Inspection on 01/02/06 for Queen Alexandra Cottage Homes

This inspection was carried out on 1st February 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 but made no statutory requirements on the home.

Other inspections for this house

Queen Alexandra Cottage Homes 11/11/08

Queen Alexandra Cottage Homes 18/12/06

Queen Alexandra Cottage Homes 07/09/05

Queen Alexandra Cottage Homes 13/02/05

Queen Alexandra Cottage Homes 23/07/04

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 Queen Alexandra Cottage Homes 557 Seaside Eastbourne East Sussex BN23 6NE Lead Inspector Debbie Calveley Announced Inspection 1st February 2006 08:15 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 Queen Alexandra Cottage Homes DS0000014032.V266804.R01.S.doc Version 5.0 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. Queen Alexandra Cottage Homes DS0000014032.V266804.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Queen Alexandra Cottage Homes Address 557 Seaside Eastbourne East Sussex BN23 6NE 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) 01323-739689 The Trustees of Queen Alexandra Cottage Homes Mrs Gillian Irene Thomas Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Queen Alexandra Cottage Homes DS0000014032.V266804.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is twenty-five (25). That service users must be aged sixty-five (65) years and over on admission. 7th September 2005 Date of last inspection Brief Description of the Service: Queen Alexandra Cottage Homes is registered to provide care with nursing for up to twenty-five service users who meet the registration category of older people. The home forms part of an Edwardian building, which was purpose built to provide sheltered accommodation for older people, it has been established since 1905. The accommodation offered in the home consists of seventeen single rooms with ensuite facilities and four double rooms without an ensuite facility. Lounge areas are now offered on both floors and are attractively decorated with good quality furniture. The conservatory/ lounge leads out to a paved patio where residents can sit and enjoy the gardens. There is a dining area which is situated next to the kitchen which is used by approximately sixteen residents. There are ample bathing facilities available which have the necessary equipment to meet the needs of the residents accommodated in the home. The home is situated on the outskirts of Eastbourne in a residential area, approximately two miles from the town centre, and it is on a main bus route. The sea front is approximately half a mile away and immediately opposite the home, there is a shopping area, with a post office and a supermarket. Queen Alexandra Cottage Homes also contains self-care bungalows and flats for those requiring supported living. In the middle of the buildings there is a large garden, which is designed in to smaller areas with shelter and water features which are enjoyed by all. Queen Alexandra Cottage Homes DS0000014032.V266804.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place on the 1 February 2006. It commenced at 8. 15 am and was conducted over 5.5 hours. There were twenty-five residents living in the home on this day. A second visit was arranged to meet residents relatives and took place on the 06/02/06 at 3.30 pm. The methodology of the inspection included a tour of the building, inspection of documentation and records, the delivery of care for six residents and informal interviews with eight residents, two relatives and six members of staff. The overall quality of care provided at Queen Alexandra Cottage Homes was observed to be of a good standard and the outcome for service users living in the home is one of warmth and comfort. Some requirements remain outstanding and these were in connection with documentation and recording and do not detract from the positive outcomes of the care given. The home are aware of these shortfalls and are working towards meeting the standard required. What the service does well: The comprehensive Statement of Purpose and Service Users Guide give prospective residents the information required to enable them to make an informed choice about where they live. The health needs of the residents were seen to be met and the standard of care is maintained to a high standard. The atmosphere of the home is pleasant with good interaction seen between residents and staff. The residents are enabled to exercise the choice and control of their every day life. The relatives and representatives are welcomed to the home and are kept informed of any changes and are complimentary about the service provided at Queen Alexandra Cottage Homes. There is a variety of good nutritious food offered and fresh fruit is readily available. Meals are taken in comfortable and homely surroundings. The home is clean, safe and well maintained, which is appreciated by the residents and their relatives. Queen Alexandra Cottage Homes DS0000014032.V266804.R01.S.doc Version 5.0 Page 6 There is a stable work force of reliable and caring staff, which work well together as a team. