CARE HOME ADULTS 18-65
Albany House 16/18 Albany Road Stratford On Avon Warwickshire CV37 6PG Lead Inspector
Catherine Mundy Unannounced Inspection 28th September 2005 09:30 Albany House DS0000004382.V252238.R01.S.doc Version 5.0 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 Albany House DS0000004382.V252238.R01.S.doc Version 5.0 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 Adults 18-65. 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. Albany House DS0000004382.V252238.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Albany House Address 16/18 Albany Road Stratford On Avon Warwickshire CV37 6PG 01789 261191 01789 296359 albanyhouse@rethink.org 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) Rethink Mrs Mary Ullah Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places Albany House DS0000004382.V252238.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. In addition to undertaking the corporate induction programme, a structured induction programme specific to the role and responsibilities of Registered Manager be completed within 3 months of registration. A programme of monthly (minimum) supervision meetings by senior manager be put into place. Supervision meetings should be structured to encompass all aspects of the manager`s role and responsibilities as well as specific issues arising within the home. Successful completion of National Vocational Qualification in Management within 12 months. 27th October 2004 2. 3. Date of last inspection Brief Description of the Service: Albany House is a Home owned by “Rethink” (previously The National Schizophrenia Fellowship). It is an 8-bedded nursing home for people with mental health needs. It is situated within walking distance of Stratford town centre and local parks. The home aims to provide a supportive residence in which 8 people with enduring mental health needs can have a sense of belonging, be treated with respect and exercise choice in their daily lives. Each individual is encouraged to participate in activities suited to their own needs and wishes, to access local resources and facilities and to manage social and familial relationships beyond the home. Through the long term development of trust between residents and staff, the fostering of hope and focus on the strengths, the home endeavours to enable people to approach their potential and to achieve some recovery in the quality of their lives. Albany House DS0000004382.V252238.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This announced inspection took place on 28th September 2005, between the hours of 9.30 am and 4.30 pm. During this time the inspector had the opportunity to meet the residents and staff, tour the home and examine records relating to the residents and the management of the home. The Registered Manager was present during this inspection. What the service does well: What has improved since the last inspection?
Of the seven requirements made at the last inspection five have been met in full and one is part met. The files examined confirmed that the home has completed risk assessments and risk management strategies have been devised to address the risks identified. Albany House DS0000004382.V252238.R01.S.doc Version 5.0 Page 6 The standard of one resident’s bedroom has improved with the replacement of the flooring in this room. Risk of scalding when using the ground floor shower has been reduced by the disablement of the shower. Staffing vacancies within the home have been filled. The files examined confirm that the home has good recruitment practices that protect the residents from abuse. The home is in the process of implementing a system for monitoring the quality of the service provided in the home. This will include the homes own assessment, external audit and will seek the views of the residents, their relatives and the staff. The completion of the homes Statement of Purpose will enable the residents, their relatives and the staff to measure the homes performance against the service intended to be provided, as detailed in this document. This document will also provide prospective residents with information to assist them to make a decision as to whether to accept a placement in the home. 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. Albany House DS0000004382.V252238.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Albany House DS0000004382.V252238.R01.S.doc Version 5.0 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 the following standard(s): 2, 3 and 4 The home has an acceptable admissions procedure in place, which ensures that a prospective residents needs are assessed prior to a placement being offered in the home. Accurate recording of introductory visits will enhance this further. EVIDENCE: Since the time of the last inspection two residents have moved into the home. Examination of their files confirmed that an assessment of needs has been completed by the home. This is in addition to an assessment provided by professionals involved in the delivery of the residents Care Programme Approach (CPA). Minutes from CPA reviews were also