Inspection on 01/06/06 for Alexandra Lodge Care Home

This inspection was carried out on 1st June 2006.

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

The inspector 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 Home 30/05/07

Alexandra Lodge Care Home 30/11/05

Alexandra Lodge Care Home 16/06/05

Alexandra Lodge Care Home 17/02/05

Alexandra Lodge Care Home 04/08/04

Alexandra Lodge Care Home 31/03/04

Alexandra Lodge Care Home 21/08/03

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Alexandra Lodge Care Home 2 Lucknow Drive Mapperley Park Nottingham NG3 5EU Lead Inspector Joanna Carrington Key Unannounced Inspection 5th June 2006 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 Care Home DS0000002185.V297621.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 Home DS0000002185.V297621.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alexandra Lodge Care Home Address 2 Lucknow Drive Mapperley Park Nottingham NG3 5EU 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) 0115 9626580 0115 9626580 Mr Samuel Cofie-Cudjoe Mr Joseph Crentsil, Mrs Mercy Cofie-Cudjoe Manager post vacant Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Alexandra Lodge Care Home DS0000002185.V297621.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th November 2005 Brief Description of the Service: Alexandra Lodge is a care home registered to provide personal care and support for up to nineteen older people. The home is located in a quiet area of Mapperley Park on the outskirts of Nottingham City Centre. There are local facilities within walking distance and easy access to public transport. The home is a two-storey Grade II listed building with an added purpose built extension. The older part of the building still has many of its original features. There is one double bedroom and seventeen single bedrooms; none of the bedrooms are en-suite but assisted bathing facilities are provided. There is a stair lift available to residents who have some mobility problems. There are well maintained gardens, which residents can look out to when sitting in the large lounge. The care home fees as a Social Services funded resident are either £267 or £307 for very dependent needs or as a self-funding resident £307 per week. Alexandra Lodge Care Home DS0000002185.V297621.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over nine hours on 1st June 2006 plus a feedback visit on the 2nd June 2006. This was the homes key inspection for this inspection / financial year. All of the key standards were assessed. Judgements made in this report are not only from what was found on the day of the inspection but also based on information and evidence gathered over the year. The main method of inspection was called ‘case tracking’ which meant selected four residents and tracking the care and support they receive through checking their records, discussion with them and staff and observation of care practices. Due to the confusion and communication difficulties of residents only two were spoken with. Altogether two staff members, four health care professionals and three relatives were spoken with. A partial tour of the premises took place in order to assess environmental standards. Staff files of four staff members were checked to ensure that recruitment practices are safe and that staff are trained in meeting the needs of residents. The owners Mr and Mrs CofieCudjoe were available for discussion and feedback throughout most of the inspection. What the service does well: What has improved since the last inspection? All requirements set at the last inspection have now been met. Recruitment practices at the home now ensure the safety and protection of residents. Criminal Record Bureau and POVA first checks are obtained for all new staff, before they commence their employment. Alexandra Lodge Care Home DS0000002185.V297621.R01.S.doc Version 5.2 Page 6 The complaints procedure is now being utilised much better. Concerns are being recorded using their format, including date complaint was received and what action has been taken to resolve issue. Care plans for personal care provide more detail on how support is to be given, which is important for ensuring there is consistency with care. The preferences of individual residents must also be documented. This is particularly important where their preference may conflict with their relatives. For the promotion of residents and staff health and safety a Fire Officer has now carried out fire drills and instructions. Service user and relative surveys have been distributed and returned. The information has been reported on and made publicly available. This helps to ensure the home is run in the best interest of residents. 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. Alexandra Lodge Care Home DS0000002185.V297621.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 Home DS0000002185.V297621.