Inspection on 01/09/05 for Alba Rose

This inspection was carried out on 1st September 2005.

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

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

Other inspections for this house

Alba Rose 17/04/07

Alba Rose 16/01/06

Alba Rose 01/03/05

Alba Rose 06/10/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Alba Rose Keldhead Hall Middleton Road Pickering YO18 8NR Lead Inspector Karen Ritson Unannounced 1st September 2005 09.30 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. 0 J53 J04 S7625 Alba Rose V243704 310805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Alba Rose Address Keldhead Hall Middleton Road Pickering North Yorkshire YO18 8NR 01751 472754 01851 477170 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) Alba Rose Partnership Mrs Ann Barnes Care Home Only 19 Category(ies) of Older Persons mixed gender 19 registration, with number of places 0 J53 J04 S7625 Alba Rose V243704 310805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 01/03/05 Brief Description of the Service: Alba Rose provides services for nineteen older people, which include physical personal care, meals provision, laundry and domestic services. In addition, recreational and social opportunities are offered. Care is delivered by staff over a 24-hour period. Those needs that cannot be met by the home are addressed through community services, e.g. G.P. consultations, community nursing attendance. The registered providers are Mrs. Anne-Marie Whincup and Mr. Christopher Whincup. The registered manager is Mrs. Ann Barnes. The property is built on three floors with the service users’ accommodation located on all levels. A passenger lift provides access to all floors. All bedrooms except one have en suite facilities. There are seventeen single bedrooms and one shared room. The bedrooms are individually decorated and the service users are encouraged to furnish them with their personal belongings. The home is located in a quiet area on the western edge of Pickering. The building, originally built as a private dwelling and used later as a convent, has been converted to suit the needs of older people. The building reflects aspects of its former use. The home is set within its own large grounds with stepped access to the front of the property and level access to the side. There is parking space available for several vehicles. 0 J53 J04 S7625 Alba Rose V243704 310805 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 September 1st 2005. The manager and proprietor were available throughout the inspection. There was a calm and peaceful atmosphere on arrival at the home, with service users either in their rooms or chatting in the lounge. Six service users and four members of staff were spoken to. Their comments are detailed within the body of the reports but all service users without exception expressed great confidence in the staff teams’ ability to provide quality care. This inspection took eleven hours to complete which includes time for preparation and writing the report. What the service does well: What has improved since the last inspection? Developing the written plan of care has been improved to place service users at the centre of the process, so that they have the opportunity to inform staff of their priorities of care. Assessments have been made more thorough. Quality assurance audits continue to highlight areas which service users and staff feel are important and these are acted upon as part of the regular running of the home. The kitchen was in the process of being refitted. 0 J53 J04 S7625 Alba Rose V243704 310805 Stage 4.doc Version 1.40 Page 6 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. 0 J53 J04 S7625 Alba Rose V243704 310805 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 0 J53 J04 S7625 Alba Rose V243704 310805 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) 3 and 6 Service users are assured that their care needs will be met. EVIDENCE: The home provides a detailed and comprehensive assessment of care. A social history is provided, with all areas of care required including risk assessments where necessary. These are more detailed than at the last inspection and provide a clearer basis upon which to develop the care plan. All assessments are carried out with service users involvement. A high proportion of the service users commented that they had been asked what they felt their care needs were and the assessment had been drawn up from their comments, observation and from professional advice. Service users and staff alike reported that the service users were involved and central to this assessment process. One service user was particularly impressed with the amount of detailed knowledge the home had endeavoured to gather prior to her admission and she felt reassured that the staff knew everything required to make her life at Alba Rose safe, comfortable and enjoyable. This home does not offer intermediate care. 0 J53 J04 S7625 Alba Rose V243704 310805 Stage 4.doc Version 1.40 Page 9 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 and 10 Service users health care needs are fully met. EVIDENCE: Staff work alongside service users in developing a care plan and in devising achievable goals. This process is service user led. The service users and staff discuss goals, which are agreed and recorded. Management keep in mind that goals should be specific, measurable, achievable, realistic and timely. Service users were spoken to and it became clear that each specific goal is individually tailored and arranged in order of priority as deemed by the service user. Each area of the care plan is reviewed each month with goals adjusted according to need. Goals ranged from quality care for a very dependant resident who required regular turning in bed and specific emotional support, to a plan for one service user to go swimming. Those who express unrealistic hopes are advised in a way which would help a more achievable goal to be agreed and care needs which the service user may not be aware of are also detailed. All service users spoken to said they felt involved and that staff valued their views. All enjoyed the sense they were working towards a goal. Some service users said they were happy to continue in the home with no specific goals in mind and staff had respected these wishes. The home has strong links with the local surgeries and all contact with these and any other external agency is 0 J53 J04 S7625 Alba Rose V243704 310805 Stage 4.doc Version 1.40 Page 10 recorded. The provision for service users regarding exercise continues to be particularly creative. A physical exercise instructor visits the home on a weekly basis to offer a variety of different exercises using equipment for which there are thorough risk assessments in place. The service users said this encouraged them to try out exercises they would not usually attempt and that they felt safe as the instructor was present at all times to help individuals where needed. Service users have enjoyed using a rowing machine, throwing bean bags, balls, bowls, balloons and using other objects to enhance hand and eye coordination. A number have visited the gym itself and completed the outing with a pub meal. Medication is handled appropriately and staff have had suitable accredited training. Medication administration is subject to regular internal quality audits, the records of which were open to examination. All recording was in order. 