Inspection on 15/11/05 for Albemarle

This inspection was carried out on 15th November 2005.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Albemarle 30/08/07

Albemarle 06/09/06

Albemarle 09/02/06

Albemarle 09/03/05

Albemarle 05/08/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Albemarle Baxtergate Hedon Hull East Riding Of Yorks HU12 8JN Lead Inspector Sarah Sadler Unannounced Inspection 15th November 2005 09:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Albemarle DS0000019641.V266147.R02.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 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. Albemarle DS0000019641.V266147.R02.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Albemarle Address Baxtergate Hedon Hull East Riding Of Yorks HU12 8JN 01482 896727 01482 890511 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) Humberside Independent Care Association Limited Mrs Dorne Jayne Tilley Care Home 43 Category(ies) of Dementia - over 65 years of age (43), Old age, registration, with number not falling within any other category (43) of places Albemarle DS0000019641.V266147.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th March 2005 Brief Description of the Service: Albermarle is situated in the market town of Hedon in East Yorkshire and was built approximately 30 years ago as a care home for older people. The home is registered to provide care and accommodation for up to 43 older people, some of who may have memory impairment. There are three lounges, a dining room and a seating area in the main entrance. The accommodation consists of mostly single bedrooms on two floors with access to the upper floor by stairs or passenger lift. The home is undergoing extensive upgrading of the environment at the present time Service users have easy access to the wide range of shops and facilities in Hedon and access to public transport. Albemarle DS0000019641.V266147.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was undertaken over one day by one inspector. The inspection was part of the annual inspection programme from April 1st 2005 to March 31st 2006. During the inspection a tour of the premises was undertaken, residents, visiting professionals, a student social worker on placement and members of staff were spoken to. A large amount of time was spent with residents, observing their everyday life. Some time was spent reading resident and other records within the home. What the service does well: What has improved since the last inspection? What they could do better: Evidence that the electrical and gas systems met the relevant legislation was not available on the day of the inspection and an immediate requirement was issued regarding this, from which the home responded appropriately. These records must be kept within the home. Service users continue to be at risk of injury from unguarded radiators and the date for the completion of this work must be forwarded to the CSCI. Albemarle DS0000019641.V266147.R02.S.doc Version 5.0 Page 6 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. Albemarle DS0000019641.V266147.R02.S.doc Version 5.0 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 Albemarle DS0000019641.V266147.R02.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Service users are assessed prior to admission to ensure that the home can meet their needs. EVIDENCE: Three of the four service user files all contained copies of the Local Authority community assessment and/or care plan. All files contained an individual plan of care that had been developed from an assessment of the service user. Albemarle DS0000019641.V266147.R02.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Service users are supported to meet their physical health and personal care needs. Service users are treated with dignity. Service users are on the whole supported to meet their medication needs. EVIDENCE: Service user files contained plans of care that detailed the needs of each individual. Files included risk assessments, which also addressed nutritional and moving and handling risks. Daily diary notes are kept and visits from or appointments to professionals are recorded. Some weight and personal hygiene records are also kept, however these were not always completed or up to date. One service user confirmed that the home is “Very good” in supporting them to access their GP and that they also attend optical appointments. A professional confirmed that any instructions are followed and that advice is sought from them as necessary. The student confirmed that service users are supported to be taken to doctor and optical appointments. The professional also confirmed that the staff responds well to the meeting of the service users’ personal hygiene needs. Albemarle DS0000019641.V266147.R02.S.doc Version 5.0 Page 10 Service users’ privacy and dignity are maintained with staff confirming that personal information is handled sensitively and that any needs are addressed in private. The student confirmed that service users’ dignity is upheld, for example service users are supported in the handling of the passing away of a fellow resident. Medication records were up to date with all medication received administered and disposed of being accounted for. The registered manager confirmed that staff not yet completed accredited medication training. Albemarle DS0000019641.V266147.R02.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Service users’ leisure interests are on the whole met. Service users are supported to maintain relationships. Service users receive good support in the meeting of their dietary needs. EVIDENCE: One service user spoken with confirmed, “ I am very happy here”. “ Two years ago I went to Blackpool on holiday and I went to Scarborough this year.” “ I can go out with my daughter and I could go out with the carers if I wanted to”.” If activities are offered I join in – bingo” “ I used to play dominoes”. The home has the shared use of a minibus although one service user commented that there sometimes are difficulties in accessing a driver. No activities were observed throughout the day of the inspection and one person interviewed confirmed that there are not many activities on a daily basis. Staff confirmed that service users are offered a variety of activities, for example dominoes, bingo and walks. Also that service users are offered choices throughout the day, for example, what to wear, what perfume or aftershave to use, whether to stay in their room or join in with others, whether to go out. Albemarle DS0000019641.V266147.R02.S.doc Version 5.0 Page 12 A service user confirmed that they could have ‘ visitors anytime, and everyday’. Service users are offered choices at mealtimes and the meals were well presented. Tables were pleasantly set with cutlery and condiments available. The registered manager has worked with the service users and staff team in developing two sittings at each mealtime to ensure that each person is offered appropriate support in a relaxed atmosphere. This appears to be working well with service users relaxed and supported by staff in both making choices and the eating of their meal. Discussions with the chef reflected that any specialised diets could be catered for, for example, vegetarian diets. Albemarle DS0000019641.V266147.R02.