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Inspection on 18/12/06 for Queen Alexandra Cottage Homes

Also see our care home review for Queen Alexandra Cottage Homes for more information

This inspection was carried out on 18th December 2006.

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The comprehensive Statement of Purpose and Service Users Guide give prospective residents the information required enabling them to make an informed choice about where they live. One resident said " I refer to it when I need to, I find it very helpful" some residents were not aware of the meaning. The atmosphere in the home was comfortable and relaxed. All parts of the home were clean, comfortable and well maintained. The quality and choice of meals remain good and all residents spoken with confirmed this. ` The food is good` `we get a choice of food everyday` ` the food is always freshly prepared`. Satisfactory arrangements are in place to safeguard residents` finances.Staff provision is well maintained with good recruitment practice being followed and appropriate numbers of staff suitably qualified working in the home. The staff group on the whole is stable; very few agency staff has been used in the past two months. Both residents and their relatives spoke highly of all the staff saying `staff are always nice and kind` `staff are helpful, approachable and are available to talk to`. The training for staff is good, and covers a wide variety of resident related conditions, which give the staff an understanding of the residents needs.

What has improved since the last inspection?

The care planning system in use has been reviewed and a new system has been introduced. The information recorded on individual care plans was seen to be of an improved and consistent standard. The documentation pertaining to resident`s individual needs, such as fluid and dietary intake were completed in full and an accurate reflection of the resident`s status.

What the care home could do better:

The policies and procedures of the home in respect of the management of medication need to be followed to promote competency and good practice, which will benefit the outcomes of the residents health needs. Despite an audit being commenced following the last inspection, shortfalls were still evident. The introduction of formal quality assurance and quality monitoring systems would enable the management to objectively evaluate the service and ensure it is run in the residents best interests.

