Inspection on 24/07/07 for Albany House

This inspection was carried out on 24th July 2007.

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 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

Albany House 19/01/10

Albany House 19/11/09

Albany House 04/08/09

Albany House 08/08/06

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Albany House The Square Tisbury Salisbury Wiltshire SP3 6JP Lead Inspector Karen Mandle Unannounced Inspection 24th July 2007 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 DS0000065877.V341192.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000065877.V341192.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Albany House Address The Square Tisbury Salisbury Wiltshire SP3 6JP 01747 870313 F/P 01747 870313 albanyhouse@bmcare.plus.com www.bmcare.plus.com BM Care Limited 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) Mrs Janet Matthews Care Home 21 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (21) of places DS0000065877.V341192.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Albany House can accommodate one named service user with Dementia however, the registered person must notify CSCI if the service user is no longer accommodated. This condition will then be removed. 8th August 2006 Date of last inspection Brief Description of the Service: Albany House is an older detached building, which is situated in the village of Tisbury, Wiltshire. The home benefits from a good location within the centre of the village, within walking distance of the local amenities. A main line station from Waterloo to the west country is also located in Tisbury and again within walking distance of Albany House. Accommodation is provided on 2 floors of the home with the majority of the bedrooms provided being single. The home provides two communal areas and a large conservatory, which leads to a pleasant patio area and garden. Albany House is registered to provide personal care for 21 older people. The home was purchased by BM Care Limited in Jan 2006. The registered manager of the home is Janet Matthews. DS0000065877.V341192.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit for this key inspection commenced 24th July 2007 and was completed on the 2nd August 2007. Helen Hindel, senior carer was in charge of the home during the first day of the inspection. Helen was very helpful and open to the inspection process. The Manager Janet Matthews was available to assist the inspector during the second visit. The inspector was able to freely tour the building, visit with many service users, and observe the staff interacting with service users. Prior to the site visit-taking place, the inspector sent surveys to the home to gain the opinions from the service users. Ten surveys were returned, all of which gave positive comments about the service provided. The inspector was able to speak with many of the service users who were complimentary of the care and support offered by the home. Comments made by service users are contained in the body of this report. Three requirements were set and two good practice recommendations following this inspection. The judgments contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the service does well: What has improved since the last inspection? The Statement of Purpose has been revised, which now reflects the current ownership of the home. A pressure area risk assessment had been implemented to ensure correct measures are in place to reduce the risk of service users suffering from pressure damage. Service users are weighed monthly. The fire alarm system is being tested weekly. The providers are continuing to improve the environmental standards. The kitchen has been DS0000065877.V341192.R01.S.doc Version 5.2 Page 6 refurbished. The garden and patio area were excellent, which two service users commented on. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000065877.V341192.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000065877.V341192.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An up to date Statement of Purpose is provided. All service users are assessed prior to admission to ensure that the home is able to meet the individual care needs of the service user. The home is not registered to provide intermediate care. EVIDENCE: Each service user is assessed by Janet Mathews, the manager, prior to admission. Ensuring that through the assessment process the home is able to meet the personal care and social care needs of the service user. Two-pre admission assessments were seen which provided information of the service users care needs. A record of the assessment is kept on the service users’ file. DS0000065877.V341192.R01.S.doc Version 5.2 Page 9 Two service users confirmed that they had chosen to live at Albany House by saying, “ I came here because my family live in the area” and “I am a local person and knew of the home and decided it was where I needed to live”. The Statement of Purpose had been revised to reflect the change of ownership, which took place during the end of 2005/2006, and now contains all relevant information relating to the service provided by the home. Albany House is not registered to provide intermediate care therefore Standard 6 is not applicable. DS0000065877.V341192.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are provided with care plans, however not all care needs are identified through the care plans and care records are not being reviewed monthly. Health care needs are closely monitored. The medication procedure continues to improved, however the storage of some medication was not safe. Service users are treated with respect by the staff. EVIDENCE: The care records of three service users were reviewed. The care records did not provide enough information regarding the care needs of the service users, ensuring that staff had been provided with clear instructions on how to meet care needs. However the manager is currently implementing a new format, which she believes will resolve this on going problem with recording. The manager will need to ensure that care plans will be reviewed monthly and DS0000065877.V341192.R01.S.doc Version 5.2 Page 11 when care needs change. All care staff should be involved with care planning, which should be encouraged by the manager. The manager should also ensure that unnecessary duplication of documents is not used and old documents removed for the care records. Whilst the care plans provided minimum information, the daily report