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3 Quality for this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are opportunities for residents and relatives to visit and assess the suitability of the home, and each resident has a written contract when they move to the home. The current admission procedure does not, however, ensure that the home is suitable in meeting the needs of prospective residents. EVIDENCE: For all four residents that were case tracked there is a receipt held on their file, which is either signed by the resident or their relative, to say that they have received a contract and service user guide, which provides information about the services and facilities of the home. The contract covers all the necessary areas as outlined under Standard 2.2. A relative spoken with confirmed that this information had been received and a couple of relatives spoken with explained how they visited the home a few times before deciding on whether the care home was suitable. A resident that has recently moved to the home had regular afternoon visits before moving in. Three of the four residents case tracked had copies of the placing authority’s multi-disciplinary community care assessment on their files, which was used to Alexandra Lodge Care Home DS0000002185.V297621.R01.S.doc Version 5.2 Page 9 inform whether the home would be suitable in meeting their needs. A selffunding resident that has not had involvement from Social Services had a ‘preassessment’ form filled in but this was dated when they were admitted. A full pre-admission assessment must be carried out before a prospective resident moves to the home which covers all aspects of need, as identified under Standard 3 of the National Minimum Standards for Older People. This is set as a requirement. Alexandra Lodge Care Home DS0000002185.V297621.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality for this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health, personal and social care needs of residents are set out in individual care plans but improved record keeping is necessary otherwise this shortfall has the potential to place residents at risk. Residents are treated with respect and their right to privacy is upheld. EVIDENCE: There are individual plans of care that cover aspects of health, personal and social needs and these are reviewed monthly, so that any changes in need can be identified and the necessary amendments to care plans made. All of the relatives spoken with confirmed that they are involved in the care of their relative and that the owners of the home always keep them informed of any changes. A relative spoken with described his mother’s preferences with how certain elements of her personal support is given, and this was reflected accurately in her care plan. All residents have a moving and handling assessment, but more detail on individuals’ care plans is required, to ensure that the appropriate level of assistance is given and to promote residents safety. For one resident case tracked their mobility is assessed as poor, but the care plan only states, “assist Alexandra Lodge Care Home DS0000002185.V297621.R01.S.doc Version 5.2 Page 11 as necessary, using wheelchair if needed”. This does not provide specific enough guidance nor does it indicate whether this resident needs to be assisted with walking at any time. The owners must ensure that any accident that has resulted in an admission to A&E or where a medical practitioner has been called upon that this is notified to the Commission in accordance with Regulation 37 of the Care Home Regulations. This is so that the home can be effectively regulated in providing safe care. A district nurse visiting the service discussed the advice given to care staff about the treatment of one resident’s pressure sore care. This information had not been transferred onto the resident’s care plan, which is required. Daily records must improve to ensure that effective treatment and monitoring takes place. For one resident on their communication records, there is an entry on the 1st March, following a district nurse visit confirming a pressure sore due to leg positioning, then no further entry until 21st March 2006 to confirm that the leg has healed. A record of treatment and intervention is required. For another resident there was an accident record filled in but no corresponding record in the care plan. Care staff must ensure that they describe any bruising or sore areas accurately on records as some confusion was noted on one residents care plan. A district nurse reported that they have provided body maps to the home to aid in this process, and the manager showed these forms and work in progress to adapt them and add to care files. There was a record on a resident’s file of consent being obtained for the use of bed rails and of the discussion that took place with the district nurse over the risks for and against the use of them. The district nurse concerned confirmed this. In addition to this consultation process, in accordance with Health and Safety legislation a full written risk assessment should have also been undertaken, and must always be taken when bedrails are considered for any resident. Two doctors were also spoken with during the course of the inspection, both making very positive comments about the quality of care. The owners of the home were described as very caring and attentive towards residents in the home and one doctor praised the owners for their ability to recognise health problems early on for example, with chest infections, and then subsequently requesting doctors visits. Nutritional assessments are on files for residents that have dietary needs and there are ‘Care Charts’ in place for monitoring weight, general health and also to ensure hair and nails are regularly attended to. Both residents spoken with said that they are treated with dignity and respect. Staff spoken with were able to explain the important values when working with older people, particularly