Inspection on 29/09/05 for Albemarle

This inspection was carried out on 29th September 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 15/11/07

Albemarle 19/07/06

Albemarle 20/03/06

Albemarle 02/11/04

Albemarle 25/05/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Albemarle 50 Kenilworth Road Leamington Spa Warwickshire CV32 6JW Lead Inspector Lesley Beadsworth Unannounced Inspection 29th September 2005 09:30 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 DS0000004202.V255542.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 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 DS0000004202.V255542.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Albemarle Address 50 Kenilworth Road Leamington Spa Warwickshire CV32 6JW 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) 01926 425629 01926 315627 The Albemarle Rest Home Limited Care Home 24 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (24) of places Albemarle DS0000004202.V255542.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd November 2004 Brief Description of the Service: Albemarle is care home providing personal care and accommodation for 24 older people aged 65 years and over. The home is located in Leamington, close to shops, pubs, the post office and other amenities. The home provides 24 single rooms, 20 of these are en-suite. Nine bedrooms are on the ground floor; seven of these have en-suite facilities. There are six bedrooms on the first floor, all have en-suite facilities and there are a further eight bedrooms on the mezzanine floor, six of these have en-suite facilities. All floors are accessible by use of a chairlift and stairs. The home has a large garden to the rear of the property, which is well maintained and easily accessible. There is ample parking at the front of the house. Albemarle DS0000004202.V255542.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day between the hours of 09:45 and 20:00. The acting manager was present for most of the inspection and the responsible individual and partner and the prospective manager were also in the home during parts of the inspection. All present cooperated fully with the inspection process. The inspection included a tour of the premises, talking with the responsible individual, acting manager, prospective manager and the staff and looking at resident records. The majority of the time was spent familiarising and orientating with the home on what was the inspectors first visit, and talking with five residents in private and several others sitting in groups in communal areas. Five members of staff were also spoken with at this inspection. What the service does well: Staff were seen to treat residents with respect and with care and that this is usual was confirmed by residents spoken with. Staff were also seen to knock on doors before entering residents’ private accommodation. The home has an imposing frontage and an attractive and impressive reception area with a wide staircase leading off it. The larger ground floor lounge at the front of the home is attractively decorated and furnished and has a homely appearance. A dining room on the other side of the reception area is also attractive. There is a further lounge/dining room at the rear of the home and overlooking the garden. The greater majority of the furniture and floor covering in the home is good quality, domestic in character and in good condition. All lighting seen in communal and private accommodation is also domestic in character and of sufficient brightness. Portable air conditioning had been provided for the communal living areas for the residents’ comfort in the hot weather. There were no unpleasant odours noted during the inspection. The gardens are very pleasant and well maintained with accessible pathways for residents to enjoy the garden. Assessments made at the pre-admission stage covers all the elements required of this standard and had been completed in sufficient detail to provide the information required to assess if the home could meet the needs of the prospective resident and to prepare adequately for the admission. Care files examined demonstrated that residents’ ongoing health needs are met with evidence of visits being made to or by a dentist, optician, chiropodist and district nurses. There is a good skill mix amongst the management team with the prospective manager having recent management training and up to date knowledge of the National Minimum Standards, one deputy manager having had extensive experience and offering long term continuity to the home and another deputy Albemarle DS0000004202.V255542.R01.S.doc Version 5.0 Page 6 manager having qualified as a Registered General Nurse and having several years experience of management at this home and other nursing homes. What has improved since the last inspection? What they could do better: The home has been without a permanent and consistent manager during the current year creating potential risk to the residents. The risk has been minimised by the presence and leadership of the two deputy managers and the support of the responsible individual/homeowners. However the home has been unable to develop management strategies, records, policies and procedures or continued leadership to ensure that staff have the guidance and direction required to ensure the consistent care and safety of residents. It is important that the prospective manager completes her application for registration promptly. Because of the management difficulties experienced at Albemarle since the last inspection there has been limited progress in ensuring that all the necessary documents, proof of identity, Criminal Record Bureau (Criminal Records Bureau), Protection of Vulnerable Adults (POVA) checks and any necessary proof of permission or ability to work in the UK are kept on file for individual employees at the home. This requirement will therefore be carried over with management needing to complete this as a matter of urgency. There were several health and safety issues that needed to be addressed. Residents continue to have easy access to the kitchen, which could create infection control and safety risks when food is being cooked or when the kitchen is unattended. It was noted that one resident, with limited understanding, made numerous attempts throughout the day to enter the kitchen. There is no evidence to demonstrate that hot water temperatures are kept at or close to 43°C and hand testing during the inspection indicated that the temperatures were higher than this in some cases. Albemarle DS0000004202.V255542.R01.S.doc Version 5.0 Page 7 Some radiators that would be considered by the inspector as high risk were without guards. Movable furniture is not an adequate preventative to accidental burning from radiators and those in bedrooms where residents may fall against them and not be immediately observed need to be considered as high risks. The need to place furniture in front of a radiator also reduces the choices for residents as to how their room can be arranged. The registered person must ensure that door wedges are not used as a means of keeping doors open. If a resident wishes to have their bedroom door open then this needs to be by means of a hold open device linked to the fire alarm system and that meets with the approval of the Fire Service. There are care plans available for all residents but due to the absence of a manger and the long-term sickness of the deputy manager who was acting manager these have not progressed as planned. The newly appointed manager and the deputy manager have intentions to concentrate on addressing this to ensure that staff have adequate information on which to base their care of the residents. Although the case files included clinical trigger management plans there was no specific risk assessments related to pressure development. The deputy manager advised that there were plans to use a ‘Waterlow’-type risk assessment. There are a few minor shortfalls in the medication process that may cause risk to residents and not fully protect the staff responsible for medication. The disposal or discharge of medication from the home must be recorded. The medication trolley must be secured to a suitable wall. It is also recommended that the 14-week Medication Administration Record Sheets be changed to a 28-day format in line with the amount of medication provided and as can be supplied by the pharmacist. These Medication Administration Record Sheets can also be used for recording the receipt of medication. With the lack of progress with care plans there was little evidence to demonstrate that there had been any improvement in making more opportunities available for residents to state their preferences in areas of their daily lives, although some residents spoken with said that they chose when to get up and when to go to bed. It was noted that several bedroom doors banged quite loudly when allowed to close themselves. This could be very disruptive, particularly during the night, and would affect the comfort for the people living at the home. Please contact the provider for advice of actions taken in response to this Albemarle DS0000004202.V255542.R01.S.doc Version 5.0 Page 8 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Albemarle DS0000004202.V255542.R01.S.doc Version 5.0 Page 9 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 DS0000004202.V255542.R01.S.doc Version 5.0 Page 10 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): 1,3 The home has information available for prospective residents but this is not up to date. Assessments made are ensure that the home can meet the needs of residents and prepare for their admission. EVIDENCE: Albemarle has a Service User Guide and Statement of Purpose that were required to be reviewed and brought up to date at the previous inspection to provide prospective residents with the appropriate information to enable them to make an informed choice about living at the home. The responsible individual advised that this has not yet been carried out and this requirement will be carried over. Five care files were examined and a pre-admission assessment was found in each of these files. Assessments made at the pre-admission stage covers all the elements required of this standard and had been completed in sufficient detail to provide the information required to asses if the home could meet the needs of the prospective resident and to prepare adequately for the admission. Albemarle DS0000004202.V255542.R01.S.doc Version 5.0 Page 11 All files seen also contained Care Management assessments and care plans as appropriate. Albemarle DS0000004202.V255542.R01.S.doc Version 5.0 Page 12 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 Limited progress has been made in improving the care plans. Residents’ ongoing health needs are met. There are some minor shortfalls in the medication process that may put residents at risk. EVIDENCE: Four care plans were viewed at this inspection. There are care plans available for all residents but due to the absence of a manager and the long-term sickness of the deputy manager who was acting manager these have not progressed as planned. The newly appointed manager and the deputy manager have intentions to concentrate on addressing this to ensure that staff have adequate information on which to base their care of the residents. Care files examined demonstrated that residents’ ongoing health needs are met with evidence