Inspection on 04/10/07 for Princess Alexandra House

This inspection was carried out on 4th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Princess Alexandra House 20/12/06

Princess Alexandra House 10/11/05

Princess Alexandra House 25/05/05

Princess Alexandra House 10/12/04

Princess Alexandra House 23/09/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Princess Alexandra House 34 Preston Park Avenue Brighton East Sussex BN1 6HG Lead Inspector Jennie Williams Key Unannounced Inspection 4th October 2007 10:30 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 Princess Alexandra House DS0000014226.V346965.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. Princess Alexandra House DS0000014226.V346965.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Princess Alexandra House Address 34 Preston Park Avenue Brighton East Sussex BN1 6HG 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) 01273 565691 www.princessalexandrahouse.co.uk Mrs Carole Franklin Mrs Carole Franklin Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Princess Alexandra House DS0000014226.V346965.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is eighteen (18) Service users must be older people aged sixty-five (65) years or over on admission 20th December 2006 Date of last inspection Brief Description of the Service: Princess Alexandra House is a care home registered for eighteen (18) places for people over sixty-five (65) years of age. No nursing care is provided at this home. District nurses will provide nursing input for those residents requiring this. Most residents currently residing at the home remain fairly independent. Princess Alexandra House is located in a quiet residential area of Preston Park. There is limited parking at the home, however free unrestricted street parking is available. There are some local amenities in the area and there is nearby access to public transport. Residents’ bedrooms are located over three floors. There is a passenger shaft lift that accesses all floors. One room is located on a mezzanine level and a stair lift is available, if needed, to assist this individual to access the main floor. There are twelve single rooms of which nine are provided with en suite facilities. Three rooms are for double occupancy, however these rooms are used as single rooms unless two people choose to share a room eg. couples. Double rooms are provided with en suite facilities. Two of the double rooms have step in showers in the en suite, however these are not in use due to the accessibility for the residents currently residing in the rooms. For the single rooms without en suite facilities, no more than two rooms share the nearby toilet facilities. There are suitable numbers of toilet and bathing facilities located throughout the home to meet the needs of residents. There is a goodsized dining room and lounge room. Residents have access to a wellmaintained garden area. Residents need to be able to mobilise on an incline to access the garden summerhouse. Weekly fees range from £368 to £550 per week. There are additional fees; hairdressing, chiropody, newspapers/magazines and personal toiletries (at cost). This information was provided to the CSCI on the 04 October 2007. Prospective residents find out about the home through social services referrals, word of mouth and from themselves/relatives living in the area. Princess Alexandra House DS0000014226.V346965.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. It should be noted that following recent CSCI consultation, it was identified that service users prefer to be called people who use services. It was confirmed that the home uses the term residents. For the purpose of this report, people who use the service will be referred to as residents. This unannounced site visit took place over six hours on the 04 October 2007. Evidence obtained at this site visit and information that the CSCI have received since the last inspection forms this key inspection report. Eight residents were spoken with as group in the lounge room. All 13 residents eating in the dining room at lunchtime were met and advised to let the Inspector know if they wished to speak with her individually. Two care plans were viewed and specific areas of care were looked at in a further two care plans. Five staff were spoken with throughout the site visit, this included; three carers, the deputy manager and the Registered Provider/Manager. Four staff files were viewed along with the individuals training records. One visitor was spoken with at the site visit. A tour of the environment was undertaken and some individual rooms were viewed, with the resident’s permission. Medication procedures were inspected. Recent results of the quality assurance surveys were viewed. The home had received no complaints, so records were not viewed. The procedure for dealing with residents’ personal allowances was discussed. An Annual Quality Assurance Assessment (AQAA) was sent to the home prior to the site visit. This was to obtain information about the establishment to assist CSCI in the inspection process. Health and safety records were not viewed as this information has been provided in the AQAA. There were fourteen residents residing at the home on the day of the site visit. What the service does well: The home has information available for prospective residents/representatives on the facilities and services provided to make an informed decision if their needs can be met at