Inspection on 18/06/08 for Alexandra Lodge Care Centre

This inspection was carried out on 18th June 2008.

CSCI found this care home to be providing an Adequate service.

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 Care Centre 20/07/09

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Alexandra Lodge Care Centre 355-357 Wilbraham Road Chorlton Manchester M16 8NP Lead Inspector Geraldine Blow Unannounced Inspection 09:30 18 & 19th June 2008 th 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 Care Centre DS0000070835.V364574.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 Care Centre DS0000070835.V364574.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alexandra Lodge Care Centre Address 355-357 Wilbraham Road Chorlton Manchester M16 8NP 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) 0161 860 5400 0161 862 9043 Dr Jawed Hamid Manager post vacant Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Alexandra Lodge Care Centre DS0000070835.V364574.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only. Care home with Nursing - code N, to people of the following gender:Either. Whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category - Code OP. The maximum number of people who can be accommodated is: 36 Date of last inspection Brief Description of the Service: Alexandra Lodge Care Centre can provide accommodation for 36 older people. The home has recently been purchased by Dr Jawed Hamid. The home is located in the Chorlton area of Manchester close to main public transport routes, local shops, public houses and other social and recreational amenities. Parking facilities are available to the front of the property. The home is a three storey detached property set within its own grounds. Bedroom accommodation is provided on all 3 floors and consists of 34 single and 1 double bedroom. Twenty-one bedrooms offer en-suite facilities. The home is accessible by steps or a ramp to the main entrance. The charges for fees range from £373 to £510 per week. There are additional charges for magazines, papers and hairdressing. Alexandra Lodge Care Centre DS0000070835.V364574.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This report is based on information gathered by the Commission for Social Care Inspection (CSCI) and supporting information received in the Annual Quality Assurance Assessment (AQAA) submitted by the manager prior to this visit. Residents, staff and relatives were sent comment cards. At the time of this visit 1 resident, 1 staff and 3 relative comment cards had been received by CSCI. Some of their comments have been included in the body of this report. This visit was unannounced, which means that the manager and staff were not told that we would be visiting. This visit, which was the first visit since the new providers have been registered with CSCI forms part of the overall inspection process and took place on Wednesday 18 June and Thursday 19 June 2008. The opportunity was taken to look at all the core standards of the National Minimum Standards (NMS). This report is an overview of what the inspector found during the inspection. As part of the visit we (the commission) spent time examining relevant documents and files. We also spent time talking with the owner of the home, the manager, several people living at the home, members of staff and a tour of the building was undertaken. Feedback was given to the manager during the course of this visit and on conclusion of the visit. The opportunity was taken to look at all the core standards of the National Minimum Standards (NMS). This inspection was also used to decide how often the home needs to be visited to make sure that it meets the required standards. What the service does well: Before a prospective resident is admitted to the home a pre-assessment of their needs is undertaken to make sure that the person’s needs can be met. Visitors are welcome in the home at any time and can visit in the resident’s own room or in any of the communal areas of the home. All of the comment cards received from relatives indicated that staff at the home usually support people to live the life they choose. Alexandra Lodge Care Centre DS0000070835.V364574.R01.S.doc Version 5.2 Page 6 Systems are in place to support people to raise any concerns they have and details of how to make a complaint are on display in the main reception. In the returned comment card the resident indicated that they knew who to speak to if they were not happy and that staff do listen and act on what you say. Although the manager is not yet registered with CSCI she demonstrated a commitment to improving the quality of service delivered to the people living at the home. 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 Lodge Care Centre DS0000070835.V364574.R01.S.doc Version 5.2 Page 7 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 Care Centre DS0000070835.V364574.R01.S.doc Version 5.2 Page 8 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&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to make sure that people’s needs are assessed before admission. EVIDENCE: Prospective residents are encouraged to visit the home before making a decision to move in. The returned comment card from the person living at the home stated that they had received enough information about the home before moving in. In addition a website had been developed which gives details and photographs of the home. A documented pre-admission assessment form is in use to ensure all residents’ assessed needs can be met prior to admission. Residents placed by the local Alexandra Lodge Care Centre DS0000070835.V364574.R01.S.doc Version 5.2 Page 9 authority had a care manager’s assessment of needs or a funded nurse assessment. The AQAA evidenced that the Primary Care Trust (PCT) had purchased 6 beds to provided intermediate care. The contract finished in February 2008. Alexandra Lodge Care Centre DS0000070835.V364574.