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Queen Alexandra Cottage Homes DS0000014032.V266804.R01.S.doc Version 5.0 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 Queen Alexandra Cottage Homes DS0000014032.V266804.R01.S.doc Version 5.0 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): 1, 2, 3, 4 and 5. The Statement of Purpose and Service Users Guide give prospective residents the information required enabling them to make an informed choice about where they live. A contract/statement of terms and conditions is given to all residents on admission, which confirms the facilities offered and care agreed. The home welcome and encourage prospective residents and their representatives to visit the home prior to admission to enable them to assess the suitability of the home and meet the staff and fellow residents. EVIDENCE: A Statement of Purpose and Service Users guide, which conforms to the Care Homes Regulations and National Minimum standards, is in place. It is available to all residents and their relatives and is written in a clear and user-friendly format. There is a comprehensive statement of terms and conditions, which includes the services covered by the fees and the room to be occupied. Queen Alexandra Cottage Homes DS0000014032.V266804.R01.S.doc Version 5.0 Page 9 Five contracts were viewed, which were in the residents’ folders. It was confirmed from viewing the residents’ files that a pre-admission assessment using the homes own assessment tool is completed on all prospective residents. The assessment takes place at the residents’ place of residence, and input from other relevant professionals is sought when required. It is said that the residents’ representatives are involved if possible. Five pre-admission assessments were viewed. Four residents spoken with were able to confirm that they were visited before admission whilst three could not remember being involved. The pre-admission assessment identifies any specific needs of the prospective resident and this informs the admission process. The home provides nursing care for elderly people, and the documentation available demonstrates that a full assessment of the resident’s specific needs is completed following admission to the home, and then reviewed. Trial visits can be arranged and residents and their representative can spend a day in the home prior to admission. This enables them to meet the staff and other residents, and sample the food and activities. There is a month’s trial either way to ensure that the home is suitable and the home can meet the needs of the resident. Three residents confirmed that they had visited the home prior to their admission, one resident said her daughter had visited and chosen the home and another said that she had no idea how she came to be admitted to the home. One residents’ daughter said that her father had progressed from the supported living accommodation to the nursing care wing over a period of time. Queen Alexandra Cottage Homes DS0000014032.V266804.R01.S.doc Version 5.0 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. Residents’ would benefit from a more comprehensive care planning system that guides staff in all aspects of personal and health care and that all risks are identified and planned for. The medication practices at this time do not ensure the continued well-being of the residents. Feedback from the residents’ evidence that they feel respected and treated with consideration and courtesy. EVIDENCE: A sample of care plans were viewed and found to be more detailed and easier to identify the resident’s care needs than at the last inspection. There is still some work to do to ensure the documentation is consistent and that the reviews are an accurate reflection of the residents needs. The wound care plan in use at present is not an effective way of monitoring the status of the wound, and the home are continuing to look at ways to improve the documentation. It is evident that the pre-admission information is used effectively in the formation of care plans. The manager and staff have a good understanding of Queen Alexandra Cottage Homes DS0000014032.V266804.R01.S.doc Version 5.0 Page 11 the residents needs and were able to discuss them and explain the support that is provided. The risk assessments in the care plans regarding nutrition, tissue viability, moving and handling and dependency rating were found up to date. Recommendations of good practice were made in respect of developing the moving and handling risk assessments to include the equipment used and size of slings. The clinical room was found clean and tidy, with the records of the equipment checks up to date. The fridge was clean and of the required temperature. The medication policies and procedures are in need of updating, they were last reviewed in 2003. The medication administration charts were viewed and were found to have gaps where the medication had not been signed for - the medication when tracked was seen to be missing from the blister pack. Some instructions of frequency of medication were not being accurately followed. These were identified to the manager to investigate. Evidence of staff using tippex was found on one resident’s chart and there is a need for staff to date and sign medication changes. The eye drops kept upstairs in a domestic fridge need to be kept in a protective box. Staff were observed to treat residents with care and respect and it was evident that staff and residents are comfortable with each other. Residents spoken with confirmed they are enabled to make choices about their daily lives. The feedback from residents concerning the staff were, “ the staff are really very kind and nothing is too much bother”, “they treat me very well thank you” “could not ask for better care”. Queen Alexandra Cottage Homes DS0000014032.V266804.R01.S.doc Version 5.0 Page 12 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. Residents would benefit from a daily programme of activities based on their individual preferences. The homes encourages and enables residents to maintain contact with their families and friends, by having an open door policy and a welcoming reception. The dietary needs of residents are well catered for and offer a balanced and varied selection of food that has been updated in line with the personal likes and choices of residents. EVIDENCE: There is an activity programme in place, which is displayed in the home for six hours a week over three days. According to the information supplied by the home residents can join the activities and outings in the adjoining wing of the Queen Alexandra Cottage Homes. The activity co-ordinator also works as a carer and knows the residents well, and the residents were positive about her sessions. However again the general feeling from staff and residents regarding the activities is that they do not suit individual