Inspection on 30/08/07 for Albemarle

This inspection was carried out on 30th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Albemarle 06/09/06

Albemarle 09/02/06

Albemarle 15/11/05

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 Rob Padwick Key Unannounced Inspection 30th August 2007 13:45 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.V350014.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Albemarle DS0000019641.V350014.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Albemarle Address Baxtergate Hedon Hull East Riding Of Yorks HU12 8JN 01482 896727 01482 890511 manager.albemarle@hica-uk.com 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 Donna Tina Jackson 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.V350014.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP and Dementia - Code DE(E) The maximum number of service users who can be accommodated is: 43 8th September 2006 2. Date of last inspection Brief Description of the Service: Albemarle 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 has recently undergone extensive upgrading to the environment and this programme of improvements is in the final stages of completion. Service users have easy access to the wide range of shops and facilities in Hedon and access to public transport. The standard fees charged by the home are £410 to £450 with additional charges made for hairdressing, chiropody etc. Albemarle provides information about the home to service users in its Statement of Purpose and Service User Guide. Albemarle DS0000019641.V350014.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) since the last key inspection of the home on 8th September 2006, including information gathered during a site visit to the home A questionnaire asking for information about the service was sent to the provider before the inspection visit and information from this was included as part of the inspection process. Other information used, included feedback from questionnaires sent out to people living in the home, their relatives and professional staff who know them well, together with official notifications received by the Commission for Social Care Inspection about the home. The inspection visit for this service lasted for 7.5 hours and during this period, time was spent talking with people living in the home and observing their daily lives. Other time was spent looking at their care plans and other records and talking to staff and relatives who were visiting. The inspection visit also included a tour of the properties. What the service does well: What has improved since the last inspection? The home now has a manager who is registered with the Commission for Social Care Inspection and work had been implemented to promote the continence of people living in the home as previously required. The standard of recording about people living at Albemarle had generally improved and further training had been provided to ensure they were able to do their jobs. A programme of activities had been developed for people living in the home and further improvements to the building had included the decoration and upgrading of a number of bedrooms in the home. Albemarle DS0000019641.V350014.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. Albemarle DS0000019641.V350014.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Albemarle DS0000019641.V350014.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6 People who use this service experience good outcomes in this area. The needs of people living in the home had been assessed to ensure that the service was able to meet these satisfactorily and information was available to ensure that people could make an active choice about moving into the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The case files of two of the most recently admitted people to the home contained evidence of a pre assessment of their needs that had been undertaken before they were admitted, in order to ensure the manager could determine the suitability of the home for them. The case file of another person admitted earlier that week as an emergency, contained evidence that the manager had started to carry out a full assessment of their needs and that care plans were in the process of being developed from these. The manager indicated that she had prior knowledge of the needs of this individual and evidence was available to confirm she had liaised with Social Services about these. Up to date information about the service is issued to people thinking Albemarle DS0000019641.V350014.R01.S.doc Version 5.2 Page 9 about moving into the home and up to date copies of these were displayed on the hall notice board. Relatives and people living in the home confirmed they had been actively involved in decisions about moving in to Albemarle. The manager indicated that not all of the people living in the home had previously been issued with contracts between them and the provider organisation, but these were now being issued to new residents and plans were in place to ensure that everyone was provided with one in order to safeguard their legal rights. The manager confirmed that the service does not admit people for intermediate care. Albemarle DS0000019641.V350014.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use this service experience good outcomes in this area. Staff had been provided with information about the health and personal care needs of the people living in the home in order to ensure that they could be assisted to be as independent as possible and their dignity maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living in the home indicated their health and personal care needs were being met and information about these were included in their individual care plans, which documented the support needed from staff. Those inspected covered a range of emotional, psychological and physical health concerns, together with details about their individual life histories and particular interests together with information about the management of risks that had been identified for them. Daily recording in the care plans was generally of a good standard with evidence of actions taken by staff and information about how the individual’s concerned had been. Care plans were being monitored and evaluated regularly to ensure they reflected current information and these were kept in the bedrooms of people living in the home to enable them to have input over the care provided, which is good practice. Positive feedback was Albemarle DS0000019641.V350014.R01.S.doc Version 5.2 Page 11 received from Community professionals associated with service and action had been taken to