CARE HOMES FOR OLDER PEOPLE Queen Alexandra Cottage Homes 557 Seaside Eastbourne East Sussex BN23 6NE Lead Inspector Debbie Calveley Key Unannounced Inspection 18th December 2006 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Queen Alexandra Cottage Homes DS0000014032.V323902.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. Queen Alexandra Cottage Homes DS0000014032.V323902.R01.S.doc Version 5.2 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 01323 727533 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.V323902.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is twenty-five (25). Service users must be aged sixty-five (65) years or over on admission. Two places to be available for service users aged between sixty (60) and sixty-five (65) years on admission. 1st February 2006 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 1906. The accommodation offered in the home consists of seventeen single rooms, thirteen 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. Copies of inspection reports and the homes Statement of Purpose are made available on request. Fees charged as from 1 April 2006 range from £555 to £800, which does not include toiletries. Additional charges are made for hairdressing, chiropody, newspapers and outside activities such as visits to the theatre. Intermediate care is not provided. Queen Alexandra Cottage Homes DS0000014032.V323902.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Queen Alexandra Cottage Homes will be referred to as ‘residents’. This was a key inspection that included an unannounced visit to the home and follow up contact with resident’s representatives and visiting health and social care professionals. This unannounced inspection was carried out over 7 hours on the 18th of December 2006. There were twenty-one residents living in the home on the day of the inspection, of which five were case tracked and spoken with. During the tour of the premises six other residents both male and female were also spoken with, as were two relatives. The purpose of the inspection was to check that the requirements of previous inspections had been met and inspect all other key standards. A tour of the premises was undertaken and a range of documentation was viewed including the Service Users Guide, Statement of Purpose, care plans, medication records and recruitment files. Four members of care staff, one trained nurse were spoken with in addition to discussion with the Registered Manager and the Responsible Individual. The pre-inspection questionnaire was received back from the registered manager on the 28 November 2006 completed in full. Comment cards received from seven residents/relatives were generally positive and indicated that both groups were satisfied with the services provided. Two comment cards were received from social and healthcare professionals, and two staff surveys were received from staff. The information contained in the returned surveys has been incorporated into this report. What the service does well: The comprehensive Statement of Purpose and Service Users Guide give prospective residents the information required enabling them to make an informed choice about where they live. One resident said “ I refer to it when I need to, I find it very helpful” some residents were not aware of the meaning. The atmosphere in the home was comfortable and relaxed. All parts of the home were clean, comfortable and well maintained. The quality and choice of meals remain good and all residents spoken with confirmed this. ‘ The food is good’ ‘we get a choice of food everyday’ ‘ the food is always freshly prepared’. Satisfactory arrangements are in place to safeguard residents’ finances. Queen Alexandra Cottage Homes DS0000014032.V323902.R01.S.doc Version 5.2 Page 6 Staff provision is well maintained with good recruitment practice being followed and appropriate numbers of staff suitably qualified working in the home. The staff group on the whole is stable; very few agency staff has been used in the past two months. Both residents and their relatives spoke highly of all the staff saying ‘staff are always nice and kind’ ‘staff are helpful, approachable and are available to talk to’. The training for staff is good, and covers a wide variety of resident related conditions, which give the staff an understanding of the residents needs. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Queen Alexandra Cottage Homes DS0000014032.V323902.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Queen Alexandra Cottage Homes DS0000014032.V323902.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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. 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: There is a range of well-documented information about the home and the services it provides. This includes a Statement of Purpose and Service User Guide. Copies of these are available in the home. It was confirmed whilst talking to residents and from surveys received that the contract arrangements were clear and understood. Queen Alexandra Cottage Homes DS0000014032.V323902.R01.S.doc Version 5.2 Page 9 A review of the care documentation confirmed that pre-admission assessments are completed, and are currently completed by the manager or a senior nurse. The information contained in these assessments is then used to provide the basis of the care documentation in the home. The prospective residents’ are seen either in their home or hospital before admission and the manager confirmed that wherever possible the family or representative is involved. Two relatives confirmed that they were consulted about the pre-admission visit and were given the opportunity to attend. The manager was able to verbally demonstrate her knowledge and awareness of the different specialities required in the home and ensures that the Registered Nurses employed have attended relevant courses to deal with the needs of the elderly and also specialised courses for certain diseases. Trial visits/respite visits to the home can be arranged. The manager confirmed that residents are invited to a trial period to ensure suitability of the home; this is clearly stated in the Statement of Purpose and in the statement of terms and conditions, one survey stated. Queen Alexandra Cottage Homes DS0000014032.V323902.