Inspection on 02/05/06 for Alice Lodge

This inspection was carried out on 2nd May 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Alice Lodge 02/05/08

Alice Lodge 22/11/07

Alice Lodge 15/12/05

Alice Lodge 31/01/05

Alice Lodge 06/12/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Alice Lodge 40 Brighton Road Purley Surrey CR8 2LG Lead Inspector David Halliwell Key Unannounced Inspection 2nd May 2006 09:30 Alice Lodge DS0000025748.V292015.R01.S.doc Version 5.1 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 Alice Lodge DS0000025748.V292015.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Alice Lodge DS0000025748.V292015.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Alice Lodge Address 40 Brighton Road Purley Surrey CR8 2LG 020 8668 8448 020 8763 0706 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) Ms Alice Manteaw-Dankyi Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16) of places Alice Lodge DS0000025748.V292015.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th December 2005 Brief Description of the Service: Alice Lodge is one of a number of care homes owned by this proprietor Mrs Dankyi. This particular home has recently been refurbished throughout. The home caters for adults with mental illness. There are 14 bedrooms, some are shared and some are ensuite. There is a large open-plan lounge and a separate dining room. The home has the usual facilities for such a home including kitchen, small laundry, office bathrooms and toilets. The home has a smoking room and garden to the rear and parking to the front. Alice Lodge provides a rehabilitation and accommodation resource for people with mental illness. Alice Lodge DS0000025748.V292015.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection on 3rd and 4th April. All the key standards were inspected over the course of this inspection. Staff and service users were interviewed, both service user and staff files were inspected and a tour of the home was undertaken together with the Deputy Manager. A number of service users were spoken with at this time in addition to the more formal interviews. What the service does well: What has improved since the last inspection? What they could do better: Alice Lodge DS0000025748.V292015.R01.S.doc Version 5.1 Page 6 Some of the previous requirements are still outstanding from the last inspection and these need to be met without further delay. This is important because they impact on the success of the home in meeting the National Minimum Standards and have indirectly caused other new requirements to become necessary which are now highlighted in this report. The registration of a new manager would greatly assist in the task to address some of the staffing issues that have arisen and other problems to do with the conduct and general management of this home including record keeping. 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. Alice Lodge DS0000025748.V292015.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Alice Lodge DS0000025748.V292015.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 & 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users can feel confident that their needs will be assessed at Alice Lodge and that their aspirations will be taken into account by staff. Service users do not routinely receive a written contract, a service users guide or a statement of terms and conditions within the home although there are copies of the latter two documents available for all residents to look at if they wish. EVIDENCE: The Inspector reviewed 4 of the service users files held at Alice Lodge and found that pre-admission assessments of needs were undertaken in all cases. 2 service users were interviewed for the inspection and various other residents were spoken to by the inspector and they all confirmed that they felt their needs are assessed and that their wishes are taken into consideration in the care planning process. 2 members of the staff group were also interviewed by the Inspector. They identified their key worker responsibilities for 2 – 3 residents each within the home. They confirmed needs assessments are undertaken for all service users and that they are reviewed regularly and care plans adjusted to take account of changing needs. Alice Lodge DS0000025748.V292015.R01.S.doc Version 5.1 Page 9 All of the above information means that the needs of the service users are assessed as a part of the overall care planning process used within the home. The file review however revealed that no service user guides or statements of purpose had been issued individually to residents and this was confirmed by residents that the Inspector spoke to. The Deputy Manager told the Inspector that a copy of both these documents is available to service users to read, however the Inspector found that some residents had not seen either documents. This would indicate the lack of accessibility residents have to see and to read them. It also means potentially that residents are not fully aware of all the information about the home and about the contract they have with the home and services that they should be receiving. It is a requirement that each resident be issued with an updated, revised Service User Guide and a written contract which outlines the terms and conditions of the home. Alice Lodge DS0000025748.V292015.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Assessments of needs and care plans are being reviewed at least every six months involving all the key people involved with the service user. The service users are also enabled to make decisions about their lives with assistance as needed. Arrangements are in place to assist service users to take ‘responsible’ risks as part of their structured rehabilitative programme. However this needs to be developed further to promote their greater independence, choice and rehabilitation. EVIDENCE: The inspection of service user files revealed that the assessments of needs and care plans are formally reviewed in writing by the staff within the home on a fairly regular basis (3 – 4 monthly) in each case seen by the Inspector. Reviews involving the referring agencies and other professionals were also seen to be undertaken at least once per year but usually every six months. Alice Lodge DS0000025748.V292015.R01.S.doc Version 5.1 Page 11 Whilst this means that some of each service users changing needs and personal goals are being reviewed in their individual care plans the regularity and the quality of these reviews needs building upon. It is recommended that the care planning process should consider all