of visits being made to or by a dentist, optician, chiropodist and district nurses. Preventative measures such as pressure relieving mattresses and cushions were seen to be in use during the inspection. However although the case files included clinical trigger management plans there was no specific risk Albemarle DS0000004202.V255542.R01.S.doc Version 5.0 Page 13 assessments related to pressure development. The deputy manager advised that there were plans to use a ‘Waterlow’-type risk assessment. There are a few minor shortfalls in the medication process that may cause risk to residents and not fully protect the staff responsible for medication. The current Medication Administration Record Sheets consist of tri-fold A4 card, which are completed by the senior staff. These cover a period of 14 weeks, are awkward to use and are subject to errors being made. The home is recording all medication received into the home but is handwriting the list of a substantial number of medicines, again creating a risk of an error being made. Medication Administration Record Sheets can be used for this purpose without the need to re-write the medications. Discharge and disposal of medication is carried out by the deputy manager taking the items to the pharmacist. Whilst when the pharmacist collected them from the home these were itemised in a hard backed book and signed for by the pharmacist, this no longer takes place. The home needs to resume this practice to complete the audit trail of medication that enters and leaves the home. The bulk of the medication is stored in the medicine trolley that is not secured to the wall. There were some minor storage problems but these were addressed at the time of the inspection. Controlled drugs were stored correctly and numbers checked were accurate. All staff responsible for medication have undertaken appropriate training in order to safeguard residents. Staff were seen to treat residents with respect and that this is usual was confirmed by residents spoken with. Staff were also seen to knock on doors before entering residents’ private accommodation and to use residents’ preferred names. Albemarle DS0000004202.V255542.R01.S.doc Version 5.0 Page 14 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): 14,15 Residents may not be offered opportunities to make sufficient choices about their daily lives. Meals are nutritious and balanced and offer a healthy and varied choice. EVIDENCE: With the lack of progress with care plans there was little evidence to demonstrate that there had been any improvement in making more opportunities available for residents to state their preferences in areas of their daily lives, although some residents spoken with said that they chose when to get up and when to go to bed. This requirement from the last inspection will therefore be carried over in this report. These areas will be further assessed at the next inspection. There was evidence to demonstrate that information was available regarding advocacy services. People living at the home spoken with all said that the food was enjoyable. Menus were found to be balanced and the lunch taken was tasty and well presented. Meals are taken in pleasant surroundings in a bright dining room at the front of the home. The mealtime appeared unhurried and staff were readily available to offer assistance when required by the residents. The kitchen was viewed at the end of the day and was clean and in good order. Albemarle DS0000004202.V255542.R01.S.doc Version 5.0 Page 15 Albemarle DS0000004202.V255542.R01.S.doc Version 5.0 Page 16 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): No standards were assessed from this section on this occasion. EVIDENCE: Albemarle DS0000004202.V255542.R01.S.doc Version 5.0 Page 17 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): 19,20,25 Albemarle, in general, offers comfortable, safe and mainly well-maintained surroundings both inside and outside the premises. Some serious matters outstanding put residents at risk of serious harm. EVIDENCE: The home has an imposing frontage and an attractive and impressive reception area with a wide staircase leading off it. The larger ground floor lounge at the front of the home is attractively decorated and furnished and has a homely appearance. One resident said that there were not enough armchairs in this lounge for her to be able to use it, but this was not able to be checked at the time of the inspection. A pleasant dining room on the other side of the reception area is attractive but has a bad stain following a leak, on the ceiling. Some of the furniture in this room is past its best but the responsible individual advised that dining chairs were about to be replaced. There is a further lounge/dining room at the rear of the home and overlooking the garden. The greater majority of the furniture and floor covering in the home was good quality, domestic in character and in good condition. All lighting seen in Albemarle DS0000004202.V255542.R01.S.doc Version 5.0 Page 18 communal and private accommodation was also domestic in character and of sufficient brightness. Portable air conditioning had been provided for the communal living areas for the residents’ comfort in the hot weather. The gardens are very attractive and well maintained with accessible pathways for residents to enjoy the garden. Wedges to keep doors open were provided in some bedrooms. Wedging doors open can create a risk to residents in the event of fire. Not all radiators and pipework have guards to prevent accidental burning. The assessment that those with furniture in front of them are safe is not taking into account that furniture can be moved, as was the case in one bedroom viewed where an armchair