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 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some shortfalls were identified in ensuring that the health care needs of residents were being met. EVIDENCE: A sample of care plans were seen and 3 residents were case tracked. The care files examined all contained a plan of care and were organised and easy to use. However some shortfalls were identified. Not all of the residents identified care needs had been incorporated into the care plan. For example one care file identified that the resident had previously had suicidal thoughts and was ‘very low in mood’. A care plan had not been implemented to address this specific care need. In addition the resident has short and long-term memory loss and this had not been included in the plans of care and there were no details of how staff should best manage this need. Alexandra Lodge Care Centre DS0000070835.V364574.R01.S.doc Version 5.2 Page 11 Some parts of the care plans were detailed and contained person centred information. For example one file detailed the preferred times of going to bed, getting up and what time the resident liked to have a shower. However other plans were vague and did not give specific details of how care needs could be met. For example in relation to hygiene needs the care plan did not give any details of exactly what help was needed to maintain personal hygiene. It is recommended that that all resident’s care plans are developed using a person centred approach and contain sufficient detail for staff to meet all resident’s identified needs and personal preferences. The plans of care had been reviewed on a monthly basis and contained appropriate risk assessments. However it was noted that one resident was self-medicating some of her medication. To ensure that residents are not placed at any unnecessary risk a risk assessment must be undertaken prior to any resident self-medicating. A daily record was completed for each resident. However some entries were vague and from discussions with the manager it was clear that the reports did not always accurately reflect the care given over a 24-hour period. A recommendation has been made. Evidence was seen that residents were registered with a local General Practitioner (GP) and evidence of GP visits. There were arrangements in place to access to other health care professionals if needed. The records regarding medication were examined. It was day 4 of week 2 of the recording. There were no gaps in the recording of medication and medication had been signed into the home. Surplus, unwanted or expired medicines were appropriately documented and stored while waiting to be picked up by the waste management company. The manager confirmed that a copy of the GP’s original prescription is not kept in the home. It is recommended that the GP’s original prescriptions come directly to the home so that the manager can sign the exemption declaration on behalf of the resident before they are sent to the pharmacy for dispensing. It is also recommended that there is a copy of the GP’s original prescription so that the medication received into the home can be checked against medication prescribed. The manager confirmed that at the time of this visit there was no system of auditing medication although it was her intention to implement one. To ensure that residents are receiving medication as prescribed by the GP, medication should be accounted for at all times by means of an audit trail. Alexandra Lodge Care Centre DS0000070835.V364574.R01.S.doc Version 5.2 Page 12 Residents and the majority of staff spoken to confirmed that privacy and dignity was respected during day-to-day interactions and residents are encouraged to exercise choice in their daily lives. Alexandra Lodge Care Centre DS0000070835.V364574.R01.S.doc Version 5.2 Page 13 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 adequate. This judgement has been made using available evidence including a visit to this service. Limited activities were provided and residents were able to maintain contact with family and friends. EVIDENCE: From the files inspected evidence could not be provided that residents had consistently been consulted regarding their social interests, hobbies or their religious or cultural needs. There was a social history assessment sheet, which included a section to record the resident’s religious beliefs. However in 2 of the 3 files looked at this had not been completed. The manager stated that at the moment activities are provided on an “ad hoc” basis and the AQAA detailed some of the activities that take place. However there was no documented evidence to support activities were being provided. One comment received in the resident comment card was that there are sometimes activities provided. One resident spoken to said that there were no activities provided and she did get bored. It is recommended that people are consulted about the social and leisure activities that they enjoy and want to participate in and clearly record this through their care plan. It is also Alexandra Lodge Care Centre DS0000070835.V364574.R01.S.doc Version 5.2 Page 14 recommended that a record is kept of the activities provided and who attends. The manager confirmed that they were currently considering employing the services of an activity coordinator. A copy of the menus was seen and the manager stated that there is a daily menu on display just outside the dining room. The menus evidenced that a choice of meals is available and during this visit a number of residents did not want the meal served and an alternative was provided. The manager confirmed that the staff ask the residents the evening before what