Inspection on 13/06/05 for Albany House

This inspection was carried out on 13th June 2005.

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.

Other inspections for this house

Albany House 20/10/08

Albany House 14/11/06

Albany House 10/10/05

Albany House 15/03/05

Albany House 09/08/04

Albany House 06/05/04

Albany House 16/12/03

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

CARE HOME ADULTS 18-65 Albany House 17 Esplanade Whitley Bay Tyne & Wear NE26 2AH Lead Inspector Jim Lamb Unannounced 13 June 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Albany House B53-B03 S362 AlbanyHouse V223123 130605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Albany House Address 17 Esplanade Whitley Bay Tyne & Wear NE26 2AH 0191 252 5021 N/A N/A Mrs Anne Elkin 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) Mrs Anne Elkin CRH 10 Category(ies) of MD - Mental Disorder (6) registration, with number MD - Mental Disorder over 65 (4) of places Albany House B53-B03 S362 AlbanyHouse V223123 130605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 15 3 05 Brief Description of the Service: Albany House provides care and accommodation for 10 service users who have mental health needs. The home is situated on The Espanade, a busy street close to the sea front in the coastal town of Whitley Bay. The towns many shops and leisure facilities are very accessible and the area has good transport links. The accommodation is provided over three floors within a converted Victorian terraced house. On street parking is available for non-permit holders on the oppisite side of the street at the front of the home. The rear yard has a sitting area that is easily accessible. Albany House B53-B03 S362 AlbanyHouse V223123 130605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 10.am. It took place over 4 hours during the morning and early afternoon. The inspector spoke to four service users separately, two members of staff and the registered manager. Records were also examined. What the service does well: What has improved since the last inspection? What they could do better: Albany House B53-B03 S362 AlbanyHouse V223123 130605 Stage 4.doc Version 1.30 Page 6 The home needs to devise a policy and procedure for the care of people who remain under provision of the Mental Health Act 1983; this is a remaining outstanding requirement. The registered manager will need to complete NVQ level 4 registered managers award by 31.12.05. 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. Albany House B53-B03 S362 AlbanyHouse V223123 130605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Albany House B53-B03 S362 AlbanyHouse V223123 130605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 2 4 The homes statement of purpose includes all information required by this standard. The service users needs are appropriately assessed. All potential service users are given the opportunity to visit the home prior to admission. EVIDENCE: Details of the extra charges and what these are for, are in the contract given to service users and are agreed prior to their admission. The homes Statement of Purpose contained the full range of information required. Two service users interviewed confirmed they had been given copies of the guide. Which were available in large print. The inspector saw a copy of the standard contract used. It contained the range of information required by the standards. Four service users interviewed confirmed they had a copy of their individual contract. Three service users’ files were checked and on each were a copy of a full needs assessment. These were carried out by appropriately trained people eg - the referring social worker and for those self-funding by the registered manager. Albany House B53-B03 S362 AlbanyHouse V223123 130605 Stage 4.doc Version 1.30 Page 9 They did contain a range of appropriate information and service users interviewed confirmed they were involved in drawing up both these initial assessments and the home’s subsequent service user plans. The 4 service user plans checked by the inspector were comprehensive, and listed details of service user’s needs and actions taken by the staff to meet these needs. Four residents interviewed said their needs were met and they were happy with the care offered to them. Three care plans were checked and staff members interviewed. These confirmed that a range of specialist services was provided to service users. Staff interviewed had had a range of relevant training and experience. All service users are invited to visit the home prior to admission to meet other service users and staff. Overnight stays can also be arranged. Albany House B53-B03 S362 AlbanyHouse V223123 130605 Stage 4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 8 9 10 The home ensures that there is a proper assessment and risk profile completed prior to service users moving into the home. Service users are consulted about the running of the home. EVIDENCE: There is evidence of a comprehensive assessment in the service users’ care plans. There is also a comprehensive risk assessment of service users. There was evidence of advocacy arrangements, as well as family input. Each service user has an allocated key worker. Care plans are drawn up with service users. There is evidence that plans are amended and reviewed on a regular basis. Care plans for those over 65 are kept under review in accordance with Older Persons Standards. Albany House B53-B03 S362 AlbanyHouse V223123 130605 Stage 4.doc Version 1.30 Page 11 Self-advocacy is promoted, service users can access a range of external agencies that promote independence, and any rights that are restricted are linked to risk assessments. Each service user receives support from staff to manage their finances. Service users’ said that they are able to make decisions for themselves. Albany House B53-B03 S362 AlbanyHouse V223123 130605 Stage 4.