when assisting with personal care. Dignity and respect is covered comprehensively during the induction process. The pharmacist attended the home during the inspection and confirmed that he provides two sessions of training to staff that covers important elements of Alexandra Lodge Care Home DS0000002185.V297621.R01.S.doc Version 5.2 Page 12 medicine management. Certificates are required, to provide evidence that staff have the necessary training before administering medicines. A competency assessment is also carried out and this was seen on the staff files inspected. The medicines of the residents’ case tracked were audited. A monitored dosage system is used for most medicines. There were no errors found with the recording and administration of drugs but staff must ensure, for the purposes of auditing and to account for numbers of drugs that quantities received into the home are recorded on administration records. Alexandra Lodge Care Home DS0000002185.V297621.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality for this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Contact with family and friends including going out with family, is promoted. However, social and recreational activities organised by the home are lacking, which does not provide residents with stimulation or any choice over how they wish to occupy their time. Residents receive a wholesome balanced diet but need to be made aware of alternative meals, to ensure they have some choice. EVIDENCE: All three relatives spoken with commented on how they are always made to feel welcome when they visit the home and care staff were observed interacting with visitors. The manager discussed conflict that occasionally presents between the wishes of family and the wishes of the resident, and how when this happens it is the choice of the resident that is accommodated. This applied to some issues regarding residents’ case tracked. It is recommended that any conflict be documented clearly in care plans as a way to indicate that it is the resident’s choice that is being met. One resident continues to go to church every Sunday with a church volunteer, something that is very important to him. Residents have opportunities to go Alexandra Lodge Care Home DS0000002185.V297621.R01.S.doc Version 5.2 Page 14 out with their relatives but there are very rarely opportunities to go out on organised activities with the home, or even just to be taken by staff, to for example the local shop or post office. Staffing numbers do not allow for this, which is discussed further under the section ‘Staffing’, later on in this report. There was no schedule for activities available and no activities were provided on the day of the inspection. There is very little time for staff to spend time with residents as they were seen to be very busy. Menu records show that wholesome nutritious meals are on offer and the meal served on the day of the inspection was attractively presented and residents were seen to enjoy their meal. Residents spoken with in the dining room did not know what the meal was until it was served, so would not have not been able to choose an alternative. Records of what meals have been provided need to be more detailed, to evidence that there is variation, otherwise for example, ‘a selection of vegetables’ could mean the same vegetables are served every day. There are African-Caribbean residents living at the home and the manager reported that the nearby African-Caribbean centre provides meals to the community, which they access, for when residents wish to eat African-Caribbean meals. The manager reported that the residents have so far requested the food served for everyone. Nevertheless, this is a cultural and dietary need, and therefore residents’ wishes in relation to this need, must be documented in the relevant care plan. Alexandra Lodge Care Home DS0000002185.V297621.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality for this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements to the use of the Complaints Procedure have been made, which assures residents that their views and concerns are listened to, taken seriously and acted on. Staff are aware of their responsibilities in accordance with local Safeguarding Adults procedures, which helps to ensure that residents are protected from abuse. EVIDENCE: At the last inspection a requirement to use the Complaints Procedure for responding to concerns expressed was set. Since the last inspection two concerns have been recorded in accordance with their Complaints Procedure, including the timescale for responding to complaint and the action taken. All three relatives spoken with said that they understand the Complaints Procedure and always feel comfortable sharing their concerns with the owners. This record shows that these concerns have been responded to appropriately. This requirement has therefore now been met. Staff files show that Adult Abuse training has been accessed for staff, including, as recommended at the last inspection, training provided by the Nottinghamshire Adult Protection Unit. Staff spoken with demonstrated an understanding of their responsibilities for whistle-blowing, in accordance with the Nottinghamshire Committee for the Protection of Vulnerable Adults (NCPVA) Policy and Procedures. Since the last inspection there has been an NCPVA investigation, following a referral to Social Services regarding bruising to a resident. An outcome of this Alexandra Lodge Care Home DS0000002185.V297621.R01.S.doc Version 5.2 Page 16 investigation has not yet been formalised but findings point towards issues around staff training as opposed to abuse. (Please refer to the section on Staffing later on in this report.) Agencies that do pass on concerns regarding the protection of vulnerable adults must ensure, in accordance with procedures that they are open and communicate their concerns with the home. At the time this was being followed up, which included a visit by Social Services, the owners were unaware that the procedures had been invoked. Alexandra Lodge Care Home DS0000002185.V297621.