they would like for their meals the following day. A number of African Caribbean people live at the home and due to this Afro Caribbean food is regularly provided for those residents. Comments received regarding meals from residents varied. One resident said that the food was “good” and there is always a choice. Another resident spoken to said that he did not like the food and there was sometimes a choice. The received resident comment card stated that they usually liked the food. Discussions with the manager and the chef confirmed that fridge and freezer temperatures were not consistently being recorded on a daily basis and cooked food is not being temperature probed. This has the potential to put residents at risk. A recommendation has been made under standard 38 to address this. Residents and staff spoken to confirmed that there is open visiting and visitors are made welcome. All of the returned relative comment cards indicated that the home usually supports people to live the life they choose. All members of staff spoken to, with the exception of 1, stated that resident choice is encouraged. Alexandra Lodge Care Centre DS0000070835.V364574.R01.S.doc Version 5.2 Page 15 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. Systems are in place to enable people to raise concerns and polices and procedures are in place to protect people from abuse. EVIDENCE: The complaint procedure was on display in the main reception area and it is on display on the back of resident’s bedroom doors. However it was noted that it contained the previous contact address and phone number of the registering body. To ensure that people have up to date, accurate information it is recommended that the procedure be updated with the current contact details of CSCI. There was a ‘complaint’ folder and although the new providers had not received any complaints the manager was aware of the need to record any complaints made, which included details of the complaint, any staff statements and copies of any correspondence and an outcome of the investigation. She stated that she has an open door policy and encourages people to raise any concerns or complaints they may have. The returned resident comment card and residents spoken to during this visit indicated that they knew who to speak to if not happy and that staff do listen and act on what you say Alexandra Lodge Care Centre DS0000070835.V364574.R01.S.doc Version 5.2 Page 16 There were policies and procedures in relation to the protection of adults from abuse and there was a copy of the Manchester ‘No Secrets’ guidance. The manager was able to clearly describe the events to be taken in the event of an allegation of abuse being made. Two allegations had very recently been made, via social services, and the manager had appropriately informed CSCI. Evidence was seen that safeguarding adults training was being provided. It is recommended that following safeguarding adults training a competency assessment is undertaken to ensure that staff have fully understood the training and know what to do in the event of an allegation of abuse being made. Alexandra Lodge Care Centre DS0000070835.V364574.R01.S.doc Version 5.2 Page 17 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 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally a clean environment is provided. EVIDENCE: During this visit a tour of the building was undertaken which included the communal areas and some residents’ bedrooms. Generally it was clean and tidy and residents spoken confirmed that was usually the case. The manager confirmed that since the new provider had taken over several bedrooms had been redecorated and new carpets had been laid. It addition handrails had been fitted to the corridors to aid some residents mobility and several carpets had been steamed cleaned. The manager stated as each bedroom becomes vacant they will be re-decorated. Alexandra Lodge Care Centre DS0000070835.V364574.R01.S.doc Version 5.2 Page 18 The garden had been made secure and new fencing had been erected. There was a patio off the dining room, with attractive patio furniture and the manager said that residents were being encouraged to make use of the garden in the nice weather. The waste bins were stored in the garden area, although the manager stated it was her intention to plant quick growing shrubs to section off the bins. It was also noted that old mattresses, beds and other waste items were stored in the garden area. The manager confirmed that she was waiting for a skip to be delivered. To ensure that residents are not placed at any unnecessary risk it is recommended that the rubbish is removed as soon as possible. During a tour of the building it was noted that several of the bedside lamps were missing the shades. The manager stated that they were in the process of trying to replace these. During a tour of the building it was noted that there was a collection of toiletries in one bathroom and the manager confirmed that some communal toiletries i.e. shampoo and bubble bath were used. It is recommended that communal toiletries are not used. In addition it was noted that gloves, aprons and wipes (Personal Protective Equipment PPE) were not stored close to toilets or bathrooms. In an attempt to minimise the risk of cross infection and possible distress to residents, it is recommended that PPE are easily accessible to staff should they need them. Alexandra Lodge Care Centre DS0000070835.V364574.R01.S.doc Version 5.2 Page 19 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 adequate. This judgement has been made using available evidence including a visit to this service. Not all staff have received appropriate training. EVIDENCE: At the time of the site visit 25 residents were accommodated and the staff rota showed that during the day there was 1 nurse and 