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Inspection on 07/09/05 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 7th September 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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 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. 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?

At the last inspection, gaps were identified in the medicine administration charts, on this visit they were seen to be correctly completed and staff have been vigilant in ensuring that any gaps are immediately identified and followed up to ensure that residents are receiving their medication.

What the care home could do better:

The care planning and documentation in respect of the residents had been identified on a previous occasion as a concern as it does not reflect accurately the work staff do to meet the residents needs. Work is on-going to change the format of the care plans, however there is a need to ensure that whilst care plans are being changed over that they are kept up to date and correctly reflect the care that is required. The danger of not maintaining accurate records is always that staff may not provide safe and consistent care and that changes in needs cannot be tracked. All staff need to be reminded that all injuries to residents whether seen or not need to be recorded in the accident book. There are requirements on this inspection under standard 9, regarding the over ordering and stocking of eye drops and controlled pain relief medication, to prevent wastage of this items. The administration of medicine policy and drug confirmation policy need to be updated to include all new staff and to ensure that all staff are aware of homes policies on using medicine trolleys at all times. The checks on equipment and temperatures of clinical fridge and room need to be delegated amongst staff to ensure that they are completed when staff are on annual leave or off sick, and the controlled medication checks need to be ongoing on a regular basis. Evidence of the use of tippex was found on the administration charts, and staff need to be reminded to sign and date all medications changed or discontinued to provide a clear tracking system.

CARE HOMES FOR OLDER PEOPLE Queen Alexandra Cottage Homes 557 Seaside Eastbourne East Sussex BN23 6NE Lead Inspector Deborah Calveley Unannounced 7 September 2005 8:00 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 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 H59-H10 14032 Queen Alexandra Cottage Homes V234895 070905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Queen Alexandra Cottage Homes Address 557 Seaside Eastbourne East Sussex BN23 6NE 01323 739689 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) The Trustees of Queen Alexandra Cottage Homes Mrs Gillian Irene Thomas Care Home with nursing (N) 25 Category(ies) of Old age, not falling within any other category registration, with number (OP) 25 of places Queen Alexandra Cottage Homes H59-H10 14032 Queen Alexandra Cottage Homes V234895 070905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users to be accommodated is twenty-five (25). 2. That service users must be aged sixty-five (65) and over on admission. Date of last inspection 13 February 2005 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 elderly. 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 accomodation 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 accomodated 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 H59-H10 14032 Queen Alexandra Cottage Homes V234895 070905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 7 September 2005. It commenced at 8 am and was conducted over 5.5 hours. There were twentyfour residents living in the home on this day, with one admission expected. 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 six 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. There were some standards not met during the inspection and these were in connection with documentation and recording and do not detract from 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. There is a stable work force of reliable and caring staff, which work well together as a team. Queen Alexandra Cottage Homes H59-H10 14032 Queen Alexandra Cottage Homes V234895 070905 Stage 4.doc Version 1.40 Page 6 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 H59-H10 14032 Queen Alexandra Cottage Homes V234895 070905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Queen Alexandra Cottage Homes H59-H10 14032 Queen Alexandra Cottage Homes V234895 070905 Stage 4.doc Version 1.40 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 standard(s) 1, 2, 3, 4 & 5. 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. Six contracts were viewed, which were in the service users 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 service users. 