the home. Prospective residents are provided with opportunities to visit the home prior to moving in to ensure the home will meet their needs. Residents were complimentary about the staff working at the home and felt that their personal care needs were being met. Residents felt that their privacy and dignity are respected. Routines of daily living are to the individual’s choice and preference. Activities are provided at the home that is Princess Alexandra House DS0000014226.V346965.R01.S.doc Version 5.2 Page 6 within an individual’s choice, interest and ability. Residents commented that they couldn’t find a better place to live. Visitors are welcomed at the home and residents may receive visitors in private. Residents were complimentary about the provision of food at the home and confirmed that an alternative is provided if an individual does not like the main meal on offer. Residents feel comfortable to make complaints, reassuring them that they are being listened to. Residents found their rooms to be comfortable and the home was clean and free from offensive odours. Staff receive training appropriate to their roles to ensure their safety and that residents needs continue to be met. Staff were observed to have a good professional rapport with residents and were heard to be calling them by the preferred term. Some of the comments received from residents were the staff are “wonderful” and “marvellous”. Residents and staff felt that it is an ‘extended family’ atmosphere within the home. Residents and staff benefit from supportive and approachable management within the home. The quality assurance and quality monitoring system implemented ensures that the home is run in the best interest of service users. What has improved since the last inspection? What they could do better: There have been no requirements made at this inspection. Any minor shortfalls noted have been highlighted throughout the report of which the Registered Provider/Manager is already addressing or will address. Princess Alexandra House DS0000014226.V346965.R01.S.doc Version 5.2 Page 7 The AQAA received from the home evidences that the home is working to improve the quality of the service provided at Princess Alexandra House. It provides CSCI with information on areas that have been improved in the last twelve months and what their plans for improvement are within the next twelve months. The AQAA identifies that there was nothing that they could do better in some areas. On discussion with the Registered Provider/Manager it was confirmed that when anything is identified, as needed improving, it is addressed immediately. 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. Princess Alexandra House DS0000014226.V346965.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Princess Alexandra House DS0000014226.V346965.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, 5 & 6. People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has information available for prospective residents/representatives on the facilities and services provided to make an informed decision if their needs can be met at the home. The pre admission process ensures that only residents whose needs can be met at the home are admitted. EVIDENCE: There is a Statement of Purpose available upon request at the home that provides prospective residents/representatives information about the care and facilities provided at the home. A visitor and residents spoken with confirmed that they received information about the home. Residents know where to locate the recent CSCI inspection reports if they wish to read them. Princess Alexandra House DS0000014226.V346965.R01.S.doc Version 5.2 Page 10 The Registered Provider/Manager or deputy manager undertakes the assessments of all prospective residents prior to being admitted to the home. Information from other health professionals is obtained wherever possible. Prospective residents are able to visit the home prior to being admitted if they wish. Residents spoken with confirmed that they or a relative had visited the home prior to moving in. One resident commented that she came for a trial visit and decided to stay. The resident informed the Inspector that ‘staff make the moving into the home easier without them even realising they are doing this.’ It was noted that there are checklists in place for newly admitted residents. This ensures that rooms are prepared, what actions are required by staff on the day of arrival etc. This assists in ensuring that the admission process goes smoothly for the new person. A written statement viewed on the homes’ quality assurance surveys stated, “My stay here was meant to be temporary, but was so happy I decided to stay and am happy and comfortable with care I am receiving.” The Registered Provider/Manager confirmed that there was no one residing at the home from any minor ethnic/religious groups with any special cultural or religious needs. The new pre admission assessment form requests information if the home needs to be aware of any of these specialists needs. Staff spoken with confirmed that they felt all residents were appropriately placed and all their needs were being met. All residents spoken with confirmed that their needs were being met at the home. It was confirmed that the Registered Provider/Manager takes appropriate action if someone’s needs change and can no longer be met at the home. The home does not have dedicated accommodation to provide intermediate care, however respite care is provided if there is a spare room available. The home does not take emergency admissions. Princess Alexandra House DS0000014226.V346965.