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is now 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 do not protect the health and well being of residents at this time. Residents confirmed they are treated with respect and courtesy. EVIDENCE: A new care plan system has recently been introduced. The care documentation pertaining to five residents were reviewed as part of the inspection process. These were found to include plans of care, nutritional assessment, personal histories and risk assessments. The care documentation was full and demonstrated that the care was reviewed and evaluated on a regular basis. Some areas of improvement of were discussed, and these were mostly regarding staff interpretation of outcomes and action required and it was Queen Alexandra Cottage Homes DS0000014032.V323902.R01.S.doc Version 5.2 Page 11 confirmed by the manager that more training sessions for staff were to take place. Staff spoken to confirmed that they received a full report on each resident daily and read the care documentation that is kept in a lockable container in the in the staff office. The staff felt that their views were taken into account when planning and implementing resident’s care. The clinical room was found clean, tidy and well organised. There are policies and procedures in place for the storing, administrating, disposal and receipt of medication. A self-administering policy is in place, but there were no residents at this time self-administering their medication. The temperature of the fridge and room are recorded daily and of an acceptable temperature to maintain dressings and medications. The medication administration charts were viewed and despite an audit being performed, gaps were identified, signatures and dates were missing from verbal changes to doses and completion of courses. Discrepancies were found in the controlled medication book and the manager is to investigate the entries. Photographs of residents are available to aid identification, but as discussed, dating the photograph and regular updating of photographs would be beneficial as some residents bear little resemblance to the photograph. The manager is aware that improvement to the medication systems is required and training courses for staff are planned. Throughout the inspection it was observed that residents were treated with dignity and respect. One relative said that ‘ the staff always show respect to residents and nothing was too much trouble’. A resident remarked that ‘ the staff respected her feelings and that she never felt she was a nuisance”. Two surveys received from relatives stated, ‘the care their relative received was very good and the staff were always very kind and respectful’. A relative spoken with said the “care could not be better, staff are wonderful’. Queen Alexandra Cottage Homes DS0000014032.V323902.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to make a range of choices about their lives as well as maintaining links with friends and relatives. 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: Activities in the home take place for six hours a week over four days, however residents can join the activities and outings in the adjoining wing of the Queen Alexandra Cottage Homes. All residents receive an activity programme. There are one to one activities, arts and crafts, cards, quiz and games and bible sessions provided for those residents wishing to attend. Monthly musical entertainment is provided monthly and seasonal parties for the residents are held. Outside visits are also arranged for those residents that are able. The activity co-ordinator also works as a carer and knows the residents well, and the residents were positive about her sessions. Positive interaction was seen throughout the inspection between staff and residents. Feedback from surveys and from the inspection was again mixed, and therefore it would be beneficial to seek feedback from residents, staff and visitors on a regular basis Queen Alexandra Cottage Homes DS0000014032.V323902.R01.S.doc Version 5.2 Page 13 to ensure that the home are meeting the needs and expectations of the residents. There is evidence of representatives of different faiths visiting the home and 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. There is flexibility to the daily routine and residents’ preferences are taken into account. The menu was viewed and displayed a varied and nutritious variety of food. There was evidence that an alternative choice for all meals was available and fresh fruit is also readily available. The mid-day meal was nutritious and attractively presented. It was confirmed that a vegetarian option is available if requested. The main complaint regarding the meals was the size of portions, too large for many of the residents’, which put them off eating. The manager is aware of this and is already taking action. Staff were seen assisting less able service users in a dignified manner. Residents spoken with were all complimentary about the choice and quality of food. Queen Alexandra Cottage Homes DS0000014032.V323902.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaint procedure 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: The home has a clear complaints procedure and a copy of this is readily available in the home. A system of recording complaints was demonstrated to the inspector during her visit to the home. Relatives and visiting professionals spoken to confirmed that they were confident that any complaints or concerns that they had would be listened to and responded to effectively. The home has relevant guidelines on the protection of vulnerable adults and staff have received appropriate training. The management team has a clear understanding of adult protection guidelines and have initiated this procedure appropriately in the past. Queen Alexandra Cottage Homes DS0000014032.V323902.R01.S.doc Version 5.2 Page 15 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, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable, clean and safe environment for those living there and visiting. Residents are enabled and encouraged to personalise their room, and rooms are homely and reflect the resident’s personalities and interests. EVIDENCE: Queen Alexandra Cottage Homes provides a safe, well-maintained and comfortable environment for its residents, there are adequate communal bathrooms and shower rooms in the home with specialist equipment, which enables frail residents and those with a physical disability to enjoy the facilities available. Specialised equipment to encourage independence is provided e.g. handrails in bathrooms, hoists, wheelchairs and lifts to all areas of the home. Call bells are provided in all areas of the home, which enable residents to call for assistance when required. Queen