of the service users needs and focus on care plan objectives that will enable rehabilitation to more independent accommodation if it is indeed within the potential of that service user. The subsequent revision and adjustment of care plan objectives in reviews will eased if care plan objectives are specific, measurable, appropriate, realistic and be timely for each service user. Residents spoken to by the Inspector confirmed their involvement in the care planning process and that on the whole they do have their wishes listened to and addressed and that they have choices and are able to make decisions in the way that their needs may be met. Regular risk assessments were seen on each file reviewed by the Inspector and it seemed apparent from the files seen that service users are supported to take some risks in order to try and achieve a more independent lifestyle. Recommendation: To develop care planning in the way described above in order to attain the goal of rehabilitation where ever possible for each service user. Alice Lodge DS0000025748.V292015.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Opportunities for the personal development of service users could be expanded if care plans included more detailed programmes for developing independent living skills, for instance shopping, budgeting, cooking, dealing with stress and conflict and social skills for improving communication and social interaction. Service users are able to take part in appropriate leisure and other activities some of which are part of the local community. Service users are also encouraged to maintain appropriate relationships. There is strong emphasis in the home on respecting resident’s rights in all aspects of daily living. The menu is varied, offers choice and provides a healthy diet. Alice Lodge DS0000025748.V292015.R01.S.doc Version 5.1 Page 13 EVIDENCE: The Deputy Manager informed the Inspector that service users do go on holidays with the unit and some also go on holiday with friends and family. This was evidenced in the daily records held on file for service users. Interviews with staff and service users indicated that residents are supported by their key workers to maintain their friendships outside of the unit and to take part in local community events and outings. Where appropriate key workers sometimes escort service users to go shopping and to use the local leisure facilities. Service users often arrange their own activities and contacts with the local community and develop such relationships as their mental health will allow. The level of these contacts and activities however is often quite restricted by the higher levels of mental health needs of the residents. The Deputy Manager informed the Inspector that service users receive their mail unopened and staff were seen to interact with the residents in a friendly and respectful manner. Service users do participate in household chores and were seen by the Inspector to be appropriately supported by staff in preparing food snacks at the time of this inspection visit. Service users can and often do make full use of local public transport facilities in order to get out and about and to see friends and family. Residents interviewed felt that transport facilities were good. Opportunities for the personal development of service users could be expanded and it is recommended that care plans include more detailed objectives for developing independent living skills, for instance shopping, budgeting, cooking, dealing with stress and conflict and social skills for improving communication and social interaction. Policies seen by the Inspector to be established within the unit ensure that service users rights to privacy, respect and dignity are respected. Residents who were interviewed also confirmed that they felt staff respected these rights. The Deputy Manager informed the Inspector that residents do not have a key to the front door but that it is always open to allow access. Residents have keys to their own bedrooms, their mail is unopened, their preferred form of address is used by staff and staff do knock on their doors before entering. The Inspector observed staff to be interacting with residents in a friendly and respectful manner. The conservatory is allocated for smokers and there are appropriate policies regarding drug and alcohol taking on the premises. Alice Lodge DS0000025748.V292015.R01.S.doc Version 5.1 Page 14 With regards to meals and meal times there is a planned and varied menu which residents told the Inspector they enjoyed. The Inspector saw suitably planned menus for 3 weeks ahead. Specific needs are catered for and alternative choices are provided. However it was reported that not enough fresh fruit is available for residents and the Inspector found this was supported by a lack of a fruit bowl or fruit available during the day. It is recommended that a selection of seasonally fresh fruit is made available for residents during the day. Alice Lodge DS0000025748.V292015.R01.S.doc Version 5.1 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported appropriately by care staff and the service users confirmed that they can ask for help and get support in a manner that suites them. Service users’ physical needs are being met to ensure their well being however more work is required in identifying service users emotional needs. A range of support mechanisms are in place to support service users in taking their medication - this enables service users to either manage their own medicines in a safe manner or receive support from staff. EVIDENCE: Several of the service users told the Inspector they could choose what time they got up and when they went to bed. They also told the Inspector that they do receive the support they need in a helpful way. The homes incident book revealed that there had been 3 incidents since the last inspection but that these had all been dealt with appropriately at the time. Alice Lodge DS0000025748.V292015.R01.S.doc Version 5.1 Page 16 A check of the homes complaints book revealed that no complaints had been made since the last inspection. This may be a sign that service users do not know how to complain. Provision to each resident of a Service Users Guide (which includes details of the complaint process) will help address this issue. Service users physical needs are identified in the care plans of those residents files inspected and are reviewed. The identification of residents emotional needs were less evident in those care plans seen by the Inspector. This indicates that while service users physical needs are being