been at the home for a considerable time, she has a diploma in management and has the skills and experience to manage the home effectively, although it is acknowledge that a number of the management elements are the responsibility of various council departments and as such are outside her direct control. Alexandra Lodge DS0000044121.V336123.R01.S.doc Version 5.2 Page 23 The home undertakes its own quality assurance monitoring in the form of questionnaires to relatives and service users. The results from a recent series of questionnaires were available and were viewed by the inspector. There were 16 questionnaires returned from service users and of these sixteen, ten were positive with six expressing some dissatisfaction, the manager has taken appropriate action to address the concerns raised in the questionnaires. Service user meetings are held at 3 monthly intervals and those spoken to felt that the timings of these meetings was about right, they said that they could always speak to staff or the manager if they had any pressing issues and said that their views would be listened to and acted upon. The inspector spoke with relatives who said that there are relatives meetings every 3 months and they said that they could speak with the manager at any time if they had any concerns Financial arrangements in the home are satisfactory and the home does not manage any of the service users monies. The local authority manages these in individual accounts and the manager receives a statement every month for all service users as to the balance they have in the account. Records in the home were kept secure and a representative of the provider has carried out monthly visits in accordance with the regulations. Reports of these visits are held in the home and were seen by the inspector, these reports showed that service users, representatives and staff have been consulted with and that the premises had been inspected. Health and Safety policies are in place and available to all staff members and staff have undertaken training in health and safety. Annual tests of fire alarms system and fighting equipment had been carried out and certificates were in date for boilers and gas installations, electrical wiring, hoists and lifting equipment, passenger lift and testing of private electrical equipment. The fire log was inspected and all relevant training and testing is carried out within the specified timescales. All service users and staff spoken to were happy with the health and safety arrangements in the home. Alexandra Lodge DS0000044121.V336123.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Alexandra Lodge DS0000044121.V336123.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? 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 OP7 Regulation 15 Requirement The manager must review the care planning process to ensure clear information is available for staff on the care needs of each service user. At present there is not always clear information for staff on what care is required and care plans do not always give staff clear guidance on how care should be delivered. The home must consult with the district nurse so that there is clear information for staff on the normal blood glucose range of the service user for whom staff monitor blood glucose levels. Currently there is no clear information for staff on what the normal safe blood glucose level is for the service user and there is no information on what action staff should take should blood glucose levels be unusually high or low Timescale for action 10/06/07 2 OP9 13(2) 10/06/07 Alexandra Lodge DS0000044121.V336123.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Alexandra Lodge DS0000044121.V336123.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Lodge DS0000044121.V336123.R01.S.doc Version 5.2 Page 28 - 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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