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24 and 26 Quality for this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in an environment that is safe, well maintained and clean and hygienic throughout. Bedrooms are personalised with residents’ own belongings and possessions. EVIDENCE: On a tour of the premises it was evident that the home is kept clean and hygienic. The home smells fresh. There are good laundry facilities available that are sited away from any areas that prepare or serve food and washing machines have a sluicing facility on them. All parts of the home are pleasantly decorated and there is a traditional and homely feel throughout. Bedrooms seen are personalised with individuals’ personal items such as pictures and belongings. Prospective residents can bring their own furniture if they choose to but all the rooms seen contained furniture provided by the home. The beds provided are very low, unless they have specialised mattresses on. For residents that require assistance with moving / transferring from the bed it is recommended that their moving and handling Alexandra Lodge Care Home DS0000002185.V297621.R01.S.doc Version 5.2 Page 18 assessments are reviewed to ensure that the height is suitable in respect of residents retaining their independence for as long as they can and that staff can provide assistance safely. Alexandra Lodge Care Home DS0000002185.V297621.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality for this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements made to recruitment procedures, now ensure that residents are protected. Staffing levels and gaps in training do not ensure that the needs of residents are being adequately or safely met. EVIDENCE: Four staff files were randomly selected for inspection. All staff had two written references, at least one being from a previous employer, and a satisfactory criminal record bureau check and POVA First check. There was evidence to indicate that new staff members do not commence their employment at least until the return of a POVA First check. This is a significant improvement since the last two inspections. The Commissioning team for Nottingham City have recently visited the home to carry out an extensive audit on staffing, which as a result the owners have been required, as part of their contract, to arrange up to date health and safety training and National Vocational (NVQ) level 2 for care staff. There is currently no staff employed at the home trained to NVQ Level 2. The target of at least 50 of care staff qualified to NVQ 2 should have been achieved by now therefore this is set as a requirement. It is acknowledged that the owners are taking this very seriously and written evidence was seen to indicate that work is in progress by attending Skills for Care meetings and sourcing NVQ providers. Alexandra Lodge Care Home DS0000002185.V297621.R01.S.doc Version 5.2 Page 20 Four staff files were examined as part of this inspection. All four staff members have now attended accredited Moving and Handling training, and evidence was seen that all staff members have either recently attended a course or are booked to attend one very shortly. For staff that do not have first aid training, booking forms and organised dates were seen for their due attendance. Two of the four staff members selected do not have Food Hygiene and Infection Control training, which are also required. The catering and domestic arrangements are more than adequately served but the levels of care staff is of concern. Most shifts are run with two staff members. This is less than a ratio of one staff member to nine residents, when the home is fully occupied. This is not an acceptable or safe level, particularly as there are an increasing number of residents with deteriorating mobility, confusion and very dependent needs. In the communal lounge a resident was observed calling for assistance for at least ten minutes. There has been a high level of falls and injuries in the home, which are not witnessed. There are residents that require regular support with moving and repositioning for the prevention and treatment of pressure sores, which, with the current level of staffing, it is questionable that this need can be adequately met. Staffing arrangements must be reviewed as a matter of urgency, to ensure that numbers are appropriate to meeting the needs of residents. Given that there was evidence available to demonstrate that action is already being taken to address some of the above issues then the outcome area has been assessed as adequate, despite these issues being very serious and potentially impacting on the safety and welfare of residents. Alexandra Lodge Care Home DS0000002185.V297621.