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. Six pre-admission assessments were viewed. Five of the residents spoken with were able to confirm that they were visited before admission whilst one could not remember being involved. The pre-admission assessment identifies any specific needs of the prospective resident and this informs the admission process. Queen Alexandra Cottage Homes H59-H10 14032 Queen Alexandra Cottage Homes V234895 070905 Stage 4.doc Version 1.40 Page 9 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. Unplanned/ emergency admissions are rare, but if they do occur, assessment and care planning takes place within twenty-four hours. Two 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 resident said that she had visited many homes before finally making her choice and that she had liked the atmosphere and the staff of Queen Alexandra’s best. Queen Alexandra Cottage Homes H59-H10 14032 Queen Alexandra Cottage Homes V234895 070905 Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9 & 10. Residents would benefit for 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. Not all care plans contained sufficient information to evidence that the health, personal and social care needs of individual service users are being met. There has been an improvement in the documentation regarding medicine administration, which safeguards the well being of the residents. EVIDENCE: Six care plans were viewed and whilst the format of the care plan system has improved, it was noted that the positive outcomes observed at this time are still dependent upon staff knowledge and memories rather than full and detailed recording. The care plans did not identify all aspects of the individual’s needs in respect of wound care, identified nutritional problems and social needs. There was evidence of work being done to improve the documentation, but there is still work to be done to ensure that the care given is correctly documented so that the care can be tracked. These were discussed with staff during the inspection. Residents spoken with said they believed staff were aware of their care needs and felt that they are properly looked after. Basic Queen Alexandra Cottage Homes H59-H10 14032 Queen Alexandra Cottage Homes V234895 070905 Stage 4.doc Version 1.40 Page 11 risk assessments had been carried out but they do not clearly identify the hazards nor include sufficient detail for the management of risks, this is especially true for those who require specific moving and handling techniques, are at risk of falls or tissue breakdown, or have particular disabilities. There was no evidence in the care plans inspected to suggest that residents or their representatives were consulted about the care process. Three of the residents spoken too, did not remember discussing the care plans with the staff. Two residents confirmed that they were consulted about the care they were getting. The relative spoken to said they were kept informed of the care given to their mother but were had not been involved in any aspect of the care planning. The clinical room was tidy and well stocked. The medication charts were found in the main to be correctly completed, however there are requirements regarding the signing and dating of verbal orders, the use of tippex and dates for completed courses. There was evidence seen of over stocking of medication e.g eye drops and controlled medication for individual residents. These need to be monitored to ensure that there is no unnecessary wastage. The records pertaining to stock checks of controlled drugs had not been done for some time and theses need to be completed on a regular basis, and the checks for temperature checking, fridge temperatures and bedrail checks were also behind schedule and need to be done on a regular basis. The policies for medication administration need to be updated to ensure that all staff are aware of the proper procedures and all new staff need to sign the drug policy confirmation that it is in the policy folder. During the course of the inspection, staff were seen interacting positively with the residents, the residents were complimentary about the staff, two residents said that “all the carers were nice and nothing is to much trouble for them”, another said “the staff are very good and patient”. The residents were treated with courtesy and respect when being moved around the home and the dignity of residents was seen to be upheld in all aspects of care. Queen Alexandra Cottage Homes H59-H10 14032 Queen Alexandra Cottage Homes V234895 070905 Stage 4.doc Version 1.40 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 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 three days a week. The activity co-ordinator also works as a carer and knows the residents very well, and the feedback from residents was positive about her sessions. However the general feeling from staff and residents regarding the activities is that they do not suit individual residents. A planned programme of activities based on residents preferences needs to be created and implemented. This would ensure residents are given the 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. Queen Alexandra Cottage Homes H59-H10 14032 Queen Alexandra Cottage Homes V234895 070905 Stage 4.doc Version 1.40 Page 13 One resident was very vehement about the fact she was “bored rigid” and goes to bingo on a Tuesday with the residents from the residential flats, she admitted that she found it distressing at times to attend activities as not everyone could communicate as well as herself. She also mentioned that she would love to go out on trips. Three other residents also mentioned they would like more challenging activities to keep their minds active. There is evidence of representatives of different faiths visiting the home and three residents mentioned they had received communion. 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 day and that staff always give her the opportunity to ask any questions. 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 found clean and well organised. The staff were knowledgeable regarding residents preferences and habits. 