Inspection on 22/06/05 for Albemarle Care Home

This inspection was carried out on 22nd June 2005.

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 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 Care Home 20/09/07

Albemarle Care Home 11/04/07

Albemarle Care Home 11/04/06

Albemarle Care Home 25/10/05

Albemarle Care Home 27/01/05

Albemarle Care Home 04/08/04

Albemarle Care Home 06/02/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Albemarle Care Home 4 Albemarle Road Woodthorpe Nottingham NG5 4FE Lead Inspector Karmon Hawley Unannounced 22 June 2005 10.00 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 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 Care Home C53 C03 S26406 Albemarle V234324 220605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Albemarle Care Home Address 4Albemarle Road Woodthorpe Nottingham NG5 4FE 0115 9607339 0115 9621841 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Abdul Rashid Awaiting new manager registration CRH 20 Category(ies) of OP 20 registration, with number of places Albemarle Care Home C53 C03 S26406 Albemarle V234324 220605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: NONE Date of last inspection 27th January 2005 Brief Description of the Service: Albermarle Care Home provides nursing and personal care for up to 20 older people. Mr Abdul Rashid is the registered provider and a new manager is now in post and awaiting registration. The Home is located in Woodthorpe an inner city area of Nottingham, it is close to a local bus route into the city, which is well supported by road and rail networks. It is also close to shops, general practitioners surgery, pubs and other amenities. Albermarle is an extended residential house, which consists of two floor, there are two longes and a dining room on the ground floor. The home has eight single rooms and six double rooms. There are three bathrooms, two of which are fitted with bathing hoists and one with shower facilities. There is a passenger lift to the upper floor and the house is wheelchair accessible. The grounds are well maintained and offer a relaxing environment. Albemarle Care Home C53 C03 S26406 Albemarle V234324 220605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one day. Three service users, one relative and three members of staff were spoken with. Three service users care files, four staff personnel files and other related documentation related to the care and environment were examined. What the service does well: What has improved since the last inspection? 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 Care Home C53 C03 S26406 Albemarle V234324 220605 Stage 4.doc Version 1.30 Page 6 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 Standards Statutory Requirements Identified During the Inspection Albemarle Care Home C53 C03 S26406 Albemarle V234324 220605 Stage 4.doc Version 1.30 Page 7 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 standard(s) 1,2,3,5 Despite preadmission assessments being satisfactory and ensuring needs can be met, service users are unable to make a fully informed choice and be assured their needs will be met due to the lack of a statement of purpose and terms and conditions of admission. EVIDENCE: A statement of purpose was not available on the day of inspection, however a service user handbook designed to help service users to settle into the home was. This offered basic information about the home and the facilities available, however it was noted that activities such as artwork and divisional therapy is offered, there was no evidence to substantiate this. The complaints procedure is included. No terms and conditions of admission or service users contracts were available for inspection. Preadmission assessments are carried out in the community prior to service users being offered a place in the home; the assessment covers the requirements of this standard. Respite care is offered and emergency admissions are accepted, the same procedures are applied in these instances. Albemarle Care Home C53 C03 S26406 Albemarle V234324 220605 Stage 4.doc Version 1.30 Page 8 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 standard(s) 7,8,9 Service users needs are assessed and appropriate plans of care are in place. Risk assessments require restructuring to ensure information is available is linked into the care plan thus reducing and managing risks appropriately. Whilst improvements have been made with regards to medications further attention is required to ensure service users are fully protected. EVIDENCE: There was evidence of specialist services being accessed and appropriate aids available. Assessment tools were in use to ascertain needs with regards to manual handling, pressure sores and nutritional needs. These formed the basis of the service users care plan, which cover the activities of daily living. Care plans in place were in depth and ensured highlighted needs were addressed with the exception of one file observed. Risk assessments were also in use, these did not link into care plans and offer clear management as to how the risk would be managed. There was evidence of service users receiving NHS entitlements. Reviews take place however these are not service user focussed and do not reflect outcome or goals. Daily records are maintained and note significant events. The drugs policy remains unchanged from the last inspection and therefore still requires attention. However general practices, stock control and record Albemarle Care Home C53 C03 S26406 Albemarle V234324 220605 Stage 4.doc Version 1.30 Page 9 keeping has improved. Fridge and room temperature are not done on a daily basis and the room temperature was noted to be consistently above 25 oC. Albemarle Care Home C53 C03 S26406 Albemarle V234324 220605 Stage 4.doc Version 1.30 Page 10 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 standard(s) 12,13,14,15 Service users are facilitated to exercise choice and control over their lives, personal preferences are acknowledged and respected thus ensuring satisfaction with care received. Whilst a nutritional diet is offered service users may be at a degree of risk