Inspection on 09/02/06 for Albemarle

This inspection was carried out on 9th February 2006.

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

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

Other inspections for this house

Albemarle 30/08/07

Albemarle 06/09/06

Albemarle 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 Sarah Sadler Unannounced Inspection 9th February 2006 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 DS0000019641.V283100.R01.S.doc Version 5.1 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.V283100.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Albemarle Address Baxtergate Hedon Hull East Riding Of Yorks HU12 8JN 01482 896727 01482 890511 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Humberside Independent Care Association Limited Mrs Dorne Jayne Tilley Care Home 43 Category(ies) of Dementia - over 65 years of age (43), Old age, registration, with number not falling within any other category (43) of places Albemarle DS0000019641.V283100.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 2005 Brief Description of the Service: Albermarle is situated in the market town of Hedon in East Yorkshire and was built approximately 30 years ago as a care home for older people. The home is registered to provide care and accommodation for up to 43 older people, some of who may have memory impairment. There are three lounges, a dining room and a seating area in the main entrance. The accommodation consists of mostly single bedrooms on two floors with access to the upper floor by stairs or passenger lift. The home is undergoing extensive upgrading of the environment at the present time Service users have easy access to the wide range of shops and facilities in Hedon and access to public transport. Albemarle DS0000019641.V283100.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was undertaken over one day by one inspector. The inspection was part of the annual inspection programme from April 1st 2005 to March 31st 2006. During the inspection a tour of the premises was undertaken, residents, visiting professionals, and staff were spoken to. Time was spent with residents, observing their everyday life. Some time was spent reading resident and other records within the home. What the service does well: What has improved since the last inspection? What they could do better: Service user records must be kept under review and include up to date information to ensure the continued meeting of service users needs. Albemarle DS0000019641.V283100.R01.S.doc Version 5.1 Page 6 Staff must undertake accredited medication training and all medicines must be singed for when administered to ensure that service users health needs continue to be met. Radiators and pipework must be guarded to have guaranteed surface temperatures to ensure the service users are safe within the home. The home must be free from offensive odours, to ensure that service users live in a pleasant environment, which is clean. 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.V283100.R01.S.doc Version 5.1 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.V283100.R01.S.doc Version 5.1 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): 6 This standard is not applicable. EVIDENCE: The registered manager confirmed that the home does not provide intermediate care. Albemarle DS0000019641.V283100.R01.S.doc Version 5.1 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 Service users health and mediation needs are not fully met. EVIDENCE: Service user files continue to include plans of care, risk assessments and records regarding their personal care and health needs. The records reflect when service users have had appointments with other specialists and if they require any additional support regarding their health needs. However of the records examined it was found that these records were not always up to date, for example the records of personal hygiene needs. Files included risk assessments for different needs including moving and handling. However these had not all been subject to recent and regular review. The deputy manager reflected a good understanding of medication and their uses, including the need to understanding the possible side effects of medicines. The deputy and registered manager confirmed that although staff have undertaken training with regards to medication they have not yet undertaken accredited medication training and this was being planned. Albemarle DS0000019641.V283100.R01.S.doc Version 5.1 Page 10 One comment received was that medication / health needs were not always met within the home. A professional confirmed that their instructions were “ sometimes followed, sometimes not.” Service users interviewed all confirmed that they receive their medication and that whenever necessary the home support them to access their GP or other professionals. Another professional confirmed that relatives felt that health needs were being met. Records for the administration of medicines were up to date, except for prescribed creams. The home currently labels the chart ‘Staff to administer’; with no signatures to record that the administration has occurred. This does not confirm that the service user has received their cream or when it was applied, which in turn could make it more difficult to assess the service user for future treatments. Albemarle DS0000019641.V283100.R01.S.doc Version 5.1 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 Service users social needs are not fully assessed and met. EVIDENCE: On the day of the inspection there was music playing in the foyer areas of the home. The majority of service users spoken with confirmed that activities take place; one professional confirmed that relatives were content with the level of activity undertaken in the home. One service user commented, “ there are not really activities, sometimes there is a group or a lad to entertain – it’s not my scene. Cards or dominoes have been done a few times, but not a lot are interested.” Service user files include an assessment of their social needs, however these are