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11 12 13 14 15 The service users social activities and meals are both well managed. Individual personal development is promoted. EVIDENCE: Each service user has a practical personal skills assessment carried out and this is reviewed and updated every six months, all service users participate in this process, and their relatives and professionals involved are invited to attend. Validated intervention treatment programmes are accessed if a need does arise. I was informed that the service users have access to a range of communitybased services, which promote and provide opportunities to learn and use practical life skills. There was evidence that each service user has the opportunity to participate in community-based activities, including supported work programmes, education and training. The staff team liaise closely with external agencies in order to monitor each service user progress. Albany House B53-B03 S362 AlbanyHouse V223123 130605 Stage 4.doc Version 1.30 Page 13 I was informed that if applicable, service users are supported to maintain links with their families. All are able to choose who they want to see and when. There was evidence that daily routines promote independence, choice and freedom of movement. I was informed that service users are involved in housekeeping tasks and food shopping. The inspector observed staff interacting in a sensitive and respectful manner with service users. The Home’s menus are based on the known likes and dislikes of the service users. At least two hot meals are provided on a daily basis. Service users have access to the kitchen and are able to prepare snacks for themselves if they wish. The service users that I spoke with said that the food was very good. I discussed the use of nutritional assessments with the homes representatives; these will be introduced, particularly for those service users over 65. A range of special diets can be catered for. Albany House B53-B03 S362 AlbanyHouse V223123 130605 Stage 4.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 19 20 There are systems in place to ensure that the service users health and personal care needs are identified and met. Medication systems are well managed. EVIDENCE: No service users currently have any moving and handling needs. I was informed that service users mainly need supervision and minimum help with their personal care tasks, such as bathing. The service users informed the inspector that their privacy and dignity are respected at all times. No service users currently have or require any technical aids or equipment. There was evidence within the service users care records that they have access to external health care services. G.P.’s visit when necessary, and service users are referred for specialist health care if appropriate. All service users receive regular health care checks. I examined the records and the procedures for the administration of medication; these appeared to be appropriately detailed. Albany House B53-B03 S362 AlbanyHouse V223123 130605 Stage 4.doc Version 1.30 Page 15 The medication systems were examined for ordering, receiving and administering and disposal. No controlled drugs are currently prescribed, should this change the proprietor is aware that a controlled drugs cabinet will have to be provided. Staff have all undertaken medication training. All procedures were found to be well organised. I was informed that the dispensing pharmacist offers good support and advice. Albany House B53-B03 S362 AlbanyHouse V223123 130605 Stage 4.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 23 Complaints are handled objectively; the service users were confident that their concerns will be listened to and acted upon. The staff have undertaken protection of vulnerable adults training. EVIDENCE: The home does have a complaints procedure, which the inspector saw. It contains details of how to contact the CSCI to make a complaint, that complaints would be responded to in 28 days and that complainants would not be victimised. Four service users interviewed confirmed that they had been given copies of the procedure and that staff listened to their concerns/ complaints and dealt with them fairly. They spoke of their key workers supporting them and helping them to complain. One service user spoken to who had made a complaint said these had been dealt with fairly. The home does keep a record of complaints. The home has a Whistle Blowing policy procedure as well as, the Local Authorities Vulnerable Adults procedures. The home also has a copy of the D.H. “NO SECRETS” for further information. Albany House B53-B03 S362 AlbanyHouse V223123 130605 Stage 4.doc Version 1.30 Page 17 The Home maintains financial records on behalf of the service users; each has an individual bank account. The manager intends to devise a new format for the recording of the service users personal finances. Albany House B53-B03 S362 AlbanyHouse V223123 130605 Stage 4.doc Version 1.30 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 25 26 27 28 29 30 The home is, clean well maintained, safe and comfortable. Service users are supported to maintain their independence. EVIDENCE: On the day of the inspection the home was clean, well decorated and well maintained. Four