due the noted deficits. EVIDENCE: There are currently no community links or volunteers working within the home. The routine with in the home is said to be flexible and choice is offered and maintained, one service user was able to substantiate this. There are no restrictions on visitors and the policy is available in the handbook. If privacy is required the dining room or the service users own room may be used. All consultations are carried out in the service users own room. Service users are able to make a choice as to whom they wish to see, this was observed to be documented. There is currently no advocacy service in use and no information available, however the manager is aware of contacts and these have been accessed in the past. The manger stated that she reviews service users plans of care with them or their relatives; there was evidence that this had taken place. On the day of the inspection Holy Communion and a service was taking place, this was well attended. The manger stated there are activities arranged and care staff carry out activities when there is time; mainly in the afternoons, however on speaking with staff they felt more activities could be Albemarle Care Home C53 C03 S26406 Albemarle V234324 220605 Stage 4.doc Version 1.30 Page 11 available. Service users spoken with felt their needs are met and staff respect their privacy and dignity. A nutritionally balanced diet and specialist diets are offered, choices are available and alternatives offered if required. There were noted deficits in the cleaning rota and the probing of food temperatures, it was stated this had been done but not signed as completed. Fridge and freezer temperature are currently only recorded weekly. One service user spoken with stated that he enjoyed his breakfast but other meals were not good, this mainly being due to his needs and preferences. Albemarle Care Home C53 C03 S26406 Albemarle V234324 220605 Stage 4.doc Version 1.30 Page 12 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 standard(s) 16 A pro-active ethos is employed to ensure service users and relevant others are confident that complaints will be listened to and acted upon. EVIDENCE: There have been no complaints received. The complaints procedure is clear, simple and accessible. One service user and relative spoken with felt staff listened to their needs and show respect. Albemarle Care Home C53 C03 S26406 Albemarle V234324 220605 Stage 4.doc Version 1.30 Page 13 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 standard(s) 19,21,23,26 In general the home is satisfactorily maintained, however the sluice area poses a trip hazard. Suitable adaptations and facilities are available; never the less hand washing facilities require attention to ensure cross contamination is contained. The home was clean and tidy but the odour problems detracted from this. EVIDENCE: The sluice room on the upper floor is still not fully completed, suitable hand washing facilities are not provided and the flooring requires repair as at present poses a trip hazard. There is a lift to the upper floor and also a stair lift, which is not working the manager, stated consideration is being given to the removal of this. There is sufficient equipment and adaptations around the home, however grab rails are on one side of the walls only. Relevant equipment was available in service users rooms, and rooms were personalised. New tables and chairs have been purchased for the garden so service users may sit outside, the garden is large and well kept and one service user was enjoying sitting outside on the day of inspection. The home in general was clean and tidy however there were two noted odour problems to which the Albemarle Care Home C53 C03 S26406 Albemarle V234324 220605 Stage 4.doc Version 1.30 Page 14 manager was made aware. The laundry room was small but tidy, there is no sluice area available here, and the one down the corridor is used. There was a hand wash facility but inappropriate soap being used. There are ample toilet and bathing facilities available. Albemarle Care Home C53 C03 S26406 Albemarle V234324 220605 Stage 4.doc Version 1.30 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 Despite adequate staffing numbers employed and service users acknowledging needs are met they are placed at a degree of risk due to the homes recruitment and selection procedure and lack of mandatory training. EVIDENCE: Personnel files did not contain all the required documentation, a registered nurse’s registration number was initially not available however this was later found; these are not checked periodically. Staff contracts are currently being updated, as are job descriptions, one staff member spoken with stated she did not have a contract in place. The manger has attended a recruitment and selection course and is now actively looking towards improving the recruitment and selection procedures within the home. Staffing rotas were observed and appropriate staffing levels are employed. Any deficits are highlighted so these can be covered appropriately. The manger stated all staff have received the General Social Care Council Code of conduct, however the staff member spoken with could not substantiate this. A service user spoken with stated that staff were exceptional and were all very nice and they treat everyone the same. Three members of staff have attained the National Vocational Qualification level two in care and one is working towards level three. A Care Skills induction programme is in use for new staff. Learn direct have been approached to commence distance learning, however there was no evidence that staff have received all mandatory training and one staff member spoken with stated she had not had any other training since being employment with the exception of the induction programme. Albemarle Care Home C53 C03 S26406 Albemarle V234324 220605 Stage 4.doc Version 1.30 Page 16 Albemarle Care Home C53 C03 S26406 Albemarle V234324 220605 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,35,36,38 The manager ensures the home is run in the best interest of service users, however there is no formal quality assurance