residents, quite a few residents said that they preferred to stay in their room as they did not ‘ fancy the set sessions’. A planned programme of activities based on residents preferences needs to be created and implemented. This would ensure residents are given the Queen Alexandra Cottage Homes DS0000014032.V266804.R01.S.doc Version 5.0 Page 13 opportunity to continue with past hobbies and pastimes. Residents’ social and leisure interests need to be recorded in both pre-admission documents and in care plans so all staff have an awareness of their interests. One resident was again very vehement about the fact she was “bored rigid” and goes to bingo on a Tuesday with the residents from the residential flats. She also admitted that she found it distressing at times to attend activities as not everyone could communicate as well as herself and also mentioned that she would love to go out on trips. One resident who has recently joined the home says she tends to go next door to join some friends she knew as nothing much went on in the nursing wing. Five other residents also mentioned they would like more challenging activities to keep their minds active. It was confirmed that there has been a high turn over of residents recently and this would be an ideal time to instigate a new programme based on residents’ preferences and ideas. There is evidence of representatives of different faiths visiting the home and three residents mentioned they had received communion. Bible sessions are held once a month in the upstairs lounge of the care wing. There is open visiting and residents are encouraged to invite friends and relatives to visit. One relative said that she always felt welcomed at any time of dad, that she felt comfortable asking questions and they always came and told her how her father was. Residents spoken with felt that they had choice and control over their every day lives, which includes when they get up, where they spend their time, have their meals and go to bed. The kitchen was not inspected in full at this inspection. The winter menu was seen and displayed a varied and nutritious variety of food. There was evidence that an alternative choice for all meals was available and that fresh fruit is also readily available. The meal served at the time of the inspection was appealing, wholesome and nutritious, the choice on this day was lamb stew or sausage plait, followed by stewed fruit or choice of the day. It was confirmed that a vegetarian option is available if requested. The evening choice was sandwiches or cheese and potato pie and whip or choice of the day. Staff were seen assisting less able service users in a dignified manner. Residents spoken with were all complimentary about the range and quality of food. Queen Alexandra Cottage Homes DS0000014032.V266804.R01.S.doc Version 5.0 Page 14 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. The complaint procedure is clearly detailed in the Statement of Purpose and Services Users Guide and is available to residents and their families enabling them to share their concerns both formally and confidentially. Staff demonstrated a good understanding and knowledge of Adult Protection policies and procedures, which protect the residents from harm and abuse. EVIDENCE: There are appropriate policies and procedures in place and it was confirmed that these are followed when investigating any concerns raised at the home. The staff interviewed, were knowledgeable of the complaint procedure and of how to start the process if the manager is not available. The complaint book was viewed during the inspection. Two of the residents and one relative referred to the “brochure” (Service Users Guide) when asked if they knew how to make a complaint, whilst one resident said she didn’t know of a proper procedure, but would go the senior nurse and that “it would be dealt with”. There have been no complaints received by the CSCI or internally by the home since the last inspection. The Adult Protection policy in the home was found to be up to date and staff interviewed were knowledgeable about the systems in place to protect vulnerable service users. There is on-going training for all staff in Adult Protection. Queen Alexandra Cottage Homes DS0000014032.V266804.R01.S.doc Version 5.0 Page 15 Queen Alexandra Cottage Homes DS0000014032.V266804.R01.S.doc Version 5.0 Page 16 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, 20, 21, 22, 23, 24, 25 and 26. Service users benefit from a clean, safe, attractive and well-maintained environment. Residents are enabled and encouraged to personalise their room, and rooms are homely and reflect the resident’s personalities and interests. There is specialist equipment in the home for residents’ use to maximise their independence. EVIDENCE: A tour of the premises was carried out, which demonstrated that all parts of the home are well-maintained and well furnished with good quality coordinated furniture. The gardens are a source of delight to the residents. All repairs and maintenance is carried out promptly and satisfactorily. There have been some changes to the facilities offered, two double bedrooms on the ground floor have been changed to single bedrooms with an ensuite bathroom. The residents are encouraged and enabled to personalise their rooms with furniture and pictures, and this was evident during the visit. All personal items Queen Alexandra Cottage Homes DS0000014032.V266804.R01.S.doc Version 5.0 Page 17 are listed in the individual care plans. Residents are offered the choice of having a lock and key for their bedroom, risk assessments are in place for this. It is demonstrated in the care plans and risk assessments that all service users are independently assessed for individual needs and the staff are aware of where to procure specialised equipment. On the day of the inspection the home was found to be warm and comfortable, with good levels of light and ventilation. Pre-set values regulate hot water supplies to areas