normally in front of a radiator had been moved to another area of the room. The need to place furniture in front of a radiator also reduces the choices for residents as to how their room can be arranged. There was no evidence available to demonstrate that hot water at outlets accessible to residents was close to 43°C, to prevent accidental scalding, including the temperature recordings that need to be taken of all hot water outlets. Before the completion of this report the responsible individual advised that a plumber had been in the home to address the hot water problems and this will be assessed again at the next inspection. The recording of temperatures must include showers and baths. Some showerheads had been removed to prevent their use for health and safety reasons but if showers are not in use the pipework must be taken back to the point where Legionella is not a risk or flushed through weekly and documentary evidence kept of this. The minor maintenance tasks required to have been carried out at the last inspection have been completed. It was noted that several bedroom doors banged quite loudly when allowed to close themselves. This could be very disruptive, particularly during the night, and would affect the comfort for the people living at the home. The laundry on the lower ground floor was not viewed at this inspection and will be assessed at he next visit to the home. The responsible individual advised that the floor was now easily cleaned. There were no unpleasant odours noted during the inspection. Albemarle DS0000004202.V255542.R01.S.doc Version 5.0 Page 19 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, 29,30 Appropriate numbers of qualified and unqualified staff were on duty at the time of the inspection. Limited progress has been made in auditing staff files to ensure that the appropriate information is kept in order to protect residents. EVIDENCE: Although the standard related to staffing was not fully assessed, there were adequate care and ancillary staff on duty at the time of the inspection. There is general domestic assistant and laundry assistant on only five days a week. Because of the management difficulties experienced at Albemarle since the last inspection there has been limited progress in ensuring that all the necessary documents, proof of identity, Criminal Record Bureau (Criminal Records Bureau), Protection of Vulnerable Adults (POVA) checks and any necessary proof of permission or ability to work in the UK are kept on file for individual employees at the home. This requirement will therefore be carried over with management needing to complete this as a matter of urgency. Previous requirements regarding the need for physical intervention training is no longer applicable as the residents for whom the training was required have now left the home. Albemarle DS0000004202.V255542.R01.S.doc Version 5.0 Page 20 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, 34, 38 The home has been without a permanent and consistent manager during the current year creating potential risk to the residents. The risk has been minimised by the presence and leadership of the two deputy managers and the support of the responsible individual/homeowners. Some matters are outstanding which put residents at risk of serious harm. EVIDENCE: The management structure of the home normally consists of a manager and two deputy managers, one of whom has been at the home for many years and offers long term continuity to residents and staff and the other who has also been at the home for several years and is Registered General Nurse (RGN). The home has been without a registered manager for the majority of this year and further to this the RGN has been on long-term sick leave. The home has therefore been coping under difficult conditions, with the RGN acting as manager when able to do so and the other deputy managing the home at other times. The responsible individual advised that he and his wife have also spent Albemarle DS0000004202.V255542.R01.S.doc Version 5.0 Page 21 considerable time in the home. There is no apparent evidence that the difficulties have had a negative impact on the residents well being but it has meant that the home has been unable to develop the management strategies, records, policies and procedures or continued leadership to ensure that staff have the guidance and direction required to ensure the consistent care and safety of residents. However a new manager had been appointed who was to commence employment within days after the inspection and who visited the home during the inspection, spending some time discussing the future plans for Albemarle. The newly appointed manager had been registered as manager at another home prior to moving to Albemarle and must apply for registration for her current post promptly. Discussion took place with the responsible individual regarding the need to provide financial and business plans for inspection if requested, and he agreed that this would be the case. Further discussion also took place regarding the need for monthly Regulation 26 reports. As the responsible individual and/or his wife are in the home on an almost daily basis it is judged to be unnecessary at this stage for the responsible individual to provide these reports to the Commission for Social Care Inspection. However the responsible individual or the manager must inform the Commission of any changes in the frequency or nature of the visits to the home that might affect this decision. There were a number of requirements related to health and safety at the previous inspection. Many of these have been addressed, including the provision of grab rails along corridors; the provision of some radiator guards in what