plan to monitor this appropriately. Service users finances are at present not fully safeguarded. The health safety and welfare of service users is currently compromised due to concerns noted. EVIDENCE: The manager has been in post for only a few months, however she is actively working towards making improvements. Supernumerary time is not allocated to enable her to concentrate on managerial issues. Quality assurance is currently carried out on an informal basis, the manager approaches service users and relatives to ensure they are satisfied with care received, this is documented within care files. Service users are able to have personal allowances held on the premises. These were checked, not all accounts were correct, only one staff member had been signing for withdrawals, there was no evidence of audits taking place and ten pounds a month is taken out for toiletries, it was noted that additional Albemarle Care Home C53 C03 S26406 Albemarle V234324 220605 Stage 4.doc Version 1.30 Page 18 amounts had then been taken out for razors. There were receipts available however none for the ten pound for toiletries. This in not mentioned in the statement of purpose/handbook, there does not appear to be any written consent for this to take place. Formal supervisor sessions do not take place at the moment, these have done so in the past and there was evidence available to substantiate this. The manager intends to recommence these. Health and safety testing and certificates were observed. The Environmental Health Department had highlighted issues with regards to fridge temperature recording. Other maintenance checks were available and satisfactory with the exception of the mains electric, the certificate stated that these should be checked in no less than twelve month, this had not been done. Emergency lighting had been tested monthly and fire alarms weekly, however since the proprietor had been on holiday there were no records available to demonstrate this had taken place, staff stated that the proprietors brother had been doing these but he had not recorded them. Fire drills and fire training were noted to be out of date. Albemarle Care Home C53 C03 S26406 Albemarle V234324 220605 Stage 4.doc Version 1.30 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 1 1 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 1 COMPLAINTS AND PROTECTION 1 x 3 x 3 x x 1 STAFFING Standard No Score 27 3 28 x 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x 1 x 1 1 x 1 Albemarle Care Home C53 C03 S26406 Albemarle V234324 220605 Stage 4.doc Version 1.30 Page 20 NO Are there any outstanding requirements from the last inspection? 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 OP1 Regulation 4(1,2) Schedule 4 5(1b,c) Requirement The responsible individual is required to ensure a statement of purpose is available for inspection The responsible individual is required to have terms and conditions of admission and service users contracts available for inspection. Service user / relatives involvement during the preassessment procedure is to be documented. This is an outstanding requirement from March 2005 and must be adressed to avoid enforcement action. Risk assessments are required to demonstrate risk management. This is an outstanding requirement from March 2005 and must be addressed to avoid enforcement action. Service users reviews are required to be individualised and service user foccused. The responsible individual is required to ensure the safe storage and disposal of medicines. This is an outstanding requirement from March 2005 Timescale for action 27th July 2005 27th July 2005 2. OP2 3. OP3 14 (1c) Immediate 22nd June 2005 4. OP7 13(4c) Immediate 22nd June 2005 5. 6. OP7 OP7 15(1b) 13(2) 27th July 2005 Immediate 22nd June 2005 Albemarle Care Home C53 C03 S26406 Albemarle V234324 220605 Stage 4.doc Version 1.30 Page 21 7. OP15 8. OP19 13(4a) 9. 10. 11. OP19 OP26 OP29 13(3) 16(k) 19 Schedule 2 18(c1) 12. OP30 13. OP33 24(1,a,b) 14. OP35 Schedule 4 15. 16. OP36 OP38 18(2) 23 (2b) and must be addressed to avoid enforcement action. Appropriate measures are to be taken to ensure the safe storage, preparation and serving of food. This is an outstanding requirement and must be addressed to avoid enforcement action. The responsible individual is required to repair the flooring within and outside the sluice area on the upper floor. Appropriate hand washing facilities are to be available at all times. The identified odour problems to be remedied. All staff employed are required to have the appropriate documentation and relevant checks in place. The responsible individual is required to demonstrate that staff employed, individually and collectively have the required knowledge and skills to meet the needs of the service user. The responsible individual is required to ensure a formal quality assurance system is in place. The responsible individual is required to implement measures to safeguard service users personal allowances. Receipts are required for all transactions Staff are to be appropriately supervised. The responsible individual is required to ensure all maintanance and testing is up to date. Immediate 22nd June 2005 Immediate 22nd June 2005 Immediate 22nd June 2005 20th July 2005 20th July 2005 14th August 2005 14th August 2005 Immediate 22nd July 2005 14th August 2005 20th July 2005 17. Albemarle Care Home C53 C03 S26406 Albemarle V234324 220605 Stage 4.doc Version 1.30 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP14 OP31 OP26 Good Practice Recommendations Information and contacts to be displayed with regards to advocacy services. Supernumerary hours are available to enable the manager to carry out managerial duties. Supervision sessions are held at least sis times a year. Albemarle Care Home C53 C03 S26406 Albemarle V234324 220605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Edgeley House Tottle Road Nottingham NG2 1RT 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 Care Home C53 C03 S26406 Albemarle V234324 220605 Stage 4.doc Version 1.30 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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