develop the home’s policies and procedures concerning the promotion of continence in the home. Relative’s confirmed they were happy with the care provided and questionnaires returned from them commented on the kindness of staff that is shown. Observation of people living in the home indicated they were treated with dignity and respect and confirmation of training provided about this was present in staff files inspected. The home had policies and procedures to ensure that the medication needs of people living in the home were met and staff responsible for this aspect of practice had received training about ensure they had the appropriate skills in this. As part of an anonymous complaint received by the Commission for Social Care Inspection, the medication records were looked at and found to be appropriately kept, although some of those concerning medication received from the Pharmacy were not always maintained clearly, which meant that it was difficult to check these. Some medication was being stored in labelled boxes in the home’s domestic fridge, as the special one for this purpose had broken down. This meant that these supplies were not securely held although the manager indicated steps had been taken to obtain a replacement fridge for this purpose. A Requirement and recommendation is made about these to ensure the safety of people living in the home is maintained. Albemarle DS0000019641.V350014.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15 People who use this service experience good outcomes in this area. People living in the home were being assisted by staff and involved in making choices about their daily life and activities in order that their lifestyle wishes and needs could be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Positive relationships were observed with staff members spending time with people living in the home to ensure that they were supported in making decisions about their lives. Since the last inspection visit the opportunities for people living at Albemarle to participate in activities of their choice had been developed and records inspected documented a variety of these, together with quality time spent with them by key workers. An activities timetable is developed monthly and inspection of the latest provided evidence of games, quizzes, trips out, music and movement sessions, visits from entertainers and a monthly church service. Questionnaires returned from family members generally indicated satisfaction with the home and confirmed staff kept them appropriately informed of concerns. One comment received from a family member however indicated that due to the levels of dementia experienced, their relative was unable to participate in those activities currently held in the home. A recommendation is made about this. Albemarle DS0000019641.V350014.R01.S.doc Version 5.2 Page 13 People living in the home indicated that food was of a good standard and menu’s inspected confirmed that a variety of healthy and nutritious meals were being provided with choices and specialist options available for those requiring alternatives. In order to ensure sufficient staff are available to support people living in the home, meals are severed in two sittings and staff were observed providing sensitive assistance to those requiring it in a dinning room area that was clean, bight and airy. Meal times appeared unrushed and evidence was seen in the case files inspected that the dietary needs of people living in the home were being monitored appropriately. Albemarle DS0000019641.V350014.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use this service experience good outcomes in this area. Training on the protection of vulnerable adults had been given to staff to ensure people living in the home were safeguarded from abuse and that their concerns and complaints were taken seriously. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Policies and procedures were available to ensure the concerns of people living in the home were taken seriously and that they were safeguarded from abuse. People living in the home and their relatives said they were happy with the service and comments received in questionnaires from them indicated they knew how to make a complaint if this was needed. The home’s records contained evidence of action taken to resolve the six complaints received since the last inspection visit and details had been provided to them about an advocacy service, which is good practice and demonstrates a positive attitude to welcoming concerns and suggestions. As indicated previously, the Commission for Social Care Inspection had received an anonymous complaint about medication practices in the home (See Health and Personal Care) however this could not be substantiated on this visit, although a recommendation was made in this respect. Staff records contained evidence of training relating to the protection of vulnerable adults, which had been provided as part of the home’s induction process and staff spoken to indicated they would act appropriately if this was required. Albemarle DS0000019641.V350014.R01.S.doc Version 5.2 Page 15 The records of money held on behalf of people living in the home were accurately maintained together with evidence of robust systems relating to income and expenditure. However the management and administrative arrangements for these needed developing (see Management and Administration) to ensure that it is not possible for individual’s to develop a negative balance in the pooled bank account that is held on their behalf. Albemarle DS0000019641.V350014.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use this service experience good outcomes in this area. The service provided people living in the home with a well maintained environment that was safely meeting their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was clean, bright and tidy and evidence was seen in the maintenance records of regular checks of equipment being carried out to ensure the safety of people living in the home. Following the last inspection visit, policies and procedures had been strengthened regarding the promotion of continence and discussion with the manager confirmed that training on these had been delivered to staff with more planned for the future. A questionnaire returned from a relative commented positively on the cleanliness of the home and stated it “feels like home”. At the time of this inspection visit some building and maintenance work was being carried out to upgrade parts of the building and evidence was seen of other work recently completed to Albemarle DS0000019641.V350014.R01.S.doc Version 5.2 Page 17 improve a number of bedrooms, which the provider organisation had commissioned. Albemarle DS0000019641.V350014.