CARE HOMES FOR OLDER PEOPLE
Alba Rose Keldhead Hall Middleton Road Pickering North Yorkshire YO18 8NR Lead Inspector
Jean Dobbin Unannounced Inspection 16th January 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 Alba Rose DS0000007625.V274599.R01.S.doc Version 5.1 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. Alba Rose DS0000007625.V274599.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Alba Rose Address Keldhead Hall Middleton Road Pickering North Yorkshire YO18 8NR 01751 472754 01751 477170 albarose@freenetname.co.uk 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) Alba Rose Partnership Mrs Ann Lesley Barnes Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Alba Rose DS0000007625.V274599.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 1st September 2005 Brief Description of the Service: Alba Rose is a large, old detached house situated on the western side of the small town of Pickering It has an open aspect over the surrounding countryside. It was formerly a convent as well as a private residence, but has now been converted to provide care for nineteen residents on three floors, with a vertical passenger lift to aid access. There are seventeen single bedrooms and one shared room, which are on all three levels. All bedrooms except one single have en suite facilities. There are large landscaped gardens providing easy access for residents, and parking is available on site. Alba Rose provides personal and social care for residents over the age of 65 and there are close links with the community nursing team. The home has a ‘minibus’ with wheelchair access, which is used to maintain links with the local community. Alba Rose DS0000007625.V274599.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This summary relates to an unannounced inspection on Monday 16th January 2006, lasting seven hours including preparation work. The registered manager and one of the proprietors, Mrs Anne-Marie Whincup, were present throughout the visit. The inspection included a tour of the service users’ areas, both communal and private as well as looking at some policy documents, recruitment file and records of how the service user’s care is planned and assessed. The accident book and complaints file were also examined. There had been no complaints since the last inspection. There was the opportunity to talk with a number of residents, staff and two visitors to the home. Their comments are contained within the main report. What the service does well: What has improved since the last inspection?
Care planning continues to be ‘resident led’ with the emphasis on a supportive and enabling culture within the home. Planned decoration and refurbishment is ongoing. The new kitchen is established and there are plans to further improve the gardens for the resident’s benefit. Alba Rose DS0000007625.V274599.R01.S.doc Version 5.1 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. Alba Rose DS0000007625.V274599.R01.S.doc Version 5.1 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 Alba Rose DS0000007625.V274599.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Residents can be assured that their individual needs can be met EVIDENCE: The care needs records of four residents were examined during the inspection. These suggested that there had been a comprehensive assessment carried out prior to moving to the home. This information included understanding their physical, emotional and spiritual needs, to ensure Alba Rose staff would be able to support them appropriately. There were also wide-ranging details about the individual’s social history, and what was important to them. Those residents interviewed confirmed that the details were taken prior to moving to the home. They also said they had felt very ‘included’ and reassured by the assessment process. Residents can be sure that the care provided at Alba Rose will be based on sound assessments carried out before they move there. Alba Rose DS0000007625.V274599.R01.S.doc Version 5.1 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 the following standard(s): 7,8 Residents have clear individualised plans of care and their health care needs are met. EVIDENCE: The care planning process is carried out with the resident and decisions about their care are reached together. In that way residents are enabled to stay in control of their lives and carers work to support them. These plans are reviewed monthly with the resident to ensure that they are still important to them and that the plan is still appropriate. One resident confirmed that their file was discussed with them each month. Shared goals are prioritised by the resident and reviewed regularly by staff. These goals include maintaining social and recreational activities, as well as the day-to-day routines. There are comprehensive risk assessments in place, which are also reviewed regularly. The documentation contains details of visits and communication with external health care professionals like the GP, community nurse, speech and language therapist and local hospital services. Residents can be reassured that they will be consulted, and informed, about all aspects of their care, both within the home and from outside healthcare professionals. Alba Rose DS0000007625.V274599.R01.S.doc Version 5.1 Page 10 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: Alba Rose DS0000007625.V274599.R01.S.doc Version 5.1 Page 11 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: Alba Rose DS0000007625.V274599.R01.S.doc Version 5.1 Page 12 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 The residents live in a very pleasant environment, which is both well maintained and well decorated. EVIDENCE: Alba Rose provides a clean and comfortable environment. One resident described it as “very homely”, whilst a visitor stated that they were “so thankful that their relative was living here”. There is a planned programme of routine maintenance and redecoration, and the fire records are up to date. The gardens are easily accessible, with wide paths, raised flowerbeds and a large seating area, with views over the countryside. The home has an Infection Control policy and all those staff spoken with, were very clear about their responsibilities to ensure residents are protected by safe practices. Alba Rose is a very pleasant home and all the residents, who were spoken to, confirmed that they were very happy living there. Alba Rose DS0000007625.V274599.R01.S.doc Version 5.1 Page 13 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 A robust recruitment policy ensures residents are in safe hands. EVIDENCE: The file for the newest employee at Alba Rose was examined to check the recruitment process. This confirmed that mandatory checks had been made prior to starting work and documentation was obtained according to the home’s policy. Residents can be assured that they are in safe hands. Alba Rose DS0000007625.V274599.R01.S.doc Version 5.1 Page 14 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: Alba Rose DS0000007625.V274599.R01.S.doc Version 5.1 Page 15 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X X Alba Rose DS0000007625.V274599.R01.S.doc Version 5.1 Page 16 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. 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 OP18 Good Practice Recommendations The management need to ensure that staff understand their responsibilities should there be an allegation of abuse within the home. Alba Rose DS0000007625.V274599.R01.S.doc Version 5.1 Page 17 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
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