available. There is evidence in the resident’s files that the home can meet the needs identified in these assessments. The manager demonstrated in discussion that the home has an acceptable admissions procedure, introductions to the home are organised flexibly at a pace to suit the individual resident. Family members are also involved in this process. The residents confirm this. Written records of the residents visits, details of the care delivered and evidence of ongoing needs assessment during this time, had not been completed. Records relating to these residents commenced on the day of admission to the home. Albany House DS0000004382.V252238.R01.S.doc Version 5.0 Page 9 Albany House DS0000004382.V252238.R01.S.doc Version 5.0 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 the following standard(s): 6 and 9 The care planning system in place provides the staff with detailed information to enable them to support the residents to achieve their goals and meet the residents identified needs. EVIDENCE: The care plans examined confirmed that the residents have a comprehensive plan of care, which meets their identified needs. The resident’s long term goals are recorded with details of the plan in place to achieve these. There is evidence that the care plans have been agreed and reviewed with the residents. Daily recording is completed detailing the progress made towards achieving each of the residents identified goals. Risk assessments have been completed relating to the residents mental and physical health needs. Risk management strategies have been devised to address the risks concerned. These are subject to regular review and update. Albany House DS0000004382.V252238.R01.S.doc Version 5.0 Page 11 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 the following standard(s): 12, 13 and 16 The residents are supported to participate in a range of activities, and have opportunity to develop independence promoting skills. The provision of additional staffing will enable the home to support all of the residents to participate fully with rehabilitation, occupation and to develop their independence. EVIDENCE: Discussions with the residents and observations during the inspection confirmed that the residents are able to participate in a range of appropriate activities. Activities available in the home include board games, cards, pool and watching TV and films. Some of the residents attend a structured day placement and others attend college courses. One resident advised that she enjoys shopping in Stratford and walking in the local park. On the day of the inspection one staff member led a current affairs group with some of the residents, whilst another supported a resident to cook. In the afternoon one resident played dominoes with a member of staff. Two residents attended structured placements away from the home.
Albany House DS0000004382.V252238.R01.S.doc Version 5.0 Page 12 The residents have some opportunities to participate in activities that will promote and maintain their independence. Residents attend to their own laundry and are responsible for cleaning their own rooms. Household chores are shared on a rotational basis. One resident prepares his own meal two days per week. This activity enables him the opportunity to plan his meal and shop independently. The care plans seen reflect the long term goals of the residents to move from the home to live more independently. It was observed during the inspection that the staff on duty were engaged in activities with the residents. However the staffing ratios are not sufficient to support all of the residents to participate fully with rehabilitation, occupation and to develop their independence. A requirement to address this, made at the previous two inspections of this home, remains outstanding. Albany House DS0000004382.V252238.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 19 and 20 The residents continue to be supported to access relevant healthcare professionals, in addition the system in place for the management of the residents medications is good, this enables the staff to effectively support the residents to meet their healthcare and medical needs. EVIDENCE: The residents care plans examined confirmed that the residents health needs continue to be met appropriately by the home, this is with the support of the relevant health care professional. The home also supports routine health screening, at appropriate intervals. Records are retained of all contacts with a health care professional and of the outcome for the resident. The responsibility for the management of the resident’s medication is retained by the home. Medication is stored securely within the home. Records examined and discussions with the staff confirmed that the home continues to adopt acceptable practices. Some of the residents self medicate, the arrangements in place differ for each resident, depending upon their assessed needs and abilities. Care plans and risk assessments are available to reflect this. The residents confirmed that they are able to store their medication securely within their rooms.