4 care staff on duty during the day and 1 nurse and 2 carers on night duty. The comment received in the resident comment card was that there are always staff available when you need them. The manager confirmed and the AQAA stated that 14 care staff are employed and 7 have successfully completed NVQ Level 2 or above. A sample of staff files was seen to see whether the required documentation was in place and the necessary checks had been made. The files looked at were for three newly recruited members of staff. They contained the required documentation as required by Schedule 2 of The Care Homes Regulations 2001. Evidence was seen of POVA first and the manager confirmed that they only worked under supervision until a clear CRB is obtained. The manager confirmed that all original CRB documents are kept in a secure place. The Alexandra Lodge Care Centre DS0000070835.V364574.R01.S.doc Version 5.2 Page 20 manager stated that she has developed a form to record the CRB certificate number, type and date received to be kept on staff files so that the original can be destroyed in accordance with the Data Protection Act. It was recommended that the form be implemented. The manager confirmed that there was not a system in place to regularly check the NMC website for nurse exclusion or suspension from the register and there was not a system in place to check that nurses PIN numbers had not expired. To ensure that residents are not placed at unnecessary risk it is recommended that systems are implemented. Staff files contained photocopied documents, for example passports and certificates. However on the majority of photocopies there no evidence that the original documents had been seen. It is recommended that that all photocopied documents are signed and dated to indicate that the original has been seen. Evidence was seen of training events attended and there was a training plan for the next few months. Planned training included Person Centred Care Planning, Fire Safety Awareness, Moving and Handling Training, Basic Food Hygiene, Safeguarding Adults and Prevention of Incontinence. There was a training matrix and an individual staff training record, although there were not up to date. The manager confirmed that there were probably gaps in some staff training. It is recommended that a complete audit of training be undertaken to establish what training staff have received and to establish what further and/or refresher training each member of staff requires. In addition it is recommended that staff should be assessed as competent, following training, to ensure they are able to provide the support that residents require to meet their needs and maintain their health and safety. The manager stated she had obtained the Skills for Care workbook and was in the process of updating the basic induction programme currently in place. Alexandra Lodge Care Centre DS0000070835.V364574.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 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some improvements are needed to management procedures to ensure the home is run in the best interests of residents. EVIDENCE: The manager is in the process of applying for registration with CSCI. To ensure the home is managed in the best interests of the people living there the application for registration must be successfully completed. The home had recently completed an independent Quality Assurance Programme and it was the manager’s intention to work through the audit programme on an ongoing basis. In addition a resident satisfaction Alexandra Lodge Care Centre DS0000070835.V364574.R01.S.doc Version 5.2 Page 22 questionnaire had been developed and completed by every resident. If the resident was not able to complete the questionnaire assistance had been given either by their family of members of staff. The manager stated she intended to develop a questionnaire for relatives/visitors and visiting professionals in an attempt to obtain their view of the serve being delivered. Once the results for all questionnaires had been received the manager stated that she would review and collate the information received and produce an action plan. Policies and procedures were seen. However they were not dated so it was not clear when they were last reviewed and as already stated in this report the complaint procedure had not been updated as it contained out of date information. It is recommended that all policies and procedures be dated to evidence they are regularly reviewed in light of changing legislation and of good practice advice from the Department of Health. The AQAA indicated, as did the manager, that not all the required polices and procedures had been developed. For example there was no policy for managing residents finances, self-medicating, bullying, moving and handling and smoking and the use of alcohol and substances by residents, staff and visitors. It is recommended that the polices and procedures are reviewed and that all the required policies and procedures are developed and implemented. Systems were in place for recording residents’ finances and records regarding cash balances were being made on a regular basis. However there were no polices or procedures in relation to finances. A recommendation has been made under standard 33. The administrator supported a number of people to purchase personal items from local shops. Finance records were maintained and receipts were checked but there was no evidence of any record of agreement that people had given their permission for staff to make purchases on their behalf. It is recommended that written agreements be developed between people and the home setting out permission for the staff to purchase personal items for that person and the receipt be signed by the person purchasing items. The information provided in the AQAA