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ needs are being met with the information provided in the care plans on the assessed needs of individuals and residents/representatives are provided with an opportunity to be involved in the reviewing process to ensure choice and preference is taken into account. Residents are safeguarded by the medication procedures in place. Residents’ privacy and dignity are respected. EVIDENCE: There is a key worker system at the home and both staff and residents were clear on this process. Two care plans were viewed that provided guidance to staff on the assessed needs. Specialist needs identified at the site visit were reflected in the care plans. There was evidence that care plans are being reviewed on a monthly basis. Residents spoken with confirmed that staff discuss their care with them and are involved in the monthly reviews. Princess Alexandra House DS0000014226.V346965.R01.S.doc Version 5.2 Page 12 An initial care plan is drawn up using information obtained at the pre admission assessment and with the resident’s involvement. Reviews are done at the end of every month and any changes that occur between the reviews are recorded in the communication book and refers the reader to the care plan. These changes are written in an individuals ‘daily notes’. The home calls all the information pertaining to an individual the care plan. The initial care plan assessment is not amended to reflect changes. A discussion was had with the Registered Provider/Manager and two staff members that there are a lot of places to look to obtain information about the current needs for an individual. Discussions were had on how to make the system easier to access the information. The home will discuss procedures as a team and decide if changes could be made to make the process easier. This is not reflected as a shortfall as the system in place works well within the home and all assessed needs are being met. Residents spoken with confirmed that they are able to access their GP when needed and are provided with sight and hearing tests when required. It was confirmed that specialist advice is sought when needed. There was evidence on reading daily notes about individuals that appropriate action is taken if there are changes within an individual. District nurses were inputting into the care of one resident. The deputy manager informed the Inspector that she has already organised a speech therapist, chiropodist and registration with a GP for a newly admitted resident. Communion has also been arranged. The medication procedures for recording and storage have been changed since the last inspection and there was evidence that the home had worked hard to improve this area of care. Medication Administration Records (MAR) charts viewed demonstrated that medicines are being signed for at the time of administration. There were no controlled drugs being kept at the home at the time of the site visit. Residents are provided with an opportunity to self medicate if they choose to, based on a risk assessment. The home had clear information available on the level of self medication for an individual, with some residents managing all aspects of their medication from obtaining repeat prescriptions to arranging delivery of their own medications. Risk assessments for this are reviewed every three months or earlier if the needs of the resident change. There are photos of individuals on the MAR charts to assist staff in clearly identifying individuals. A staff member has compiled a list of all residents’ medications that provides a quick reference guide on what the medication is for and possible side effects. It was confirmed that this information assists in providing relatives/representatives with clear information on what medications their relative/friend is on and assists staff in identifying if changes within an individual may be caused by side effects of the medicines. A new medication communication book has been introduced and a staff member confirmed that this assists in ensuring all medication issues are dealt with promptly. Princess Alexandra House DS0000014226.V346965.R01.S.doc Version 5.2 Page 13 All residents spoken with confirmed that their privacy and dignity are respected and staff encourage their independence as much as possible. The male residents confirmed that they did not have a problem with only female carers working at the home. Staff were observed to knock on individual room doors prior to entering. Princess Alexandra House DS0000014226.V346965.