Albany House DS0000004382.V252238.R01.S.doc Version 5.0 Page 14 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 the following standard(s): 22 and 23. The home has a satisfactory complaints procedure in place, the residents are provided with sufficient forums in which to raise concerns or make complaints. The homes policies and procedures protect the residents from abuse. EVIDENCE: The home has a complaints procedure in place. The manager advised that this document is currently under review. A leaflet entitled ‘how to make a complaint’ is prominently displayed in the home. The residents confirmed that they are aware of the procedure to follow should they wish to make a complaint. A complaints log is available, this confirmed that there have been no complaints made since the time of the last inspection. The residents are also able to raise concerns or make complaints at weekly meetings held with their key worker or named nurse and at fortnightly house meetings. The home also plans to complete a residents survey in the near future. The manager demonstrated in discussion that acceptable procedures would be followed in the event of suspected abuse. An adult protection policy is available in the home. This was not examined on this occasion. Guidance is in place, in individual residents files, with regard to the management of aggression. The home has a policy of no restraint. Albany House DS0000004382.V252238.R01.S.doc Version 5.0 Page 15 Most of the residents maintain responsibility for their own money. Benefits are paid directly into their own bank accounts, the residents access this as they wish. The bank accounts have a facility to prevent the residents from becoming overdrawn. Some residents give their bank statements to the manager for safe keeping. The home supports three residents with management of their monies. Access to this is restricted to nominated staff members. Examination of the records relating to the finances of these residents confirmed that their monies are managed appropriately. It is noted that that the receipts kept following a withdrawal at the bank are not cross referenced with the individuals bank statements. This is a recommendation. Albany House DS0000004382.V252238.R01.S.doc Version 5.0 Page 16 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 the following standard(s): 24 The standard of the environment is good providing the residents with a comfortable and homely place to live. EVIDENCE: A tour of the home confirmed that the residents are provided with a safe, comfortable and homely place to live. Communal space includes a large kitchen, lounge/diner and conservatory. The residents are also able to spend quiet time in the ground floor office, which is furnished with two sofas and a coffee table. The home has three bathrooms, one on the ground floor and two on the first floor. The residents each have their own bedrooms. These have been decorated and furnished to reflect the resident’s personalities and preferences. The conservatory is the designated smoking area within the home. A requirement made at the last inspection to replace flooring in one residents bedroom has been addressed. Due to the needs of the resident, regular replacement of this flooring should be included in the homes maintenance and renewals programme. A requirement to fit thermostatic controls to the shower in the ground floor bathroom has not been met. Action has been taken to remove the risk of scalding by disabling the shower facility. It is noted that the resident who uses this bathroom does not like to have a shower. Shower facilities are available on the first floor of the home.
Albany House DS0000004382.V252238.R01.S.doc Version 5.0 Page 17 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 and 34 Despite the ability of the staff to perform their roles within the home the current staffing ratios restrict their ability to effectively support the residents. The homes recruitment procedures protect the residents form abuse. EVIDENCE: Four staff members participated in the inspection. Each demonstrated a sound knowledge of their roles and responsibilities within the home. The interactions between the staff and residents confirmed that the residents are supported sensitively, it is apparent that positive relationships between the staff and residents have been formed. Staffing ratios within the home allow for two staff members to be on duty for each shift. Hand over time during the day is from 1pm to 4pm. This allows a period of time to facilitate some activities with the residents. This allows little flexibility to support activities in the mornings and evenings. It is advised that for planned activities additional staff members are made available. A requirement, made at the previous two inspections of this home, to provide sufficient staffing in order to meet the residents rehabilitation needs, develop their independence and provide increased social and leisure opportunities remains outstanding. It was noted at the previous inspection of this home that the home had a number of staffing vacancies. These vacancies have been filled. The manager advised that the home is now fully staffed. Examination of the file relating to the staff member most recently employed confirms that the home adopts acceptable recruitment procedures that protect the residents.