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 cheese puff, followed by fresh fruit or rice pudding. The evening choice was sandwiches or corned beef and fried potatoes and jelly and ice cream, 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 H59-H10 14032 Queen Alexandra Cottage Homes V234895 070905 Stage 4.doc Version 1.40 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 standard(s) 16 & 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 formally and confidentially. Staff interviewed had 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. Three of the residents 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. 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 H59-H10 14032 Queen Alexandra Cottage Homes V234895 070905 Stage 4.doc Version 1.40 Page 15 Queen Alexandra Cottage Homes H59-H10 14032 Queen Alexandra Cottage Homes V234895 070905 Stage 4.doc Version 1.40 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 standard(s) 19, 20, 21, 22, 23, 24, 25 & 26. The home provides a comfortable, clean and safe environment for those living there and for those visiting. Residents are enabled and encouraged to personalise their room, and rooms are homely and reflect the residents personalities and interests. There is specialist equipment in the home for residents’ use to maximise their independence. EVIDENCE: The home is well furnished with good quality co-ordinated furniture. The residents are encouraged and enabled to personalise their rooms with furniture and pictures, and this was evident during the visit. All personal items 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. Queen Alexandra Cottage Homes H59-H10 14032 Queen Alexandra Cottage Homes V234895 070905 Stage 4.doc Version 1.40 Page 17 All rooms have a lockable facility for the storage of personal items and valuables. Two residents said they felt this increased their independence by keeping personal papers themselves rather than handing everything over to the home. There is an ongoing maintenance programme and the home was found well decorated and maintained at this time. The home provides adequate attractive communal space. The communal rooms are well used and provide adequate communal space. There is a dining area, two lounge areas of a good size, one on each floor, one leading in to a conservatory, which then leads in to the garden. The dining area was both clean and well decorated, as were the two lounges and conservatory. The garden areas are well kept and a source of delight to the residents. Three residents were enjoying the garden during the visit. There are toilet, washing and bathing facilities to meet the needs of the service users, including showers and assisted baths. Specialised equipment to encourage independence is provided e.g handrails in bathrooms, hoists, wheelchairs and lifts to all areas of the home. A call bell facility is in place and during the inspection the call bells were found in reach of the residents. Though those residents that can’t physically ring for help, need to have an appropriate risk assessment in place. 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 regularly and a record kept. Random temperatures were taken and were of the recommended level. 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. Queen Alexandra Cottage Homes H59-H10 14032 Queen Alexandra Cottage Homes V234895 070905 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 30 The staffing levels are sufficient to meet the assessed needs of the residents. The arrangements for the induction of staff are good with the staff demonstrating a clear understanding of their designated roles. Staff are provided with training pertinent to meeting the needs of the residents and to do their jobs competently. EVIDENCE: A staffing rota was viewed. The rota showed that the morning shift comprises of two trained nurses and nine cares, which the staff say is sufficient to meet the needs of the residents. Due to last minute staff sickness the morning shift on the day of the inspection was below the expected ratio of staff, but the staff worked very hard to ensure that the residents received the level of care required. The afternoon shift comprises of two trained nurses and eight carers, which was seen to be adequate at this time to meet the needs of the residents. The night shift was staffed by one carer and one trained nurse, with an extra member of staff coming in at 0630 am, this needs to be regularly reviewed and assessed as the needs of the residents are increasing and becoming more complex. The feedback from the night staff was that when it was busy, they found it difficult at times to give the care, but they also said that it depended on the residents needs. Staff informally interviewed were able to discuss the training they had received whilst working in the home. Three carers said they had had training in moving & handling, infection control, fire safety, and also study sessions on different Queen Alexandra Cottage Homes H59-H10 14032 Queen Alexandra Cottage Homes V234895 070905 Stage 4.doc Version 1.40 Page 19 illnesses that they care for in the home. One carer said she had had her induction training and she felt “well supported by the senior staff and that the training and supervision she had received had enabled her to give a good standard of care”. Another carer said she felt that the standard of care in the home is high and that the senior nurses were pro active in providing relevant training. Another carer said that the induction training she received was a good introduction to the home and the job. All staff spoken to said that the senior