service users interviewed did say it was homely and comfortable. The grounds were tidy, safe, and accessible. The fire service had made visits to the home. Requirements made had been addressed. The home does have an appropriate amount of sitting, recreational and dining space. There are sufficient rooms for a variety of activities to take place. Service users can see visitors in private in their own rooms. The dining area is large enough to cater for all service users. Albany House B53-B03 S362 AlbanyHouse V223123 130605 Stage 4.doc Version 1.30 Page 19 Furnishings and fittings were domestic in design and in good condition. Lighting was sufficiently bright and also domestic in design. The home does have a sufficient number of baths, showers and toilets. These were close to bedrooms, lounge and dining area. Doors were had privacy locks. Room sizes did meet the minimum required. Room dimensions were such there was space on either side of the bed when necessary to enable access for carers and specialist equipment. All bedrooms are single and have a washbasin. Service users’ bedrooms checked all had opening windows. The rooms were centrally heated and the heating level could be controlled within each bedroom. There was emergency lighting throughout the home. The manager said water is stored at over 60°C. Valves are in situ at water outlets to ensure water is provided close to 43°C to prevent scalding. The home was clean and free from offensive odours. The laundry facilities appeared to be well organised, COSHH information was available. The washing machine has the specified programme to meet disinfection standards. Albany House B53-B03 S362 AlbanyHouse V223123 130605 Stage 4.doc Version 1.30 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 33 35 35 The deployment and number of staff is currently sufficient to meet the needs of the service users. There are safeguards in place to protect the service users. EVIDENCE: Staff levels on the day of the inspection did meet the agreed level. Samples of 4 weeks’ rotas were checked and these stated the required numbers of staff were on duty. Staffing; 1 staff from 7.30am – 11 pm and one staff on sleep-in duty during the night. The manager is aware that, should the dependency levels of the service users increase the home will require to re-asses staffing levels. The home has a clearly defined stand-by on-call system. Staff spoken to and service users interviewed said that staffing levels were appropriate. All the staff were over 18 years of age and those left in charge were at least 21. All new staff members receive induction within 6 weeks. The manager confirmed the programme meets National Training Organisation requirements, she said it covered such things as safe working practices, the organisation and workers role and the needs of the service user group. Albany House B53-B03 S362 AlbanyHouse V223123 130605 Stage 4.doc Version 1.30 Page 21 Training needs of staff are identified via supervision. The training programme has been reviewed to ensure it meets The National Training Organisation requirements for the first six months. Albany House B53-B03 S362 AlbanyHouse V223123 130605 Stage 4.doc Version 1.30 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 38 41 40 42 43 The home is well managed although the manager requires NVQ level 4. There has been a low turnover of staff in the last six months. The home is required to develop a policy and procedure for those who remain under the provision of the 1983 Mental Health Act. EVIDENCE: The registered manager/proprietor has many years experience in senior management. She is aware that she will need to commence towards a level 4 National Vocational Qualification in management and care by 31.12.05. In the last year all of the staff team have attended several courses to keep themselves up to date. Staff interviewed were clear about the their responsibilities. Albany House B53-B03 S362 AlbanyHouse V223123 130605 Stage 4.doc Version 1.30 Page 23 Service users interviewed spoke positively about the manager saying she had encouraged service users to contribute to the development of the service. Service users are informed when inspections take place and have access to inspection reports. Copies are on display for relatives/others to see. The records that I inspected were found to be appropriately completed, these included the Health and Safey manual and maintenance records, and I was provided with information which verified that appropriate maintenance contracts for the home are in place. Water storage tanks are checked annually. Finance records have previously been forwarded to the CSCI to verify that the home is viable. Albany House B53-B03 S362 AlbanyHouse V223123 130605 Stage 4.doc Version 1.30 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 x 3 Standard No 31 32 33 34 35 36 Score 3 x 3 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Albany House Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 2 3 x 1 3 3 3 B53-B03 S362 AlbanyHouse V223123 130605 Stage 4.doc Version 1.30 Page 25 yes 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 ya 40 Regulation 12 (1) (b) 13(6) Requirement The following policy and procedure must be introduced; The care of people who remain under the Mental Health Act 1983. Outstanding requirement The registered manager is required to have a level 4 management and care qualification. Timescale for action 1.9.05. 2. ya 37 9 (i) 31 12.05 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 No recommendations were identified. 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