the home considers to be high risk areas; the provision of some window restrictors in high risk sites; Legionella risk assessments report made available; the removal of suction machines no longer in use. There are a number of outstanding issues from that inspection as follows: Residents continue to have easy access to the kitchen, which could create infection control and safety risks when food is being cooked or when the kitchen is unattended. It was noted that one resident, with limited understanding, made numerous attempts throughout the day to enter the kitchen. As mentioned previously there is no evidence to demonstrate that hot water temperatures are kept at or close to 43°C and hand testing during the inspection indicated that the temperatures were higher than this in some cases. Some radiators that would be considered by the inspector as high risk were without guards. As previously mentioned movable furniture is not an adequate preventative to accidental burning and radiators in bedrooms where residents may fall against them and not be immediately observed need to be considered as high risk. Albemarle DS0000004202.V255542.R01.S.doc Version 5.0 Page 22 Further to these issues the registered person must ensure that door wedges are not used as a means of keeping doors open. If a resident wishes to have their bedroom door open then this needs to be by means of a hold open device linked to the fire alarm system and that meets with the approval of the Fire Service. Documents relating to maintenance and service checks, and some health and safety check records were not viewed at this inspection. Albemarle DS0000004202.V255542.R01.S.doc Version 5.0 Page 23 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x 2 x x x x x 1 3 STAFFING Standard No Score 27 x 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x x x x x x 2 Albemarle DS0000004202.V255542.R01.S.doc Version 5.0 Page 24 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 Responsible individual(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4,5 Schedule 1 Requirement The registered person must review and update the Statement of Purpose and Service User Guide to ensure compliance with the regulations and standards. (the previous timescale of 28/02/05 was not met) The manager must ensure that care plans are devised from comprehensive assessments to form the basis form the care to be delivered. The care plans must be drawn up with the resident and where practicable, agreed and signed by the resident or their representative. The manager must ensure that all residents are assessed regarding their risk to developing pressure sores and that any appropriate action is taken. The registered person must ensure that all medication is disposed of safely and correctly and that a record is kept of their disposal. The medication trolley must be DS0000004202.V255542.R01.S.doc Timescale for action 30/11/05 2 OP7 15(1) 30/11/05 3 OP8 12(1) 30/11/05 4 OP9 13(2) 30/11/05 5 Albemarle OP9 13(2) 30/11/05 Page 25 Version 5.0 6 OP14 12(2)(3) 7 OP19 13(4) 8 OP19OP38 23(4) 9 OP25OP38 13(4) 10 OP25OP38 13(4) secured to a fixed point. The responsible individual and manager must make available more opportunities for residents to state their preferences. (the previous timescale of 28/02/05 was not met) The responsible individual must ensure that the stained ceiling in the main dining room is made good. The registered person must ensure that door wedges are not used to hold doors open. If a resident chooses to have their bedroom door left open a hold open device approved by the Fire Service must be provided. The responsible individual must ensure that all pipework and radiators that may create a risk of accidental burning to residents are guarded, or have a guaranteed low surface temperature, (the previous timescale of 28/02/05, and previous inspections, was not met) The responsible individual must ensure that water at hot water outlets to which service users have access, including full body immersion areas such as baths and showers, must be emitted at temperatures close to 43ºC. The responsible individual and manager must ensure that all staff files contain the information required in Schedule 2 of the Care Home Regulations 2001, including proof of permission to work in the UK. The responsible individual must ensure that all health and safety issues as follows are addressed: Residents must not be able DS0000004202.V255542.R01.S.doc 30/11/05 30/11/05 30/11/05 31/12/05 31/12/05 11 OP29 7,9, 19 Sch 2 31/12/05 12 OP38 12(1) 13 (4) 30/11/05 Albemarle Version 5.0 Page 26 to have unsupervised access to the kitchen area. Door wedges must not be used as a means of keeping doors open. If a resident wishes to have their bedroom door open then this needs to be by means of a hold open device linked to the fire alarm system and that meets with the approval of the Fire Service. 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 4 Refer to Standard OP4 OP9 OP9 OP18 Good Practice Recommendations Accidents/incidents should be audited monthly and action taken as appropriate to reduce risks identified. The manager should consider changing the use of 14 week Medication Administration Record Sheets to 28 day Medication Administration Record Sheets. The manager should consider the use of Medication Administration Record Sheets for recording the receipt of medication. It is recommended that the manager review the policy and procedure relating to the reporting of abuse to expand and update this in line with the local multi agency policies and procedures. Albemarle DS0000004202.V255542.R01.S.doc Version 5.0 Page 27 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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