accessible to residents. Outlets checked showed that hot water was delivered within the safe temperature range. Hot water is stored and distributed at temperatures that reduce the risk of Legionella On the day of the inspection the home was found to be clean and free from offensive odours. Staff ensure a high standard of hygiene and cleanliness and there are procedures in place to ensure that these standards are maintained throughout the home. Suitable laundry facilities are available which meet the required standard, all of which appeared in good working order. Adequate provisions of protective clothing are made available and suitable arrangements are in place for the disposal of clinical waste. There is written guidance for staff on control of infection. Staff consulted demonstrated a good and clear understanding of the risks associated with the spread of infections and diseases, and appeared knowledgeable in relation to how best to reduce such risks. Queen Alexandra Cottage Homes DS0000014032.V266804.R01.S.doc Version 5.0 Page 18 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 and 29. The staffing levels are sufficient to meet the assessed needs of the residents. Residents are supported and protected by the homes recruitment process. EVIDENCE: A staffing rota was viewed. The rota showed that the morning shift comprises of one trained nurse and seven carers, which the staff say is sufficient to meet the needs of the residents. The afternoon shift comprises of one trained nurse and seven carers, which was seen to be adequate at this time to meet the needs of the residents. The night shift was staffed by two carers and one trained nurse, with three members of the morning staff coming in at 07.00 am. The night staff numbers have increased since the last inspection. The number of staff on duty according to the rotas fluctuate on a daily basis and the above numbers are the higher ratio seen. It is an expectation that staffing levels are flexible to meet the assessed needs of the residents. The recruitment process was seen to be thorough and robust. The staff files evidenced that the appropriate Criminal Record Bureau Checks, POVA checks and references were in place before the commencement of employment. Queen Alexandra Cottage Homes DS0000014032.V266804.R01.S.doc Version 5.0 Page 19 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. The Registered Manager has the necessary experience and qualifications to run the home effectively. Clear professional leadership is apparent in the home. The ethos is one of kindness and caring. EVIDENCE: The manager is in her first year in post and has settled in to the role with confidence. She is a Qualified Registered General Nurse and has the experience to run the home effectively with support from the homes administrator. The management structure of the home is strong, competent and has clear lines of accountability. The feedback from residents and staff indicated that they felt supported and were able to approach the management team at any time. The ethos of the home is to focus on the residents and staff were observed doing this. Regular staff meetings and resident/relative meetings are held and Queen Alexandra Cottage Homes DS0000014032.V266804.R01.S.doc Version 5.0 Page 20 records of the meetings are kept. These form part of the quality assurance systems in the home. Two residents mentioned that they attended the resident meetings and thought it gave them the opportunity to discuss the running of the home and areas that could be improved. The manager confirmed and the staff training records show that all staff are kept updated on the Health and Safety policies, the manual is available to all and clearly defined. Staff were able to discuss the training they received and said that they were kept up to date with changes to policies in connection with fire safety and health and safety. The staff are issued with certificates yearly for Manual Handling, twice yearly for Fire Safety and Food and Hygiene. The home has a comprehensive set of policies and procedures, which govern the running of the home. All relevant legislation and procedures are in place in respect of Health and safety. The practice of wedging doors open must cease as directed by the fire service. Queen Alexandra Cottage Homes DS0000014032.V266804.R01.S.doc Version 5.0 Page 21 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 x 3 x x 3 Queen Alexandra Cottage Homes DS0000014032.V266804.R01.S.doc Version 5.0 Page 22 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 OP7 Regulation 15(2b&c) 12(1) Requirement Timescale for action 07/11/05 2. OP8 13(1b) 17(1a) Sch 3 3. OP9 13(2) That a comprehensive plan of care is generated from a comprehensive assessment and drawn up for/with each service user. (Previous time scale of 13/05/05 and 07/11/05 not met) That service users records 07/11/05 comply with schedule 3 and that the nursing documentation complies with NMC guidelines. (previous time scale of 13/02/05 and 07/11/05 not met) That tippex is not used on the 01/02/06 homes medication administration charts. (Previous timescale of 07/09/05 not met.) That all changes to service users medication are signed and dated. (Previous timescale of 07/09/05 not met.) Medication administration record charts must reflect current medication profile and must be a true and accurate record. That the medication policies are reviewed and updated. Queen Alexandra Cottage Homes DS0000014032.V266804.R01.S.doc Version 5.0 Page 23 4. OP12 16(1m) That leisure and social activities are subject to review and further development, taking in to account the service users personal references. (Previous timescale of 07/11/05 not met.) 01/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Queen Alexandra Cottage Homes DS0000014032.V266804.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Queen Alexandra Cottage Homes DS0000014032.V266804.R01.S.doc Version 5.0 Page 25 - 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!