was fairly detailed and provided evidence of health care needs of the service users being closely monitored. It was evident that any changes in health care needs were promptly addressed by contacting the GP to arrange a visit to the home. The community nursing team addresses any nursing care needs, as the home is not registered to provide nursing care. Two community nurses visited the home during the inspection both of which were very complimentary of the care provided and said “The residents are very well looked after here” and “I think it is an excellent home”. All service users are registered with a local GP practice that visits the home on a regular basis. Appropriate pressure reliving equipment had been provided to service users assessed as at risk of pressure damage. The inspector was able to visit with many of the service users who also provided positive comments about the care provided such as “They look after us very well” and “The staff do anything for you here”. Another service user said, “Since I have lived here, I have had my eyes tested and my feet seen to which the home arranged for me ”. The medication procedure continues to improve with a monitored dosage system now in place. The morning medication round had been changed from the night staff administering the morning medications to the day staff, which is considered as safer practice. However not all the controlled medication was stored correctly. The home must ensure that they are fully informed as to what is a controlled medication, if not they should contact the providing pharmacy for advice. The medication administration records were up to date but the controlled register was not. It will be recommended that a review of the medications training provided take place, to ensure that staff had received appropriate training. The controlled drugs cupboard provided was not adequate and will need to be replaced. The inspector was able to visit with many of the service users some of which by choice spent much of their time in the privacy of the own rooms. These service users expressed how much they appreciated that the care staff fully respected their privacy and dignity. A service user said, “They always knock on my door before coming in” and another said, “The staff treat you well and seem to respect what you want”. Service users confirmed that all personal care was provided in the privacy of their bedrooms or bathrooms, which was also observed taking place by the inspector whilst touring the building. DS0000065877.V341192.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Albany House has put a lot of work into developing appropriate activities for service users. Service users are supported to maintain links with family and friends. The food provided is of a good standard with varied menus supporting the dietary needs of the service users. EVIDENCE: The main activities programme is provided twice a week, which are an art class, music and singing and question time. The artwork completed by the service users was nicely displayed around the home. A clear record of all activities and who participated was kept which was inclusive of a written statement of the outcome of the activity for the individual service user. Service users who did not wish to participate with the activities were able to spend time reading, watching TV and listening to the radio. Service users are also supported to visit the village amenities for personal shopping and a service user enjoys walking to village independently. Service users when asked about the amount of activities provided said “Oh its enough for me, I don’t want DS0000065877.V341192.R01.S.doc Version 5.2 Page 13 activities everyday” and another said “If there are no activities going on, we enjoy sitting in the conservatory with each other”. Service users were able to confirm that they could receive visits from family and friends at any time, in the privacy of their bedrooms or in one of the communal rooms. A record is maintained of all visitors to the home. To support a service user who wished to smoke, the providers had built a covered deck area outside of her room leading from the patio doors. The chef showed a good understanding of the dietary needs of the service users and knew the likes and dislikes of the individual service users. The chef manages al the ordering of the food and tries to use fresh local meat and fresh fruit and vegetables. The kitchen has been refurbished to a good standard. The main hot meal of the day was served at lunchtime, which was well presented and nicely cooked. Service users were complimentary of the food provided with no complaints received regarding the quality of the food. Comments received were “The food is very good here, no complaints” and “The cook will make you what you want really”. A pleasant dining room is provided which many of the service users were seen using, however service users were also able to receive their meals in the privacy of their bedrooms if they wish. Service users needing support with their meals were provided with one to one assistance by a carer. DS0000065877.V341192.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A complaints procedure is in place and the manager approaches complaints openly. The manager and staff understand the local vulnerable adults procedure and had received training about the procedure. EVIDENCE: A complaints policy and procedure is in place and is clearly displayed for service users and visitors. The manager has an open attitude to complaints. A complaint was received about the variety of food. The manager dealt with this by ensuring an up to date list of likes and dislikes was in place for all service users. The service users revised the menus and a meeting took place with the family. The manager fully understands the local vulnerable adults procedure and how to make a referral in the event of an allegation of abuse being reported. The staff had received training in “Adult Protection” and it was evident through conversation with a senior carer that she also understood the local procedure. DS0000065877.V341192.