Inspection on 06/09/06 for Albemarle

This inspection was carried out on 6th September 2006.

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 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 Unannounced Inspection 8th September 2006 1:30 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 DS0000019641.V304769.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.V304769.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 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 Manager post vacant 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.V304769.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 9th February 2006 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 £395 to £440 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.V304769.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A Pre Inspection Questionnaire asking for information about home was sent out before this visit and information from this was included as part of the inspection process of this service. Other information that was used included reports from monthly visits carried by a senior manager from the parent company and notifications sent to the Commission for Social Care Inspection about serious incidents that had taken place in the home. 10 residents replied to a questionnaire that was sent out to those living in the home, as did 5 relatives out of a sample of 10, who were approached for their views. 5 replies out of 7 were received from Social Services staff. Health professionals, including the District Nursing service were also contacted by phone. During this visit, a tour of the building was carried out and time was spent talking with service users and seeing how they lived. Further time was spent reading care plans and files and talking to staff. What the service does well: What has improved since the last inspection? The redecoration of the home had been nearly completed with new bathrooms, toilets installed and an improvement to the kitchen made. Radiators with low surface temperatures had been fitted to keep the residents safe and the acting manager had begun to make improvements to the activities that were available for residents. Training about the residents medication had been given to staff and the health and safety records were satisfactory, to ensure that it was safe for everyone in the home. Albemarle DS0000019641.V304769.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. Albemarle DS0000019641.V304769.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.V304769.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. Residents are assessed prior to admission to ensure that the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The case file of the most recently admitted service user contained an assessment of her needs, which had been carried out before her admission to the home, in order to ensure that it could meet her needs satisfactorily. Other case files looked at contained copies of Local Authority care plans and Community Care assessments. Residents spoken to confirmed that they had been involved in the decision about moving into the home. Discussion with the acting manager confirmed that the home does not provide intermediate care. Albemarle DS0000019641.V304769.R01.S.doc Version 5.2 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 and 10 Quality in this outcome area is adequate. The residents’ were supported to meet their health and personal care needs, but better recording of the medication was needed to make sure they were kept safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents spoken to said that staff were meeting their health and personal care needs. The files of three residents looked at contained copies of “personal support plans” with information about how their individual needs should be met. Various identified areas of known risk had been identified for each of the resident’s and copies of assessments about these were included in each of the files examined, together with monthly reviews of the support plans and any alterations that were needed. Daily notes for each of the residents as well as monitoring of health related issues for the resident’s were seen, however the recording about these was not always clear or consistent and a recommendation about this is therefore made. The home had policies and procedures in order to safeguard the residents in respect of medication and information submitted by the acting manager indicated that training in this area of practice had been delivered to staff as Albemarle DS0000019641.V304769.R01.S.doc Version 5.2 Page 10 previously required. Senior staff confirmed that they had attended a course on the safe handling of medication and needed to submit a booklet for checking, in order to get a certificate for this. However, an error was found in the medication records, which related to drugs that had not being previously been checked in to the home properly. A requirement is made about this. Residents confirmed that they were treated with respect and their right to privacy was maintained when wanted. Staff were observed to assist residents in a sensitive manner and to knock on bedroom doors before entering. Albemarle DS0000019641.V304769.R01.S.doc Version 5.2 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 and 15 The Quality in this outcome area is good. Residents were being provided with a choice of healthy and nutritious meals and they were able to take part in a variety of activities although staff shortages sometimes limited these. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents said they were able to take part in a variety of social activities, and discussion with staff indicated that this aspect of practice was in the process of being developed at the time of this visit. A quiz was being held during the afternoon of this visit and discussion with staff indicated that pub nights and bingo sessions were also held. A themed “memory” room had recently been created in one of the home’s lounges and this was equipped with old photos and pictures and various items to stimulate the residents interests. A minibus was available for trips out and staff indicated that the “Hedon Hopper” was sometimes used in addition, so that wheelchair users could also join in organised events, such as a recent visit to Beverley races. Relatives and friends had contributed to fundraising for the residents at BBQ which had been held earlier in the summer and evidence was seen of plans for a Halloween night and a Christmas party. The home has an open visiting policy and relatives and friends were observed coming and going freely during this Albemarle DS0000019641.V304769.R01.S.doc Version 5.2 Page 12 inspection visit. Survey comments received as part of the inspection process indicated that staff shortages have sometimes affected the amount of activities that are available and discussion with the acting manager indicated that she was now in the process of advertising for new staff. Recommendations are made in this these matters. (See Staffing) Staff indicated that the residents were supported to have choices and be in control of their lives, as far as this was possible. Some of the residents look after their own money and one of the residents spoken with talked about various things that she did to maintain her independence. The home has a mobile shop called “Harrods” in order for residents who have difficulty in going out. Residents said that the food was good and inspection of the menu’s indicated that their were always choices available. Meeting minutes showed how residents had recently been consulted about how to improve the food and discussion with the deputy cook indicated that she was knowledgeable of the residents various likes and dislikes and was enthusiastic about her work. Case files inspected contained assessments of the residents’ nutritional needs and regular monitoring of their weight. Albemarle DS0000019641.V304769.R01.S.doc Version 5.2 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 and 18 The Quality in this outcome area is good. The residents were being safeguarded from abuse and their concerns and complaints were being taken seriously. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents comment cards stated that the staff were “helpful” and discussion with residents and visiting relatives confirmed that their views were taken seriously and that they knew how to make a complaint, if needed. The home has an acceptable complaints policy and inspection of the complaints book showed that appropriate action had been taken to resolve any issues that had been raised. Various policies and procedures were available in order to safeguard the residents from abuse and discussion with staff indicated them to know about these and that they would act appropriately if this was needed. Training records confirmed that staff had covered issues relating to the protection of vulnerable adults as part of their induction to the home. The service users’ money is kept in a separate bank account, but inspection of the records for this was not possible on the first visit to the home, as the acting manager had not yet been shown how to use the home’s computer. A second visit was therefore arranged, so that an administrator could help, and a random check of these was later found to be satisfactory. Albemarle DS0000019641.V304769.R01.S.doc Version 5.2 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 and 26 The Quality in this outcome area is adequate. The residents’ environment was safe and well maintained, but some parts of the home smelt unpleasantly. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had recently been refurbished and was bright and pleasantly decorated. One of the lounges was equipped with pictures and old photographs from the past, in order to help stimulate the residents’ memories. Bedrooms were comfortably furnished and individualised to the residents’ wishes. Maintenance records were not available in the home on the first visit to the home by the inspector, but these were obtained the following day when a second visit was made to check the residents’ money, and these were satisfactory. Wheelchair users can get to the second floor of the home by a lift. Albemarle DS0000019641.V304769.R01.S.doc Version 5.2 Page 15 Despite evidence of cleaning, an unacceptably unpleasant smell was present in some corridor areas in the home. A previous requirement about this had been made at the last inspection visit, with action taken to improve this. However, evidence from this visit indicated that this was still not being managed effectively. A further requirement and recommendation is therefore made about this matter. Albemarle DS0000019641.V304769.R01.S.doc Version 5.2 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 and 30 The Quality in this outcome area is adequate. The residents were being safeguarded by the homes recruitment process, but more staff and improved staff training would meet their needs better. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents spoken said the staff were meeting their needs and inspection of the home’s duty rota indicated that these included both care and ancillary staff. A pre inspection questionnaire completed by the acting manager indicated that the staffing levels were acceptable, however, comments received back from both some of residents and their relatives indicated that this was not always the case. Staff confirmed this and indicated that staff shortages sometimes limited the amount of activities and time that could be spent with individual residents. The acting manager stated that a number of staff had recently left the home and that agency were currently covering those vacancies, however she confirmed that she was in the process of recruiting full time replacement staff. A recommendation is made in this matter. Staff confirmed that they had received training on a variety of topics to help them do their jobs and inspection of the home’s records confirmed this. The provider organisation has an extensive training and induction programme that staff must complete and the organisation compiles a list of training that they consider mandatory. However from inspection of a sample of staff records, this needed to be developed further, to ensure that additional specialist training in infection control and dementia is provided to staff. Information Albemarle DS0000019641.V304769.R01.S.doc Version 5.2 Page 17 submitted by the acting manager as part of the inspection process, indicated that 42 of the staff have obtained a qualification at NVQ level 2 or above. Recommendations are made in these matters. Albemarle has a recruitment policy and procedure to ensure that staff are safe to care for the residents and inspection of a sample of staff records indicated this was being appropriately followed. Staff records showed that Criminal Records Bureau checks had been taken out before staff were allowed to work in the home. Albemarle DS0000019641.V304769.R01.S.doc Version 5.2 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 and 38 The Quality in this outcome area is good. The management of the home was safeguarding the residents’ health and welfare needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: An acting manager has recently been appointed for the home, and discussion with her indicated that she was enthusiastic and passionate about the home. Comments received from a member of Social Services staff confirmed that some improvements have recently been made and a member of the District Nursing staff contacted confirmed that arrangements have been put in place to help them look after the health needs of the residents. Staff spoken to stated that the acting manager was open to their views and would consider suggestions constructively. The acting manager is not yet registered with the Commission for Social Care Inspection and does not currently hold a management qualification, but indicated that she was keen to obtain this once Albemarle DS0000019641.V304769.R01.S.doc Version 5.2 Page 19 her induction to the home is completed. A requirement and recommendation is made in this matter. Discussion with residents indicated that some of them looked after their own money whilst other were managed by their families or appointed representatives. The provider organisation has implemented a computerised system for the management of individual residents personal allowances, which are kept in a separate back account. A random inspection of the records from this was satisfactory and indicated that the service users’ finances were being safeguarded. Discussion with staff and inspection of the home’s training records indicated that the health, safety and welfare of service users and staff were being promoted and protected. The home’s maintenance records for the home were not available at the time of the first visit and a second visit was therefore made to check these, which found them to be satisfactory. Albemarle DS0000019641.V304769.R01.S.doc Version 5.2 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 1 10 3 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 1 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Albemarle DS0000019641.V304769.R01.S.doc Version 5.2 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. 2. Standard OP9OP9 OP26OP26 Regulation 17 13,16 Requirement The registered person must ensure that medication records are accurately kept. The registered person must ensure that the home is free from offensive odours. (Previous timescale of 15/01/06 not met) The registered person should ensure that the home has a manager who is registered with the Commission for Social Care Inspection. Timescale for action 08/09/06 30/09/06 3. OP31OP31 9 01/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP8OP8 Good Practice Recommendations The registered person should ensure that the standard of recording in the residents’ daily notes is improved and the monitoring of health related issues is more consistently recorded. The registered person should ensure that activities are DS0000019641.V304769.R01.S.doc Version 5.2 Page 22 2. Albemarle OP12OP12 3. OP26OP26 4. 5. OP27OP27 OP28OP28 6. OP31OP31 consistently available to service users. With records kept of all activities offered and refused. The registered person should ensure that that appropriate clinical guidance is sought and a continence assessment tool is used as part of the homes management of residents’ health and social care. The registered person should ensure that additional staff are recruited, in order to meet the residents’ personal care needs at all times. The registered person should ensure that additional specialist training in dementia and infection control is provided to staff employed at the home and that 50 of the staff have obtained a NVQ level 2 qualification. The registered person should ensure that the home manager holds a qualification in management and care. Albemarle DS0000019641.V304769.R01.S.doc Version 5.2 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.V304769.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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