Inspection on 28/09/07 for Albany House

This inspection was carried out on 28th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Albany House 04/12/06

Albany House 26/01/06

Albany House 28/09/05

Albany House 27/10/04

Albany House 25/05/04

Similar services:

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

The Lodge Nursing Home

Bracken House

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

CARE HOME ADULTS 18-65 Albany House 16/18 Albany Road Stratford On Avon Warwickshire CV37 6PG Lead Inspector Kulwant Ghuman Key Unannounced Inspection 28th September 2007 09:45 Albany House DS0000004382.V348080.R01.S.doc Version 5.2 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.V348080.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 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.V348080.R01.S.doc Version 5.2 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 www.rethink.org Rethink 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) vacant post Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places Albany House DS0000004382.V348080.R01.S.doc Version 5.2 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. Albany House may also care for the person named in the application for variation of registration dated 6 March 2006. 4th December 2006 2. 3. 4. 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.V348080.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector made this unannounced visit to the home over one day in September 2007. Prior to the inspection the home had completed and returned an Annual Quality Assurance Assessment that provided the inspector with some information. During the day of the inspection three people who lived there and two people who worked there completed some surveys. The inspector spent time talking to the staff, the people living in the home and sampled two care files and two staff files along with other care and health and safety documents. The inspector was able to look at a number of bedrooms and the communal areas of the home. One complaint had been lodged with the Commission prior to the inspection and this was discussed with the manager during the inspection. What the service does well: What has improved since the last inspection? Care plans had been updated to show the long and short term goals of the people living in the home. The lounge and ground stairs bathroom had been redecorated. Albany House DS0000004382.V348080.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Albany House DS0000004382.V348080.R01.S.doc Version 5.2 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.V348080.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission process ensures that the needs of the person moving into the home are known and the individual has had the opportunity to visit the home and meet the other people living there before deciding whether to move in or not. Information available to the people moving into the home needed to be updated. EVIDENCE: One person and been admitted to the home since the last inspection. The individual had been admitted on a 28-day trial basis. There was evidence in the files to show that the individual had visited the home prior to admission. There was liaison with the discharge team and the admission appeared to have been planned and well managed. Information about the individuals needs had been gathered from the discharge team and assessment was ongoing during the trial period. Individuals’ needs and aspirations were known and taken into account when care plans were written up. The Annual Quality Assurance Assessment (AQAA) provided by the home indicated that visits and overnight stays were offered prior to admission. Albany House DS0000004382.V348080.R01.S.doc Version 5.2 Page 9 The service user guide had not been updated since the last inspection and this needed to be undertaken. Albany House DS0000004382.V348080.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff knew the needs of the people living in the home and they were assisted to become more independent and make plans for the future. EVIDENCE: Two files were sampled during the inspection. One was for a recent admission to the home and the other for someone who had been there for a long time. The file of the person recently admitted to the home indicated that there were short and long term goals identified. Individual risks and needs were identified in care plans that were identified by numbers. For example, care plan 1 was in place to facilitate a safe and supportive structured environment, care plan 2 was in place to enable the individual to prepare some meals themselves and to encourage them to eat communally. Risks were identified the individual in respect of self care and substance misuse as well as mental health deterioration and the indicators that would identify that this was happening. Albany House DS0000004382.V348080.R01.S.doc Version 5.2 Page 11 The care plans could be further improved by being more explicit about how the individual was to be helped. For example, one of the care plans indicated that the person responded better to firm boundaries however, the plan did not identify what these where and a consistent approach would be achieved from all staff, it also stated that plans needed to be developed to facilitate independent living skills and again there was no detail about what these skills were and how they would be developed and monitored. During the day it was observed that the individual was being encouraged to undertake their own laundry however this activity did appear to trigger some anxieties in the individual that staff did identify. It was important that this was recorded in the individuals care plan with a strategy to manage it after discussion with the individual. The individual was aware that there was a care plan in place and he had been involved in drawing up the plan. Individuals were encouraged to look at their lifestyles and to develop a healthier lifestyle in respect of eating and drinking. Where ever possible individuals were encouraged to take responsibility for managing their medicines and monies but support was available to help them. There were risk assessments in place however these focussed more on mental health issues. One person living in the home who went away for religious reasons on short breaks did not have a risk assessment in place for how his medication was to be managed whilst he was away from the home. Meetings were held regularly in the home to discuss issues such as holidays, household chores, activities and menus. Albany House DS0000004382.V348080.