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality for this outcome area is good. This judgement has been made using available evidence including a site visit to the home. Progress has been made on implementing quality monitoring to ensure that the home is run in the best interest of residents. Improvements to fire safety practice now ensure the health, safety and welfare of residents is promoted and protected. EVIDENCE: The home lost its previous manager in December last year. One of the owners, Mercy Cofie-Cudjoe is applying to be registered as manager. Mercy is a qualified nurse and has always been involved in the day to day running of the home. Since the last inspection quality assurance surveys have been distributed to both residents and relatives, covering all aspects of care such as cleanliness of home, meals, friendliness of staff and overall impression. The responses have been collected and a report is available to visitors and residents of the home. Alexandra Lodge Care Home DS0000002185.V297621.R01.S.doc Version 5.2 Page 22 This report was also submitted to the Commission. The owners must ensure that this exercise is undertaken on a regular basis along with quality audits of the home. A resident spoken with said he has access to money whenever he requires it. Relatives provide regular sums of money, which is then held securely in the office in a separate wallet for each resident. Whenever residents’ request money and when an item has been purchased all receipts are kept and all transactions are recorded. The Nottinghamshire Fire Service has recently visited the home. All required fire precautions are undertaken, which includes fire alarm tests and servicing of systems and equipment, regularly fire instructions and drills. The requirement set at the previous inspection has therefore been met. There are the necessary measures in place for the prevention of Legionella and the servicing of equipment and gas and electrical systems are up to date, which are all important for promoting and protecting the health and safety of residents. Alexandra Lodge Care Home DS0000002185.V297621.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 3 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 1 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 1 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X 3 X X 3 X 3 STAFFING Standard No Score 27 1 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Alexandra Lodge Care Home DS0000002185.V297621.R01.S.doc Version 5.2 Page 24 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. 1. Standard OP3 Regulation 14 Requirement Ensure a full assessment is undertaken, by an appropriately qualified person, as far as it shall be practicable to do so, before it is confirmed that home is suitable in meeting their needs and subsequently move to the home. Promote and make proper provision for the health of all service users- this refers to: 1. Ensuring care plans are detailed and correlate with other assessment records. 2. Ensuring that accident records are crossreferenced with entries in communication records and care plans. 3. Keeping a central record of all accidents occurring in the home for the purposes of health and safety monitoring and review. 4. In accordance with Schedule 3 of the Care Home Regulations ensure that there is a record of incidence of pressure sores and of all treatment provided to the service user. DS0000002185.V297621.R01.S.doc Timescale for action 01/07/06 2. OP8 12, 37 30/07/06 Alexandra Lodge Care Home Version 5.2 Page 25 3. OP8 13 4. OP12 16 7. OP30 18 8. OP33 18 5. Ensure all accidents where a medical practitioner is called upon are notified to the Commission. Ensure individual risk assessments are carried out for the appropriate and safe use of bedrails. Consult service users about the programme of activities arranged by or on behalf of the care home, provide facilities for recreation, and make arrangements to enable service users to engage in local and community activities, having regard to the needs of service users. Ensure staff receive all mandatory and fresher training. This includes Food Hygiene, Infection Control, Moving and Handling and First Aid. Review staffing arrangements and ensure staffing levels are appropriate to adequately and safely meeting the needs of residents. 30/06/06 30/08/06 30/09/06 30/07/06 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. 3. Refer to Standard OP9 OP12 OP15 Good Practice Recommendations Ensure that quantities of medication received into the home are recorded on Medication Administration Records and chase up with Pharmacist certificates for staff training. Introduce ways such as resident meetings, to involve residents in decision making over activities and other aspects of the running of the home. Document the wishes of residents regarding their cultural and racial needs in relevant care plans. DS0000002185.V297621.R01.S.doc Version 5.2 Page 26 Alexandra Lodge Care Home 4. 5. 6. OP15 OP24 OP28 Ensure there is a record of the food provided for service users in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory. Assess the height of residents’ beds for its suitability in terms of their independence and safe assistance with moving and handling. Work towards achieving 50 of the staff team qualified to NVQ level 2. Alexandra Lodge Care Home DS0000002185.V297621.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 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. 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