not always completed. There is a separate file for the recording of activities, of which an individual takes part. These records reflected that on some month’s service users undertook no activities at all and that on other months services users undertook only a few activities. Albemarle DS0000019641.V283100.R01.S.doc Version 5.1 Page 12 The registered manager and deputy manager confirmed that activities do take place regularly within the home and that it is the recording of such that requires further development. The recording of when a service user undertakes or declines an activity allows the home to develop the individuals care package in order to meet their social needs alongside their personal care needs. Albemarle DS0000019641.V283100.R01.S.doc Version 5.1 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): None of these standards were assessed at this inspection. EVIDENCE: Albemarle DS0000019641.V283100.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,25,26 Service users live in a home that continues to be improved. However some matters continue to put service users at risk of harm and do not provide comfortable surroundings in which to live. EVIDENCE: The registered manager and deputy manager confirmed that the refurbishment of the home is continuing and that work is to recommence in the week following this inspection. It is envisaged that this work, which includes the guarding of radiators and pipe work will be finished by May 2006. Upon arrival at the home offensive odours were noted and both a visiting professional and service user confirmed that there are offensive odours within the home. Comments received were: “ As soon as you come in it just follows you. It is here all the time; I can’t wait to get out. I think it is awful.” Another person confirmed that the smell is “ common”. Albemarle DS0000019641.V283100.R01.S.doc Version 5.1 Page 15 The registered manager and deputy manager confirmed that a water firm had visited the home and completed some work in relation to the meeting of the Water Supply (Water Fittings) 1999 Regulations. However no documentary evidence was available for this. Albemarle DS0000019641.V283100.R01.S.doc Version 5.1 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 Service users are supported by adequate numbers of staff, which are on the whole well, but not fully trained. EVIDENCE: One person commented that it could take a long time to find a member of staff. However several service users confirmed that staff are always available should they use their buzzer for assistance. The duty rotas reflected that there are 3 care staff on duty between 7.30 am and 10 p.m with a fourth carer on duty 8 am until 8 pm they are supported by a senior carer who is the ‘duty manager’. There is also a servery assistant 7 am until 6 pm to assist with the service users eating of their meals. This provides for 445 care hours per week an increase from the last inspection. In addition to the care staff there is the registered manager, an administrator, domestic and catering staff, and a handyperson. The deputy manager and registered manager confirmed that due to changes regarding the National Vocational Qualification, no further staff have attained this qualification. However the registered manager and manager are aware of the changes and are to assist staff with these changes in order to achieve the qualification. Albemarle DS0000019641.V283100.R01.S.doc Version 5.1 Page 17 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): 38 Service users live in a home that is on the whole safe. EVIDENCE: Some of the radiators and pipe-work remain unguarded, however work to rectify this is due to commence shortly. The registered manager confirmed that the Health and Safety certificates continue to be held at the organisations head office, as agreed with the local office of the CSCI, and that no evidence that the home meets relevant Health and Safety legislation is kept within the home. Albemarle DS0000019641.V283100.R01.S.doc Version 5.1 Page 18 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 1 X X X X X 1 1 STAFFING Standard No Score 27 3 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 2 Albemarle DS0000019641.V283100.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7OP8 Regulation 13,17 Requirement The registered person must ensure that service user records are completed and up to date. This is a previous requirement with a compliance date of 15.12.05. The registered person must ensure that: • Staff have undertaken accredited medication training. This is a prior requirement with a previous timescale of 15/02/06. • A record must be kept of all medicine administered; this must include creams. Timescale for action 15/12/05 2. OP9 13,18,19 15/02/06 3 OP19OP25 OP38 13 The registered person must 30/05/06 ensure that the radiators have covers or are low surface temperature and the pipe work is covered. A previous requirement that the radiators must be covered by 01/02/04 has not yet been complied with. The registered person must ensure that the home is free DS0000019641.V283100.R01.S.doc 4. OP19OP26 13,16 15/01/06 Albemarle Version 5.1 Page 20 from offensive odours. 5. OP26 13 The registered person must ensure that the home meets the Water Supply (Water Fittings) 1999 Regulations. 30/11/05 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 OP12 Good Practice Recommendations The registered person should ensure that activities are consistently available to service users. With records kept of all activities offered and refused. The registered person should ensure that 50 of the care staff is trained to NVQ level 2 or equivalent by 2005. The registered person should ensure that evidence that the home meets relevant Health and Safety legislation is available within the home at all times. 2. 3. OP28 OP38 Albemarle DS0000019641.V283100.R01.S.doc Version 5.1 Page 21 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.V283100.R01.S.doc Version 5.1 Page 22 - 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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