Alexandra Cottage Homes DS0000014032.V323902.R01.S.doc Version 5.2 Page 16 The lighting in the home is of domestic quality and there are above bed lights as well as the main ceiling lights. Beds and chairs were seen to be placed appropriately for maximum benefit of those wishing to read. Water temperatures are controlled and monitored monthly and a record kept. There was evidence of residents being encouraged to personalise their rooms with their own belongings and bits of furniture. The bedrooms are clean, comfortably furnished and pleasantly decorated with soft colours. One resident said ‘ the cleaning ladies are good, they always stop and chat whilst cleaning my room’. Another said “the cleaning is always first class”. A relative said, ‘I can not fault the cleanliness of the home, the home always smells nice’. Polices and procedures for infection control are in place and are updated regularly. The home was clean and free from offensive odours on the day of the inspection. Good practice by staff was observed during the day and there were gloves and aprons freely available in the home. Sluice and laundry areas were found clean and safe. The home provides a good laundry service. Queen Alexandra Cottage Homes DS0000014032.V323902.R01.S.doc Version 5.2 Page 17 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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing arrangements are good and suitable and ensure the needs of the residents living in the home are met. Residents are protected by the home’s recruitment policy and practices. EVIDENCE: The staffing rota was viewed and the staffing levels were seen to be sufficient to meet the needs of the residents at this time. It was confirmed by the manager that there is flexibility of the staffing levels and they are adjusted according to the changing needs of the residents. Staff spoken to said that the levels of staff on duty were sufficient to give the care required, they also said that the trained staff always helped out. Residents also confirmed that they had no complaints regarding the amount of staff, one resident said the “staff are always helpful, they look after me very well”. Another said, “ The staff are really nice, always take time to talk to me”. The recruitment files of five employees were viewed and evidenced that the home management team follow robust procedures when employing staff. They contained the required information and demonstrated that the appropriate induction training had been completed in respect of the job they were to undertake in the home. Queen Alexandra Cottage Homes DS0000014032.V323902.R01.S.doc Version 5.2 Page 18 Staff interviewed confirmed satisfaction with the training provided and stated that recent training was interesting and informative. Staff and records seen confirmed that they had undertaken compulsory training such as moving and handling, adult protection, food hygiene and fire safety. In addition specialist training in understanding dementia and challenging behaviour, palliative care, diabetes, anxiety and depression are also provided. NVQ training is available and staff are encouraged to complete this, at present 56 of staff have an NVQ qualification. Queen Alexandra Cottage Homes DS0000014032.V323902.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The overall management of this home is good with effective systems in place to protect residents. EVIDENCE: Queen Alexandra Cottage Homes DS0000014032.V323902.R01.S.doc Version 5.2 Page 20 The Registered Manager is a Qualified Registered General Nurse and has the experience to run the home effectively with a strong support management structure. A deputy manager completes the management team within the home. The management structure of the home is strong, competent and has clear lines of accountability. The feedback from residents, relatives 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 the staff were observed doing this. Regular staff meetings are held and records of the meetings are kept. Resident meetings are to commence in the near future. The staff mentioned the staff meetings and how beneficial they were and the staff felt that areas of improvement they put forward were acted for the benefit of the residents. The introduction of formal quality assurance and quality monitoring systems would enable the management to objectively evaluate the service and ensure it is run in service users best interests. Residents’ financial interests are safeguarded by the homes policies and procedures. All staff spoken with were aware that they must not be involved in any financial matters of the residents, they also said that they would not accept money or gifts from residents. The residents spoken with said they had no worries regarding their financial status, and felt they were supported in managing their affairs efficiently. 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 Moving and Handling, infection control and twice yearly for Fire Safety. Currently five members of staff have a first aid qualification. 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. It was confirmed that regular supervision sessions take place and all staff spoken with confirmed that the supervision sessions are beneficial. Throughout the inspection good practice was observed in regards to ensuring the safety and well being of the residents when being moved around the building. The accident forms were seen and had been correctly completed with appropriate referrals made as necessary. Queen Alexandra Cottage Homes DS0000014032.V323902.R01.S.doc Version 5.2 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 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 3 3 3 3 3 4 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 3 3 2 X 3 3 3 3 Queen Alexandra Cottage Homes DS0000014032.V323902.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? YES Queen Alexandra Cottage Homes DS0000014032.V323902.R01.S.doc Version 5.2 Page 23 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 OP9 Regulation 13(2) Requirement 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 controlled medication book is a correct record. That formal quality monitoring and quality assurance systems be created and implemented. Timescale for action 18/01/07 2. OP33 24 (1ab) (2)(3) 18/01/07 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.V323902.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Queen Alexandra Cottage Homes DS0000014032.V323902.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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