0 J53 J04 S7625 Alba Rose V243704 310805 Stage 4.doc Version 1.40 Page 11 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) 12,13,14and 15 Service users have choice and control over the way they live their lives. EVIDENCE: Service users said that the staff spent time with them to find out their preferences and interests. Individuals are encouraged to develop their own interests; at present there is a debating club, which is held informally between residents with no staff involvement. Other service users go out with staff on a one to one basis or for outings chosen by service users in the homes’ own transport. Tea on the terrace had been held recently to which service users and friends had been invited. A summer barbeque had just taken place and the home was planning a produce show with entries encouraged by all involved in the home. A survey was carried out recently regarding the lay out of the dining area, with a proposal to include a bar area and to provide bays for tables in order to provide a sense of privacy and comfort when dining. Service users had decided they did not wish to change the current arrangement however. Visitors may call at any reasonable time and all service users said they had considerable control over the way in which they lived their lives. The meals continue to be of a high standard and service users assist with the development of menus. All said they found the meals to be excellent. 0 J53 J04 S7625 Alba Rose V243704 310805 Stage 4.doc Version 1.40 Page 12 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 and 18 Service users are protected from abuse and complaints are acted upon. EVIDENCE: Service users all said that any concern was listened to, acted upon and taken seriously by the staff. There had been no formal or internal complaints since the last inspection. Service users are protected from abuse through well trained staff. All staff understood the abuse policy and procedure and were aware of the procedure for the Protection of Vulnerable Adults. Service users said they felt safe and well cared for. 0 J53 J04 S7625 Alba Rose V243704 310805 Stage 4.doc Version 1.40 Page 13 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 and 26 The home is well maintained and clean. EVIDENCE: The home is well maintained and redecorated on a regular basis. There are sufficient toilet and bathing facilities and communal space is pleasantly laid out. The paths in the garden have been made wider this year and there is an area where service users may sit, near to a raised border planted and tended by service users, or they may make use of the gazebo nearby. A vegetable garden and greenhouse are towards the end of the garden and service users may become involved in picking vegetables should they wish. A new kitchen was being installed on the day of inspection, with a new tumble drier being fitted also. The home is clean and the living environment very pleasant. All service users said they enjoyed their surroundings and that they had been kept informed regarding the new kitchen installation. 0 J53 J04 S7625 Alba Rose V243704 310805 Stage 4.doc Version 1.40 Page 14 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) 27,29 and 30 Service users’ welfare is protected by well trained and recruited staff in adequate numbers. EVIDENCE: The home is well staffed. An emphasis is placed upon recreation time with staff being employed specifically to spend time with service users in this way. Service users said there were plenty of staff to carry out their duties without having to rush and that there was time to go out in the caravelle in the afternoons, shopping or whatever the service users preferred to do. One member of staff is employed for 16 hours a week to carry out quality assurance audits. Staff are recruited according to policy and procedure and receive all required training. Staff said there was provision for them to receive training in areas of particular interest and this was discussed in regular supervision meetings. 0 J53 J04 S7625 Alba Rose V243704 310805 Stage 4.doc Version 1.40 Page 15 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) 31, 33, 35 and 38 The home is run in the best interests of the service users. EVIDENCE: The registered manager has now achieved NVQ level 4 in care and management. The home continues with a detailed and thorough quality assurance system based on regular questionnaires distributed to service users, friends, relatives, health care professionals and all others coming into contact with the home. Quality assurance audits are regularly carried out by the member of staff employed specifically for this purpose. All information is collated and fed back to service users and staff in regular meetings. Staff and service users said that suggestions were taken on board by management and many had been acted upon. Service users also commented that they felt encouraged to mention any quality issue at any time and all concerns or comments were listened to and acted upon appropriately. The results of the quality assurance surveys are 0 J53 J04 S7625 Alba Rose V243704 310805 Stage 4.doc Version 1.40 Page 16 published and available for any interested party to examine. The home has a policy of continual self -monitoring and has a proactive approach to improving the quality of service through consultation and regular review. The home gained the ‘Investors in people’ award in January 2005. The home does not become involved in service users finances. All health and safety documentation was up to date, with all certificates in place for systems and appliances. 0 J53 J04 S7625 Alba Rose V243704 310805 Stage 4.doc Version 1.40 Page 17 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 x x 4 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 4 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 4 28 x 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 4 x N/A x x 3 0 J53 J04 S7625 Alba Rose V243704 310805 Stage 4.doc Version 1.40 Page 18 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 Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations 0 J53 J04 S7625 Alba Rose V243704 310805 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross, York YO32 9GZ 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. 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