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home lead individual lives suited to their preferences. There is contact with friends and relatives where possible and healthy eating is promoted with choice and flexibility apparent at meal times. EVIDENCE: At the time of the inspector’s arrival at the home one of the people living in the home had gone to the local shop to get a newspapers. There was evidence in residents meetings that activities were discussed with the people living in the home and that individualised activities took place such as attending college, going swimming and going out for walks. One of the staff told the inspector how the guitar was played with one of the people living in the home and one of the people living there confirmed that this did happen. Albany House DS0000004382.V348080.R01.S.doc Version 5.2 Page 13 The routines in the home were relaxed and individuals identified their own times for getting up and going to bed but there was guidance on this to assist people who needed to get up for appointments and to have medication. None of the people living in the home indicated that they could not do something that they wanted to within reason. The people living in the home were encouraged to take responsibility for chores in the home and there was a variable degree of self-catering undertaken in the home with the majority taking responsibility for their breakfast and lunches. The main meals were decided at residents meetings. The mealtimes seen were relaxed and easy going. The fridge and cupboards continued to be locked but the people living in the home were in agreement with as food belonging them was being taken by one person. The people living in the home had keys to access the food. The likes and dislikes of the individuals were recorded, new recipes to be tried were available in the kitchen and information about diabetes was available. There was a good variety of food including fresh fruit available as evidenced on food receipts. A delivery of food was due on the day of the inspection. Individuals in the home were encouraged to eat healthy meals however the choice was up to the individuals. One of the people living in the home preferred to eat mainly take away foods. The home had been working with the individual to eat more healthily. The weight of individuals was being monitored and individuals encouraged to eat more or less as required. There were visits from and to friends and relatives. Albany House DS0000004382.V348080.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health care needs of the people living in the home were being met and they were being encouraged to take more responsibility for these needs. EVIDENCE: The majority of the people living in the home were able to undertake their own personal care but sometimes needed to be prompted. There was a choice of shower or bath and when individuals decided to have a wash or shower. Evidence was seen on individual care plans of the involvement of outside professionals to advise on and monitor health conditions and advise on wellbeing. Staff were very positive concerning psychiatric input to the service. A Lilly nurse is involved in the home to promote well being in the home. The people spoken to during the day and the completed surveys received indicated that they were happy with the care being provided. The home has had some success with the people living in the home being able to take a greater amount of responsibility for the management of their medicines. Albany House DS0000004382.V348080.R01.S.doc Version 5.2 Page 15 Examination of the medication system in the home at the time of the inspection indicated that individuals who were managing their own medicines signed for receipt of medicines on a weekly basis. The medicines were generally managed well however, the inspector and the nurse assisting the inspector was unable to locate any risk assessments for self medication or records for compliance checks for those managing their own medicines. The individual had not been employed in the home for long however, these documents needed to be easily located at all times. Some of the medicines could not be audited as the amounts received had not been recorded on the MAR charts. The inspector was told that the medication fridge was not working. Albany House DS0000004382.V348080.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some people living in the home said they were listened to and treated well in the home. Some were not sure of who to speak with if they were unhappy and said they did not know how to make a complaint. EVIDENCE: The records for the management of finances for the people living in the home were seen and appeared to be in order. One complaint had been received by the Commission since the last inspection. The complaint raised issues such as standards having deteriorated in the home, poor levels of hygiene, people not supported to rehabilitate and left with no stimulation, no 1:1, poor medication. This complaint was not recorded in the complaints log however in discussion with the manager it was determined that a complaint had been received from the individual and that it had been addressed by the organisation. There were some employment issues with this individual which were outside the scope of the Commission however in respect of standards having deteriorated with poor levels of hygiene and individuals not supported to rehabilitate, no stimulation provided and no 1to 1 no regulations had been breached. Some aspects of the management of medicines in the home needed to be addressed and this is raised elsewhere in the report. Albany House DS0000004382.V348080.R01.S.doc Version 5.2 Page 17 No adult protection issues had arisen at the home. The completed surveys from people living in the home indicated that one of them knew who to speak to if they were unhappy and how to make a complaint whereas two indicated that they did not know who to speak to or how to make a complaint but confirmed that staff treated them well and listened to the. The home needed to discuss this issue with the people living in the home. Albany House DS0000004382.V348080.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 28 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provided comfortable and safe accommodation however, some areas of the home were in need of redecorating and recarpeting. EVIDENCE: No changes had been made to the physical environment since the last inspection but the information provided to the Commission by the home stated that the ground floor bathroom and lounge had been redecorated. The communal areas continued to be homely and comfortable however the garden needed some attention paying to it to make comfortable for the people living in the home. The carpets identified during the last inspection as needing to be replaced were still in place. The paintwork on the banisters was worn. Albany House DS0000004382.V348080.R01.S.doc Version 5.2 Page 19 The stairs and corridors, particularly on first floor need to be re-decorated and re-carpeted as a matter of priority, following discussions with the people living their on their views and input regarding decor. Bedrooms seen by the inspector appeared to be comfortable and individualised to the liking of the occupant. The conservatory was designated as the smoking area and the people living in the home were being encouraged not to smoke in their bedrooms. The were a number of washing facilities located on throughout the home. At the time of the inspection there were tablets of soap, nailbrushes and cotton towels in one of the bathrooms. The people living in the home needed to be encouraged to take these back to their bedrooms after use if they belonged to them other wise these items needed to be removed to minimise the possibility of cross infections. The sealant around the shower unit on the first floor needed to be replaced as it was going black. Albany House DS0000004382.V348080.