met to ensure their well being more could be done to meet the emotional needs of the residents. This is linked to the recommendation made in the earlier standards section dealing with “Individual needs and choices”. It is recommended that in each assessment and review a service users emotional needs are considered and recorded on the care plans. No recording errors were noted on individual service user’s medication administration sheets. Service users are supported to take their own medication wherever possible in a safe manner. Where support is needed it is provided appropriately. Alice Lodge DS0000025748.V292015.R01.S.doc Version 5.1 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place for service users and their representatives to either complain or compliment the service and suitable procedures are in place to deal with any complaints that may arise. This ensures that service users’ views are taken into account. Whilst policies and procedures to protect vulnerable service users are in place and staff interviewed were aware of them, staff training in this area has not been evidenced and this is now a requirement for the year ahead. EVIDENCE: A check of the homes complaints book revealed that no complaints had been made since the last inspection and no complaints arose from service users or staff during the course of the inspection. This has been addressed in the previous section and reference made to the Service Users Guide. Service users were complimentary about the home, the premises and the staff team. Staff interviewed indicated their awareness of their responsibility to protect service users from abuse and to report untoward incidents to the correct authorities. However no evidence could be found at the time of the inspection that staff had received specific training on the Protection of Vulnerable Adults from Abuse and it is a requirement now that the entire staff group receive this training over the coming year. Alice Lodge DS0000025748.V292015.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Alice Lodge has been completely refurbished throughout with residents input in terms of choice of the redecorations in their bedrooms and communal areas. It is a safe and homely environment for service users and it is kept in a clean and tidy condition for the benefit of service users. EVIDENCE: The Inspector was accompanied by the Deputy Manager for a tour of the premises that included all the communal areas and some of the service users bedrooms. The standard of the refurbishment is good and the home seemed to be in very good repair. The residents all told the Inspector how they liked what had been done and that their bedrooms are as they wish them to be and that they feel at home in Alice Lodge. They confirmed that they have been able to choose their decorations. All areas were odour free, clean and tidy. Alice Lodge DS0000025748.V292015.R01.S.doc Version 5.1 Page 19 Only very minor work remains to be completed which was reported in the last inspection report. That is making good the door frame of the fire exit adjacent to the front door. Alice Lodge DS0000025748.V292015.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff team do hold a variety of qualifications which should ensure that service users can be supported appropriately. The recruitment policy and practices have improved so the wellbeing and interests of service users are being protected. There is however a lot of work still to be done to improve staffing records, staff supervision and training. EVIDENCE: The Inspector reviewed a number of staff files as a part of this inspection. The induction procedures for new staff were seen to be very comprehensive and cover key areas of the work new staff will need to know about in order to carry out their duties and responsibilities. However staffing files reviewed by the Inspector revealed that records pertaining to staff supervision were not being completed appropriately. Supervision records of these meetings were in some instances unsigned and undated and there seemed to be numerous photocopies of a single supervision session unnamed, not dated and not signed. The impression given was that this could be used as a record later for other staff. This would indicate a rather mechanical approach to the supervision process rather than the required Alice Lodge DS0000025748.V292015.R01.S.doc Version 5.1 Page 21 process which whilst there may be common areas to be approached in every supervision the actual details of discussions should be individual to the staff member being supervised. 4 staff files seen by the Inspector indicated irregular and sporadic patterns of supervision. The standard requires supervision for each staff member to be at least once every two months. It is also essential that the monitoring and review in supervision of the progress of key workers with their residents in helping them to achieve their care plan objectives is carried out and was not evident in the records. Staff who were interviewed did confirm that they receive training support and supervision and that they are aware of their responsibilities to support and protect services users. However it is required that the Manager review the whole process of staff supervision to ensure it is “fit for purpose” and that proper and appropriate records are held on file. This should assist in the more effective delivery of appropriate care and potential to achieve rehabilitation. Records indicate that staff have undergone appropriate police (CRB) checks, references and health checks, there were however some gaps on file records for identity checks and identity photographs. It is a requirement that staff records have all the proper identity checks for all staff as set out in Schedule 4 Regulation 17(2). Records held on staff files relating to N.V.Q training were incomplete. The Deputy Manager informed the Inspector that 3 staff are doing their N.V.Q level 2 qualifications; 1 member of staff is currently undertaking an N.V.Q level 3 training and 1 member of staff has completed N.V.Q. level 4 training. Whilst this information is inconsistent with previously supplied information it means that the Standard 32.6 is not being met. This requires 50 of all staff to hold an NVQ 2 by April 2005. It is clear that appropriate records for NVQ training are not being held on staff files and so it is difficult to get a clear picture of staff qualifications and it is recommended that this be addressed without delay. Alice Lodge DS0000025748.V292015.