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ lifestyle within the home is their own choice and residents are provided with sufficient stimulation to fulfil their interests and needs. EVIDENCE: Residents were very complimentary about the activities provided at the home. They confirmed that they have enough to keep them occupied. Some residents go out into the community on their own. Some of the activities provided at the home include games, music, dancing, painting and outings are arranged. Residents spoke positively about recent outings they had been on. One resident stated that she had visited her country of birth since they last saw the Inspector. Residents confirmed that they and another care home within the area will visit each other’s homes to participate in a variety of activities. Visitors are encouraged to visit the home and a visitor spoken with confirmed that there are no restrictions regarding visiting times. Residents informed the Princess Alexandra House DS0000014226.V346965.R01.S.doc Version 5.2 Page 15 Inspector that staff are very courteous to their visitors. A visitor spoken with confirmed that the home keeps them informed regarding the health and changes within their relative. Residents spoken with confirmed that their routines within the home are to their own choice and preference. They chose their own bed times, where to eat and what to wear etc. Residents were very complimentary about all aspects of living in the home and feel that they could not find a better place to live. It was observed throughout the site visit that there is a good professional rapport between staff and residents and a lot of laughter and discussions between the residents. Residents were very complimentary about the food provided at the home and comments ranged from “too good”, “choices every day” and “excellent”. Residents are weighed monthly and advice obtained if needed. Lunchtime was observed to be a social time and residents were observed enjoying their meal. Residents confirmed that anything special they want in relation to food is catered for. Menus were not viewed as there were no concerns expressed by residents regarding the provision of food. Princess Alexandra House DS0000014226.V346965.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents feel comfortable to complain, reassuring them that they are being listened to and that action will be taken, if necessary. Safeguarding Adult procedures and the training of staff ensure residents are safeguarded. EVIDENCE: There have been no complaints made to the home or directly to the CSCI since the last inspection. Records for complaints were viewed at the last inspection and identified that complaints are welcomed and investigated in a non-biased manner. There is a suggestion/complaints book kept in the lounge that provides anyone at the home an opportunity to raise any issues anonymously. All residents spoken with confirmed that they knew who to speak to if they had concerns and would feel comfortable to make a complaint and that appropriate action would be taken. There have been no Safeguarding Adults alerts made since the last inspection. The home has obtained information on the most recent guidelines on dealing with Safeguarding Adults issues. Staff spoken with confirmed that they have received Safeguarding Adults training and are aware of the procedures to follow in the event of an allegation being made. Princess Alexandra House DS0000014226.V346965.R01.S.doc Version 5.2 Page 17 Princess Alexandra House DS0000014226.V346965.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 & 26. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a clean and homely environment and are provided with comfortable indoor and outdoor communal facilities. EVIDENCE: Residents spoken with were happy with the environment within the home and with their individual rooms. Rooms viewed demonstrated that residents are able to personalise their own rooms to reflect their own choice and character. Residents’ bedrooms are located over three floors. There is a passenger shaft lift that accesses all floors. One room is located on a mezzanine level and a stair lift is available, if needed, to assist this individual to access the main floor. Princess Alexandra House DS0000014226.V346965.R01.S.doc Version 5.2 Page 19 There is a large garden at the rear of the home and residents spoke positively about the new summerhouse that had been installed in the garden. The rear garden is on an incline, so residents need to be able to mobilise on an incline to access the summerhouse. Most residents currently residing at the home are able to mobilise independently. There is a hoist available at the home, but it was confirmed that this is rarely used as it is unable to be used in the bathroom/en suite facilities due to its size. There is an inflatable cushion at the home that assist raising residents from the floor if they were to fall. It was confirmed that the training provided for the use of this equipment was undertaken in the lounge room in front of residents. This assisted in alleviating any fears/concerns residents may have regarding this process. The home was clean and free from offensive odours on the day of the site visit. Residents spoken with confirmed that the home is always kept clean. The AQAA identifies that the home uses the Department of Health ‘Essential Steps’ guide to assess their current infection control management. There was evidence that staff have received infection control training. The AQAA identifies that all staff have received training on the prevention of infection and management of infection control. Princess Alexandra House DS0000014226.V346965.