nurses are great and they all work well as a team. One resident said that the staff were wonderful and knew how to care for her specific “troubles”. Another resident said “ the staff know how to look after me I would not want to be any where else”. Queen Alexandra Cottage Homes H59-H10 14032 Queen Alexandra Cottage Homes V234895 070905 Stage 4.doc Version 1.40 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36, 37 & 38. All staff receive formal supervision at least six times a year and this promotes good practice and provides a support system for staff. There are policies and procedures in place that safeguard residents’ rights and best interests. The environment and the working practices of the staff protect and promote the resident’s health, safety and welfare needs, however shortfalls were identified regarding documentation of accidents and some queries regarding the moving and handling of two residents. EVIDENCE: The home has produced a training programme that is suitable for the staff and for the needs of the residents. The staff training schedule displayed a wide variety of training for the staff. Queen Alexandra Cottage Homes H59-H10 14032 Queen Alexandra Cottage Homes V234895 070905 Stage 4.doc Version 1.40 Page 21 Staff are supported by the management team on a daily basis and more formally through supervision. Staff spoken to confirmed they received supervision and annual appraisals. The deputy 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, as mentioned previously were able to discuss the training they received and said that the manager kept them up to date with changes to policies in connection with their job description. 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 records in the home are up-to-date, accurate and held in accordance with the requirements of the Data Protection Act 1998. Records are kept in lockable cabinets in the office. The home has policies and procedures on dealing with confidential records as a point of reference for staff. All relevant legislation and procedures are in place in respect of Health and safety. Good practice was observed throughout the inspection in respect of the safety of residents when being moved and transferred, however as discussed two residents said that staff never used the hoist and they were lifted by two nurses. The moving and handling assessments for these residents were not clear and it is asked that this is investigated and appropriate risk assessments put in place to ensure the safety of all residents and staff. The accident book was viewed and from information taken from the care plans and from dressings seen not all accidents/skin tears had been documented. This was acknowledged by the staff and all staff are to be reminded that all injuries found whether seen or not are to clearly documented. Fire precautions were seen to be adhered to and staff showed a good knowledge of the mandatory training that is required. There has been an identified problem with some door guards not working correctly and this is being documented by the home and will be monitored. Queen Alexandra Cottage Homes H59-H10 14032 Queen Alexandra Cottage Homes V234895 070905 Stage 4.doc Version 1.40 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 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 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x 3 x 2 Queen Alexandra Cottage Homes H59-H10 14032 Queen Alexandra Cottage Homes V234895 070905 Stage 4.doc Version 1.40 Page 23 no Are there any outstanding requirements from the last inspection? 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 7 Regulation 15 (2) (b) (c) 12 (1) Requirement That a comprehensive plan of care is generated from a comprehensive assessment and drawn up for/with each service user, and it is reviewed at least once a month.(previous time scale of 13/05/05 not met) That service users records comply with schedule 3 and that the nursing documentation complies with NMC guidelines.( previous time scale of 13/02/05 not met) That tippex is not used on the homes medication administration charts. That all changes to service users medication is signed and dated. That the controlled drug stock is checked on a regular basis. That the drug confirmation policy is signed by all new staff. That the policy for drug administration is updated. That the clinical room and fridge temperatures are regularly recorded. That leisure and social activities are subject to review and further development, taking in to account the service users Timescale for action 7 November 2005 2. 8 13 (1) (b) 17 (1) (a)Schedu le 3 13 (2) 7 november 2005 3. 9 7 september 2005 4. 12 16(1) (m) 7 november 2005 Page 24 Queen Alexandra Cottage Homes H59-H10 14032 Queen Alexandra Cottage Homes V234895 070905 Stage 4.doc Version 1.40 personal references. 5. 6. 38 38 17 (1) (a) 13 (5) That the accident book is completed following any injury to the service users. That suitable arrangements are in place to provide a safe system for moving and handling service users. 7 September 2005 7 september 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Queen Alexandra Cottage Homes H59-H10 14032 Queen Alexandra Cottage Homes V234895 070905 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Ivy House 3 Ivy Terrace Eastbourne East Susssex 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 H59-H10 14032 Queen Alexandra Cottage Homes V234895 070905 Stage 4.doc Version 1.40 Page 26 - 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. 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