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There remains a lot of work to be undertaken on achieving the above minimum standards of service before it is possible with confidence to say that service users benefit from a well run home. Without any Quality Assurance system currently in place service users cannot be confident that their views underpin all self monitoring, review and development by the home. Service users rights are being safeguarded by the home’s policies however the home’s record keeping needs improvements to be made as outlined below. Service users can remain confident that their health, safety and welfare are being protected. Alice Lodge DS0000025748.V292015.R01.S.doc Version 5.1 Page 23 EVIDENCE: Since the last inspection in December 2005 the Manager has not been registered and has not yet put in the application for registration with CSCI. A requirement was made in the last inspection report for this registration to be processed without delay and by the 30/4/06. This has not been achieved. The Proprietor assured the Inspector that this is being addressed now as a priority and a resolution will be found very soon. This means that there is still not a “registered manager” for the home and this remains a requirement in this Inspection Report. A sample of records were checked including kitchen, accident, client’s financial accounts and in general were found to be satisfactory. A recent Environmental Health check carried out in January 2006 requires work to be completed by the Management of the home on implementing food safety standards and undertaking risk assessments. A comprehensive work book has been supplied by the Food Standards Agency called “Safer food, better business” which will assist in this process. It is recommended that this process be initiated as soon as possible and carried out within the timescale as set out by Environmental Health. A Fire and Security check carried out in December 2005 found all the fire equipment to be satisfactory. An annual check by the LFEPA is now due and the Deputy Manager informed the Inspector that the LFEPA had been contacted at the time of the inspection requesting they undertake such a check. The results of this will be reviewed at the next inspection. The Inspector asked the Proprietor and the Deputy Manager about a quality assurance process for the unit. It appears that the only feedback currently being gained from residents is verbal. There is no structured process that seeks the views of service users, friends and families, referring and other professionals to measure the success of the unit in achieving the aims, objectives and the statement of purpose of the home. A good deal of discussion was had with the Proprietor and the Deputy Manager about developing an appropriate quality assurance process for the unit along the lines as set out in Standard 39 of the National Minimum Standards. The feedback gained from such a process should be used to inform an annual development plan for the home based on a systematic cycle of planning – action and review, reflecting aims and outcomes for service users. The feedback results should be published and made available to service users, the CSCI and any other interested parties such as referring agencies. This is now a requirement for the unit to develop an appropriate quality assurance process as referred to above. Alice Lodge DS0000025748.V292015.R01.S.doc Version 5.1 Page 24 Alice Lodge DS0000025748.V292015.R01.S.doc Version 5.1 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 X 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 2 12 X 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 1 X 1 X 2 3 X Alice Lodge DS0000025748.V292015.R01.S.doc Version 5.1 Page 26 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA37 Regulation 8(1) Requirement Manager: The provider must make application to register a manager for this home without unreasonable delay. Records: All the statutory records listed in the Schedules 1 to 4 must be maintained up to date, accurate and available for inspection by Commission for Social Care Inspection. That each resident be issued with an updated, revised Service User Guide and a written contract which outlines the terms and conditions of the home. Appropriate records for NVQ training must be held on staff files. Staff records should contain all proper identity checks. The Manager must review the process of supervision to ensure it is “fit for purpose” and that appropriate records are held on file. Staff should receive training on the protection of vulnerable adults. The development of a quality DS0000025748.V292015.R01.S.doc Timescale for action 30/08/06 2. YA41 17 30/06/06 3. YA5YA5 5 30/06/06 3. 4. 5. YA35YA35 YA34YA34 YA36YA36 18 Schedule 4,17.2 18 30/06/06 30/06/06 30/06/06 6. 7. YA23YA23 YA39YA39 18.c.i 18.c.i 31/10/06 01/12/06 Page 27 Alice Lodge Version 5.1 assurance process for the home. 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 YA3 Good Practice Recommendations Diversity and Equality: whilst the home has staff from a range of backgrounds it is suggested that guidance is provided on specific cultural expectations so that the home can make suitable arrangements to ensure the home is run with due regard to the sex, religious persuasion, racial origin, and cultural and linguistic background and any disability of service users. Staff qualifications: Whilst recognising that staff have a variety of formal qualifications relevant to their role, it remains a recommendation that the home ensure that suitably qualified staff are available having regard to the size of the home and the number of service users; the NMS indicate 50 of staff with suitable NVQ qualifications are needed. To develop care planning in order to attain the goal of rehabilitation where ever possible for each service user. That care plans include more detailed objectives for developing independent living skills. That a selection of seasonally fresh fruit is made available for residents during the day. That in each assessment and review a service users emotional needs are considered and recorded on the care plans. The Food Standards Agency “Safer food, better business” be initiated as soon as possible and carried out within the timescale as set out by Environmental Health. 2. YA32 5. 6. 7. 8. 9. YA6YA6 YA11 YA11 YA17YA17 YA19YA19 YA42YA42 Alice Lodge DS0000025748.V292015.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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. Extracts may not be used or reproduced without the express permission of CSCI Alice Lodge DS0000025748.V292015.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!