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use this service experience good outcomes in this area. A good programme of training and development had been provided to ensure staff were equipped with the skills needed to meet the needs of the people living in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Questionnaires returned from relatives and professionals associated with the service were generally positive about the staff with a number of them commenting on their caring nature. One stated “ my mother is happy and well looked after…for the first time she has put on weight…staff are very kind” whilst another commented “my mums care is excellent, we have no worries at all”. Staff were observed interacting with people living in the home in a friendly and supportive manner and discussion with those living at Albemarle indicated they were happy with the way that their needs were being met. The provider organisation has developed a strong training and induction programme and inspection of staff records confirmed that a variety of topics relating to the needs of the people living in the home had been provided so that staff are equipped with the skills needed to do their jobs. Evidence was seen that training in infection control and dementia care had been delivered to new staff together with regular support from an NVQ assessor, who was visiting to ensure the service achieved the recommended target that 50 of the staff team obtain an NVQ at level 2 or above. Evidence was seen that staff were receiving regular supervision to ensure that their professional Albemarle DS0000019641.V350014.R01.S.doc Version 5.2 Page 19 development needs were met and that the home had recently been successful in being re awarded “Investors in People” status which is to be commended. The home had recruitment policies and procedures to ensure staff were safe to work with people living in the home. Three of the four staff files inspected contained evidence that these were being followed appropriately with evidence of appropriate checks being carried out in relation to staff identity, Protection of Vulnerable Adults list (POVA First) and the Criminal Records Bureau. However, one file belonging to a staff member who had recently returned after a short break away from the home indicated that the organisation’s normally robust recruitment procedures had enabled the worker to restart employment a few days before a POVA First check had been received back. The manager was reminded of the need to ensure that employment checks are fully completed prior to the commencement of staff to ensure that people living in the home are protected from potential harm. Albemarle DS0000019641.V350014.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People who use this service experience good outcomes in this area. The administrative and management systems in the home were generally being well maintained, although to ensure the welfare of people living in the home some of these needed developing further. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection visit the manager has been registered with the Commission for Social Care Inspection and discussion with her indicated she was in the final stages of completing an NVQ 4 Management and Care as previously required. The Service has a relatively new management team with other members undertaking similar awards. A few of the questionnaires returned from staff as part of the inspection process expressed some reservations about management style, however those spoken to expressed confidence in the manager and confirmed they were happy working in the Albemarle DS0000019641.V350014.R01.S.doc Version 5.2 Page 21 home. Quality Assurance systems included action plans developed following consultation with people living in the home and the minutes from a recent “quality circle” group which included friends and relatives, provided further evidence of the involvement and participation of people involved with the service. Inspection of the homes maintenance book and other records provided evidence that health and safety checks being regularly carried to ensure the welfare of people living in the home. The records of money belonging to people living in the home were being accurately maintained with evidence of robust systems relating to income and expenditure. However, the computer records for these indicated that the management arrangements for these needed to be developed to ensure that it is not possible for individual’s to develop a negative balance in the pooled bank account that is jointly held for people living in the home. Albemarle DS0000019641.V350014.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 3 Albemarle DS0000019641.V350014.R01.S.doc Version 5.2 Page 23 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 OP9OP9 Regulation 13 Requirement The registered person must ensure that medication in the home is securely stored in order to ensure the safety of people living in the home. The registered person must ensure that new staff are only confirmed in post following completion of the required employment checks in order to safeguard people living in the home. The registered person must ensure that management arrangements are developed to ensure that it is not possible for the money held on behalf of people living in the home to develop a negative balance in the pooled bank account that is jointly held on their behalf in order to ensure that their financial interests are safeguarded. Timescale for action 01/10/07 2. OP29OP29 19 (4) (C) 01/10/07 3. OP35OP35 20 01/11/07 Albemarle DS0000019641.V350014.R01.S.doc Version 5.2 Page 24 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 OP2OP2 OP9OP9 Good Practice Recommendations The registered person should ensure that everyone living in the home is issued with a contract in order to safeguard their legal rights. The registered person should ensure that records of drugs received into the home are maintained clearly to ensure there is no mishandling of them and the welfare of people living in the service is safeguarded. The registered person should develop activities in the home to ensure that the lifestyle needs of all those living with dementia are better met. The registered person should ensure that the home manager holds a qualification in management and care. 3. 4. OP12OP12 OP31 Albemarle DS0000019641.V350014.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Albemarle DS0000019641.V350014.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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