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels and skills were able to meet the needs of the people living in the home but the manager needed to be mindful that long days being undertaken by staff did not compromise the staffing levels during the day. EVIDENCE: The staff on duty at the time of the inspection indicated a good level of knowledge, likes and dislikes and routines of the people living in the home. There was some evidence to suggest that the staffing levels had been difficult to maintain and some recruitment was ongoing. The home used a number of bank staff to cover shifts and some staff worked long shifts. There was always one qualified nurse on duty supported by a mental health worker. According to the staff rota there were always a minimum of two staff in the home during the day. Staff stated that there were four staff on duty during 1 and 4pm as there was a crossover of early and late shifts, however, examination of the rota showed that when two staff were undertaking long shifts the numbers were limited to 2. Albany House DS0000004382.V348080.R01.S.doc Version 5.2 Page 21 This would limit the amount of support individuals could get on those days and this needed to be taken into consideration when rotas were being planned. Lone night working continued to be in use. One person said that he was concerned that one person would not be able to manage if an incident occurred during the night. There were a mixture of both female and male staff. Information provided to the Commission indicated that the home had not yet reached the 50 of staff required to have NVQ Level 2 or equivalent. It also indicated that details about the training of bank staff was not known. It is important that the manager has this information to ensure that skill mixes are suitable to meet the needs of the people living in the home. The recruitment file for a new member of staff was sampled and showed that the recruitment procedures were satisfactory with the appropriate checks being undertaken. Following discussions with the manager it was concluded that she would ensure that she had information about bank staff available in the home as this information was kept in other homes. The manager told the inspector that training the staff were provided with required training however, the files needed to be organised and copies of training certificates obtained to evidence. It is advisable for the home to have a training matrix that could be used to show what training had taken place and what gaps were evident and when refresher courses were needed. The supervision records of two staff showed that the target of six supervision sessions a year were on target. Albany House DS0000004382.V348080.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home was adequate but some improvements in the monitoring and management of systems employed in the home could be improved. EVIDENCE: The manager at the home had been in post for a limited time. It was important that the home benefits from a stable management team to ensure that the home and service develops according to the needs of the people using the service. There was some evidence to suggest the home was not always being managed with the interests of the people living in the home being paramount, for example, there was evidence that the timing of the night medication varied according to whether there was one night staff on duty or two. Albany House DS0000004382.V348080.R01.S.doc Version 5.2 Page 23 The manager needed to look at whether the place where the medicines could be stored could be moved to make it safer for one person to administer. On another occasion where the planned meal could not be provided people had gone out to eat and that most individuals had paid for themselves. This should have been paid by the organisation as it was not a pre-planned event that the individuals had chosen to undertake. The inspector was told that audits were undertaken however, there was no report and development plan based on the findings that had been drawn up. The information provided to the Commission by way of the AQAA indicated that the manager needed to complete her Registered Managers Award. Information provided to the Commission indicated that the electrical circuits in the home, portable appliance checks and gas appliances had been serviced. Records checked showed that a fire drill, fire alarm test and emergency lighting tests had been carried out recently. The records also showed that the weekly fire alarm tests had not been carried out on a weekly basis as required. The information provided also indicated that many of the homes policies and procedures had been updated. The management of medicines in the home needed to be improved. Albany House DS0000004382.V348080.R01.S.doc Version 5.2 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 Standard No Score 1 2 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 X ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 3 28 3 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 X 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 3 X Albany House DS0000004382.V348080.R01.S.doc Version 5.2 Page 25 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 YA7 Regulation 13(4)(c) Requirement There must risk be risk assessments in place for individuals who manage their own medicines and compliance checks to ensure that medication is being taken as required. Risk assessments must be in place for planned absences from the home for individuals. 2. YA20 13(2) The records for the administration of medicines must be completed so that they can be audited. A working fridge must be available for the storage of medicines. 3. YA30 13(3) The risks of cross infection must be minimised by removing tablets of soap, nail brushes and other personal items from communal washing areas. 14/11/07 14/11/07 Timescale for action 14/11/07 4. YA42 23(4)(c)(v) Fire alarms tests must be carried out at regular weekly intervals. DS0000004382.V348080.R01.S.doc 01/11/07 Albany House Version 5.2 Page 26 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 YA1 YA6 Good Practice Recommendations The statement of purpose must be updated The provider must ensure that the residents’ care plans clearly identify goals and aspirations, and how they are to be met, as well as meeting ‘clinical’ needs. It is recommended that all care plans include a ‘user friendly’ ‘pen picture’ 3. 4. 5. 6. YA22 YA23 YA24 YA35 It is recommended that more consideration be given to raising residents’ awareness of the complaints protocol. It is recommended that the handling of residents’ finances is subject to, at intervals, an independent auditor. The hallways, stairs and landing are to be redecorated. (This is outstanding from the previous two inspections). A training matrix should be put in place to show that staff have the appropriate skills to care for the people living in the home. It is recommended that the service ensure that residents’ views are fully elicited as part of the Quality Assurance process and a report based on these views is made available to the people living in the home and others. The home’s routines and procedures should be based on the needs of the people living in the home. 7. YA39 8. YA40 Albany House DS0000004382.V348080.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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. 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