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Albany House is a well-maintained and homely offering a good standard of accommodation. The bedrooms are very personalised and well furnished. Infection control measures are in place. The home was clean to a good standard throughout. EVIDENCE: Albany House is a large older detached building well situated in the centre of the village close to all the local amenities that the village offers. The home is well maintained throughout offering a homely environment for service users to live in. The communal areas are furnished with domestic furnishings and provide comfortable living space for the service users. The providers are DS0000065877.V341192.R01.S.doc Version 5.2 Page 16 making good improvements to the environmental standards of the home. The conservatory, garden and patio area are now extremely well maintained offering a pleasant sitting area for service users. Service users made comments regarding the improvements, which had been made since the current providers purchased the home such as “They do so much for us and have made the home so nice”. The inspector was able to visit many of the bedrooms, which vary in shape and size, as the home is not purpose built. The bedrooms were well furnished, personalised and very homely. The bedrooms are provided with an en-suite facility. Service users are encouraged to bring with them their own furniture as well as personal items. A service users said “Please go and look at my room it’s lovely”. The home was clean throughout to a good standard with two cleaners on duty. The laundry facility was clean and organised, with systems in place to ensure the separation of potentially infected laundry. Infection control measures were in place. Hand washing facilities for staff should be provided in each bedroom to reduce the risk of cross infection. Disposable gloves and aprons seen being worn by care staff. All clinical waste was dealt with appropriately. The District Nurse was providing infection control training in September 2007 to all the staff. DS0000065877.V341192.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The recruitment procedures ensure the safety of service users as much as possible. The staffing levels provided meet the care needs of the service users. All mandatory training is provided. EVIDENCE: The staffing level provided during the inspection and according to the staffing rotas was: The manager and 3 carers until 1.00pm, the manager and 2 carers until 5.00pm, 3 carers during the evening shift until 7.00pm, two carers between 7.00pm and 9.00pm and two waking night staff. Domestic staff and kitchen staff are provided. The home is currently without a handyman. Agency staff may be used periodically. With speaking to the service users it was evident that the level of care staff provided met with the personal care needs of the service user, as the service users were very complimentary of the care provided by the staff. Comments were made such as “The staff are lovely here and very helpful” and “They do anything you ask I’m really impressed”. The employment files of three members of staff were reviewed. The employment files were of a good standard with all appropriate police checks DS0000065877.V341192.R01.S.doc Version 5.2 Page 18 made, at least two references obtained with some files having three references. The records of one overseas staff lacked a reference, however all other appropriate documents were in place. Evidence that all mandatory training had been provided was available. A clear training plan for all staff was displayed in the managers’ office. The manager supports staff with NVQ training. The District Nurse was providing infection control training. A senior carer was currently completing NVQ Level 4 and stated, “I have enjoyed it”. It will recommended, that a review takes place of the medication training to ensure that new staff are competent to manage the controlled medications. DS0000065877.V341192.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Quality assurance systems are in place ensuring the views of the service users are gained. The home will not manage personal money. The home has systems in place to meet health and safety issues. The manager understands the care needs of the service users. EVIDENCE: Janet Mathews has been the registered manager at Albany House for approximately four years. Janet has a clear understanding of the care needs of the service user group. However Janet should pay more attention to ensuring that the care records of service users are complete and should make frequent DS0000065877.V341192.R01.S.doc Version 5.2 Page 20 checks regarding the storage and administration of medications ensuring that all systems are safe. Janet had continued to development quality control systems. Resident’s meetings regularly being held, providing an opportunity for service users to express any concerns or improvements they would like to see to the service provided by the home. Janet reported that she felt service users were feeling more confident about making concerns known and making suggestions on how to make improvements to the service. Service users surveys had been conducted gaining the views and the opinions of the service users. The home will not take any responsibility for service users personal money. Albany House is well maintained providing a safe environment for service users to live in. An outside contractor regularly services the passenger lift and hoists. All staff had received fire training the day prior to the inspection. The fire alarm system had been tested weekly. The emergency lighting had been tested monthly. All electrical equipment is tested annually ensuring the safety of service users. DS0000065877.V341192.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 DS0000065877.V341192.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NO 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 OP7 Regulation 15 Requirement The Registered Person will ensure that care plans are fully completed and reviewed monthly or when the care needs of the service users change. Timescale for action 15/09/07 2. 3. OP9 OP26 13(2) 13(3) The registered person will ensure 15/09/07 that all medication is stored safely. Hand washing facilities for staff 15/10/07 will be provided in each bedroom to reduce the risk of cross infection. 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. 2. Refer to Standard OP9 OP27 Good Practice Recommendations The staff should seek the advice of the providing pharmacy regarding what is a controlled drug if they are unsure. Consideration should be given to recruiting a handy DS0000065877.V341192.R01.S.doc Version 5.2 Page 23 person. DS0000065877.V341192.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI - 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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