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Service users feel able to raise complaints and are supported and protected by the policies and procedures for complaints and the prevention of abuse. EVIDENCE: One service user confirmed that if they were not happy they would speak with “one of the bosses” and were confident that their concerns would be dealt with appropriately. Another service user confirmed, “ Yes, I would speak to …. the manager and she would sort it”. They also confirmed that they regularly attend the service user meetings. There is a complaints policy held within the home with timescales for actions to be taken. There is a copy of the Local Authority’s policy ‘ The Protection of Vulnerable Adults’ alongside the homes own policies, which include whistle blowing. Albemarle DS0000019641.V266147.R02.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,25,26 Service users live in a home that has had some improvements. Some matters put service users at risk of harm and do not provide comfortable surroundings in which to live. EVIDENCE: The registered manager confirmed that the first stage of the refurbishment of the home has now been completed and that a date for the remaining work to be completed has yet to be arranged. The refurbished rooms are very pleasant and include new furniture, with radiators being guarded. Service users are able to personalise their rooms reflecting their individual tastes. Service users are enabled through the risk assessment process to hold keys to their rooms. Many of the radiators within the home are not guarded and pose a risk to the health and safety of the service users. Albemarle DS0000019641.V266147.R02.S.doc Version 5.0 Page 15 The home appeared clean throughout although several areas had minor unpleasant smells. Two people interviewed confirmed that this is not uncommon for the home. The student confirmed that the carpets in the home are shampooed regularly. The home was clean throughout with a large laundry area. No evidence was available that the home meets the Water Supply (Water Fittings) 1999 regulations. Albemarle DS0000019641.V266147.R02.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Service users are supported by an adequate, well recruited and on the whole trained staff team EVIDENCE: The staff induction packs are cross referenced to the Skills for Care, LDAF and NVQ in care components. Staff who have recently commenced in the home have these packs in their personal files. The registered manager confirmed that these staff are booked onto training in the next few weeks, which will complete their inductions. Staff confirmed that they had undertaken training in back care and fire. Staff files included details of training, which included food hygiene, health and safety and first aid. The registered manager confirmed that 6 of the 17 care staff have attained an NVQ level 2 or equivalent in care. Staff confirmed that they were aware of the GSCC code of conduct. Staff files examined all included application forms, Protection of Vulnerable Adults (POVA) first checks, evidence of Criminal Record Bureau (CRB) checks and two written references. The duty rota reflected that there are a minimum of two care staff on duty throughout the day and night. The registered manager confirmed that there is a further member of staff employed 9.30 am to 1.30 pm to assist with morning teas, laundry and lunchtimes. This totals 399 care hours per week. In addition Albemarle DS0000019641.V266147.R02.S.doc Version 5.0 Page 17 to this there are domestic, catering, administration and the registered managers’ hours. Albemarle DS0000019641.V266147.R02.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Service users live in a home that is on the whole well managed. Service users are able to be involved in the decisions for the development of the home. However the procedures in the home do not always ensure the health and safety of the service users. EVIDENCE: The registered manager confirmed that they have completed an NVQ level 4 in care and have over the last year update their training in back care and equal rights. There continues to be a quality assurance system within the home, which seeks the views of service users, relatives and staff. Albemarle DS0000019641.V266147.R02.S.doc Version 5.0 Page 19 Individual records are kept of service users’ finances handled by the home, with receipts for any purchases. There are a variety of policies and procedures held within the home, for example, equal opportunities, risk management and advocacy polices. Health and safety policies include risk assessments for moving and handling and fire safety. Fire extinguishers had all been checked within the last year and there are records of regular fire drills and quarterly alarm checks. There is a Control of Substances Hazardous to health (COSHH) file and staff have undertaken training in Health and Safety, Food Hygiene and First Aid. There are Health and Safety polices and a Health and Safety file containing in house risk assessments for all staff with the use of different equipment in the home. This was last reviewed in July 2004. The lift and bath hoist have been service in 2005, however there was no evidence that the fire alarm, gas and electrical systems, and portable appliances had been serviced recently. An immediate requirement was issued to the home regarding this and these were received within the required timescales. The environmental health officer has visited and made requirements of the home, of which the chef confirmed had all been actioned. Albemarle DS0000019641.V266147.R02.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X X X X X 1 1 STAFFING Standard No Score 27 3 28 2 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 1 Albemarle DS0000019641.V266147.R02.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? Yes 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 Regulation 13 Requirement The registered person must ensure that the radiators have covers or are low surface temperature and the pipe work is covered. A previous requirement that the radiators must be covered by 01/02/04 has not been complied with and this matter must now be treated as a matter of urgency. Confirmation of the date on which this will be achieved must be forwarded to the CSCI as per the timescale. The registered person must ensure that service user records are completed and up to date. The registered person must ensure that staff have undertaken accredited medication training. The registered person must ensure that the home is free from offensive odours. The registered person must ensure that the home meets the Water Supply (Water Fittings) 1999 Regulations. Timescale for action 15/12/05 2 3 17 13,18,19 15/12/05 15/02/06 4 5 OP26 13 13 15/01/06 30/11/05 Albemarle DS0000019641.V266147.R02.S.doc Version 5.0 Page 22 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 3 Refer to Standard OP12 OP28 OP38 Good Practice Recommendations The registered person should ensure that activities are consistently available to service users. The registered person should ensure that 50 of the care staff is trained to NVQ level 2 or equivalent by 2005. The registered person should ensure that evidence that the home meets relevant Health and Safety legislation is available within the home at all times. Albemarle DS0000019641.V266147.R02.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 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 Albemarle DS0000019641.V266147.R02.S.doc Version 5.0 Page 24 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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