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ needs are being met with the number and skill mix of staff on duty and are safeguarded by the recruitment procedures in place. EVIDENCE: Residents were very complimentary about the staff working at the home and staff confirmed that they were very happy working at the home. Staff and residents confirmed that there are sufficient numbers of staff on duty to meet the needs of the residents. There are usually two carers working throughout the daytime hours and one staff member working a waking night. The home has a low turnover of staff that promotes continuity in care. The AQAA identifies that there are 12 permanent staff employed at the home. Six staff have National Vocation Qualification (NVQ) level 2 or above and a further four are working towards these qualifications. Staff files viewed demonstrated that generally good recruitment procedures are followed. Application forms, references and a Protection of Vulnerable Adults (POVA) First check and enhanced Criminal Record Bureau (CRB) are obtained for each individual. The Registered Provider/Manager confirmed that Princess Alexandra House DS0000014226.V346965.R01.S.doc Version 5.2 Page 21 staff who commence employment with just a POVA First check works supervised until the CRB is returned. A discussion was held with the Registered Provider/Manager regarding some improvements that could be made in regards to the recruitment procedure. This included: maintaining records of verbal references and ensuring this is followed up in writing, keep clearer information regarding the CRB dates and to read recent guidelines regarding the storage of CRBs. No requirement has been made in relation to these shortfalls as the majority of files viewed were satisfactory and the Registered Provider/Manager confirmed that she will address these shortfalls. Staff spoken with confirmed that they are up to date with all mandatory training and are provided with enough training opportunities. There was evidence of recent training being provided in the staff files viewed. All new staff undertake an induction programme that complies with the Common Induction Standards as set by Skill for Care. There was evidence of this in the new staff files viewed. Princess Alexandra House DS0000014226.V346965.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff and residents benefit from a well managed home and the quality assurance system in place ensures the home is run in the best interest of residents. The health, safety and welfare of residents and staff are promoted and protected so far as is reasonably practicable. EVIDENCE: The Registered Manager, who is also the registered provider, is registered with the CSCI and has the necessary skills and experience to manage the home. She has NVQ level 4 in care and has completed the Registered Manager Award course. The Registered Provider/Manager confirmed that she keeps herself up to date with changes in care practices by researching, undertaking training Princess Alexandra House DS0000014226.V346965.R01.S.doc Version 5.2 Page 23 that is provided to staff and by attending other courses. She confirmed that she has recently booked herself on an equality and diversity course. Staff spoken with were complimentary about the management of the home and confirmed that the Registered Provider/Manager is supportive and approachable. The home undertakes an annual survey for residents, relatives/representatives and other visiting professionals to obtain feedback to ensure that the home continues to be run in the best interest of residents. The Registered Provider/Manager undertakes an audit of these and takes any necessary action to address any changes/shortfalls that may have been identified. Some comments written in the homes quality assurance surveys were: “I am now very happy, thanks to the care and encouragement of all concerned in my care”, “I really like it here, it’s very friendly, people are helpful and understanding” and “Happy with everything and satisfied”. A newly employed administrator/carer has developed new monitoring forms to monitor the practices within the home. Some responsibilities have also been shared with other senior staff. These include: daily checks on MAR charts, weekly checks of fire alarms, complaints, water temperatures and accident records etc. A checklist tick box has been developed to clearly see when monitoring checks have been undertaken. The home does not hold personal allowances for residents. Residents manage their own money or have made their own arrangements with relatives/representatives. The Registered Provider/Manager does collect the pension for one resident, who then gives the money to the resident. The resident signs to say they have received their money. The home liaises with a relative for another resident regarding personal finances. Records for these two residents were not viewed, as there are suitable safety checks in place. Health and safety records were not viewed. Staff confirmed that they have received fire training and that regular fire drills are undertaken. The AQAA identifies that equipment in use has been tested or serviced as recommended by the manufacturer or other regulatory body. It was confirmed that residents participate in fire drills. A resident whose room has access to a fire exit was very clear of the need to ensure the room was not locked. The Registered Manager confirmed that a recent fire inspection had been undertaken and there were no shortfalls identified. Princess Alexandra House DS0000014226.V346965.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 4 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 4 X X 3 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 Princess Alexandra House DS0000014226.V346965.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Princess Alexandra House DS0000014226.V346965.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Princess Alexandra House DS0000014226.V346965.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!