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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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 42 and 43 Appropriate monitoring and assessment of risk is undertaken to ensure that the health and safety of the residents and staff is promoted and maintained. The manager’s organisational responsibilities have lead to her not being able to spend sufficient amounts of time within the home. If this situation continues the managers abilities to perform her role, as Registered Manager, will be compromised having a negative effect upon the quality of the service that is provided to the residents. The implementation of quality monitoring systems will provide the residents with the opportunity to contribute the future development of the home. EVIDENCE: A tour of the home and examination of records and risk assessments confirmed that the home takes appropriate action to maintain the health and safety of the residents and staff. Albany House DS0000004382.V252238.R01.S.doc Version 5.0 Page 19 It was noted at the last inspection that the home did not have a formal system in place to monitor the quality of the service that is provided in the home. It is noted that the organisation has taken action to address this. The home intends to commence a self assessment, which looks at key quality indicators. This will also be assessed by external auditors. The organisation has also completed a service review, which seeks the opinions of the residents, their representatives and the staff. The findings from this monitoring are to be presented to the organisations advisory group in November 2005. The home is visited, under Regulation 26, by a representative of the organisation. The purpose of these visits is to monitor the homes performance and monitor the quality of service provided. Reports made following each visit are retained in the home. These have not been provided to the Commission. Discussions with the staff and manager identified that the manager is required to spend considerable amounts of time away from the home, attending organisational meetings. Due to the competency of the manager, her deputy and the staff this does not appear to have had a negative effect on the running of the home. However if this situation continues this may have a detrimental effect on the manager’s ability to perform her role as Registered Manager effectively. The staff hold the manager in high regard, but stated that they wished that there was more opportunity to seek her advice and support. There are three conditions to the registration of this home. Documentary evidence to confirm that two of the conditions had been met was not available in the home at the time of the inspection. The third condition, for the manager to successfully complete an NVQ Level IV qualification in management is met in part. The manager advised that it is unlikely that this qualification will be attained before the 12 month deadline previously agreed with the organisation. It is anticipated that this qualification will be achieved before July 2006. The home is registered to provide care for up to 8 adults with a mental disorder, excluding dementia and learning disability. Two of the current residents have a dual diagnosis of learning disability and mental ill health. Albany House DS0000004382.V252238.R01.S.doc Version 5.0 Page 20 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 X 3 3 2 X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score 3 X X X X X X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 X 16 2 17 Standard No 31 32 33 34 35 36 Score X X 2 3 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Albany House Score X 3 3 X Standard No 37 38 39 40 41 42 43 Score X X 2 X X 3 2 DS0000004382.V252238.R01.S.doc Version 5.0 Page 21 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 YA4 Regulation 14(1)(a) (c ) Requirement The home is to complete written records of the contact made with prospective residents and of their introductory visits to the home. Sufficient staffing is to be provided to enable the residents to have an increased opportunity to participate in rehabilitation, independence promoting activities and to access leisure opportunities. This requirement has been made at the previous two inspections of this home. A formal system of measuring quality must be introduced including a format for informing residents of outcomes. This requirement has been made at previous inspections and is part met. The home must continue with the plan in place to meet this requirement.
Albany House DS0000004382.V252238.R01.S.doc Version 5.0 Page 22 Timescale for action 31/01/06 2 YA33YA16YA 13YA12 12 1b 16 2m n 18 1a 31/12/05 3 YA39 24 21(2) 30/11/05 4 YA39 26(5)(a) 5 YA43 18(2) 6 YA43 12 7 YA43 9(2)(b)(i) The organisation must provide to the Commission reports made following each visit to the home under Regulation 26. The Registered Managers organisational responsibilities must be reviewed to ensure sufficient time is allowed for the management of the home. The home must apply for a variation to registration to allow placements in the home for residents who have a dual diagnosis of mental health and learning disability. Documentary evidence to confirm that conditions of registration have been met or the plan in place to meet these conditions, with timescales, is to be provided as part of the action plan to this report. 30/11/05 30/11/05 31/10/05 31/10/05 Albany House DS0000004382.V252238.R01.S.doc Version 5.0 Page 23 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 YA23 Good Practice Recommendations It is recommended that the home cross reference receipts detailing withdrawals from resident’s bank accounts with their bank statements. Regular replacement of the flooring to one resident’s bedroom should be included in the homes maintenance and renewals programme. 2 YA24 Albany House DS0000004382.V252238.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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