demonstrated that the home’s maintenance certificates and records were up to date. However it was noted that some of the weekly fire safety testing had not been done since February 2008. In addition as already mentioned in this report other safety checks were not routinely carried out. This had the potential to put residents at risk and a recommendation has been made. A water treatment specialist randomly carries out water temperature testing on a 3 monthly basis. To ensure that residents are not placed at any unnecessary risk it is recommended that these tests be undertaken on a more frequent basis and that a test to ensure that the nurse call bells are in full working order is also implemented. Alexandra Lodge Care Centre DS0000070835.V364574.R01.S.doc Version 5.2 Page 23 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 3 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X X 2 Alexandra Lodge Care Centre DS0000070835.V364574.R01.S.doc Version 5.2 Page 24 N/A 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 (1) Requirement Timescale for action 16/07/08 2. OP9 13 (2) (c) To ensure that the health and welfare of residents is fully met a detailed plan of care must be implemented for each identified care need. To ensure that residents are not 16/07/08 placed at any unnecessary risk a thorough risk assessment must be undertaken prior to any resident self-medicating. 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. Refer to Standard OP7 Good Practice Recommendations 1. It is recommended that all of the residents individual plans of care be more person centred and contain more details of the specific action which needs to be taken by staff to ensure that all individual aspects of residents health, personal, social, cultural and spiritual needs are met. Alexandra Lodge Care Centre DS0000070835.V364574.R01.S.doc Version 5.2 Page 25 2. OP9 2. It is recommended that the daily reports are written in sufficient detail to accurately reflect the care given over a 24 hour period. 1. It is recommended that there is a copy of the GP’s original prescription so that the medication received can be checked against medication prescribed. 2. Original prescriptions should come directly to the home so that the manager can sign the exemption declaration on behalf of the resident before they are sent to the pharmacy for dispensing. 3. To ensure residents are receiving medication as prescribed by the GP medication should be accounted for at all times by means of an audit trail. 3. OP12 1. It is recommended that people are consulted about the social and leisure activities that they enjoy and want to participate in and clearly record this through their care plan. 2. It is recommended that a record be kept of the activities provided and who attends the activity. 4. OP16 To ensure that people have up to date accurate information it is recommended that the complaint procedure on resident’s bedroom doors be updated with the current contact address and phone of CSCI. It is recommended that following safeguarding adults training a competency assessment is undertaken to ensure that staff have fully understood the training and know what to do in the event of an allegation of abuse being made. To ensure that residents are not placed at any unnecessary risk it is recommended that the unwanted items stored in the garden area are removed as soon as possible. 1. It is recommended that communal toiletries are not used. 2. In an attempt to minimise the risk of cross infection and possible distress to residents it is recommended that Personal Protective Equipment (PPE) are easily accessible to staff should they need them. 5. OP18 6. OP19 7. OP26 Alexandra Lodge Care Centre DS0000070835.V364574.R01.S.doc Version 5.2 Page 26 8. OP29 1. It is recommended that written evidence be maintained that the original documentation has been seen, the date and by whom. 2. To ensure that residents are not placed at unnecessary risk it is recommended that systems are implemented to regularly check the NMC website for nurse exclusion or suspension from the register and a system to check that nurses PIN numbers have not expired. 1. It is recommended that a complete audit of training be undertaken to establish what training staff have received and to establish what further and/or refresher training each member of staff requires. 2. It is recommended that staff should be assessed as competent, following training, to ensure they are able to provide the support that residents require to meet their needs and maintain their health and safety. 1. It is recommended that the polices and procedures are reviewed and that all the required policies and procedures are developed and implemented, with particular reference to the procedures for managing residents money. 2. It is recommended that all policies and procedures are dated to evidence they are regularly reviewed in light of changing legislation and of good practice advice for the Department of Health. It is recommended that written agreements be developed between people and the home setting out permission for the staff to purchase personal items for that person and the receipt be signed by the person purchasing items. To minimise any potent ional risk to residents it is recommended that: • All cooked food is temperature probed prior to being served • Daily fridge and freezer temperatures are consistently recorded • Random water temperature testing and nurse call bell testing is undertaken on a monthly basis • Fire safety checks are consistently undertaken 9. OP30 10. OP33 11. OP35 12. OP38 Alexandra Lodge Care Centre DS0000070835.V364574.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Care Centre DS0000070835.V364574.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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