CARE HOMES FOR OLDER PEOPLE
Albemarle Care Home 4 Albemarle Road Woodthorpe Nottingham NG5 4FE Lead Inspector
Karmon Hawley Unannounced Inspection 25th October 2005 10:00 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 Care Home DS0000026406.V261821.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Albemarle Care Home DS0000026406.V261821.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Albemarle Care Home Address 4 Albemarle Road Woodthorpe Nottingham NG5 4FE 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) 0115 960 7339 0115 962 1841 Mr Abdul Rashid Vacant Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Albemarle Care Home DS0000026406.V261821.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 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 lounges 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 DS0000026406.V261821.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place in one day and was performed by one inspector. The main method of inspection was case tracking, this is a method of sampling the records of three randomly selected service users to ascertain if the needs of service users are appropriately assessed and identified needs are being catered for by the home to maintain optimum health and wellbeing of the service user. Four service users and two relatives were spoken with during the inspection so as to give the inspector an insight into the conditions and standards within the home. All were satisfied with the care received and the standards within the home. The three staff members and the proprietor were spoken with and assisted in the inspection process. Staff were able to discuss core values and principles of care and their job role in meeting service users needs. What the service does well: What has improved since the last inspection?
There have been many improvements made since the last inspection and the majority of requirements set at the last inspection have been met. The statement of purpose is in the process of being up dated to include all the requirements of this standard to ensure up to date and relevant information is available to prospective service users. There was evidence available to
Albemarle Care Home DS0000026406.V261821.R01.S.doc Version 5.0 Page 6 demonstrate that service users have terms, conditions and contracts in place ensuring they are protected. The medication policy has been updated ensuring service user safety. A contract is in place with regards to the disposal of medication to meet the new legislation in place. Appropriate measures are now in place to ensure food safety measures are maintained, evidence was available to demonstrate this ensuring service user safety. The carpets on the second floor and ground floor have been replaced improving both the quality and safety of the environment. Appropriate hand washing facilities are now in place improving infection control procedures. The manager is currently auditing the staff personnel files, improvements have been made to protect service users, however deficits need attention. Identified odour problems have been addressed ensuring a pleasant environment for service users and visitors. Staff training has been addressed and staff are working towards completing mandatory training to ensure they are fully able to meet the needs of service users. The proprietor carries out informal quality assurance at present ensuring service users are satisfied with care received, he intends to make this a more formal arrangement. Management of service users personal allowances has improved ensuring the safety of service users personal allowances. Maintenance and servicing testing is now up to date improving safety. What they could do better:
Minor improvements with regards to service users plans of care still require addressing. Evidence of service users and relatives’ involvement during the assessment procedure is still required to demonstrate that all needs have been fully addressed and set out in a plan of care. Risk assessments require further development to fully protect service users. Reviews are required to be individualised and service user focussed to reflect care and condition. All staff are required to have current disclosure checks at the correct level. Please contact the provider for advice of actions taken in response to this
Albemarle Care Home DS0000026406.V261821.R01.S.doc Version 5.0 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Albemarle Care Home DS0000026406.V261821.R01.S.doc Version 5.0 Page 8 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 Care Home DS0000026406.V261821.R01.S.doc Version 5.0 Page 9 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): EVIDENCE: Not assessed during this inspection. Albemarle Care Home DS0000026406.V261821.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,10 Despite service users health, personal and social needs being set out in a plan of care these may not be fully met due to the lack of evidence of service user and relatives input and as reviews are not service user focussed. Service users may be placed at a degree of risk due to the lack of management plans with regards to identified risks. Service users can be assured they will be treated with respect and their right to privacy is upheld. EVIDENCE: Service users undergo various assessments such as manual handling, nutrition, and the activities of daily living, information gained forms the basis of the plan of care. Plans of care in place were personalised and covered complex needs. There was evidence of reviews taking place however these remain as previous and lacked in appropriate information. Risk assessments were in place with regards to highlighting main risks, however with the exception of a risk identified in one case file there was no management plan. There were records available to demonstrate liaison with the multidisciplinary
Albemarle Care Home DS0000026406.V261821.R01.S.doc Version 5.0 Page 11 team as necessary. There was review documentation in place with regards to demonstrating that service users or relatives had been involved in the implementing of the plan of care and its review, however these had not been completed. Progress notes were maintained and reflected significant events. Service users when spoken with state that their needs are met and they were happy with care received. One relative stated that staff are extremely efficient and always polite and welcoming. Staff when spoken with were able to discuss core values and principles. All personal and nursing care is delivered in service users own rooms, staff are instructed on maintaining privacy and dignity and screening is used in double rooms. Visitors and any consultation may be received in private in service users rooms or in the dining room. Should a service user require the use of a telephone the office telephone is a mobile and this may be used. Service users receive their mail unopened; assistance is given should it be required. Service users substantiated that they are treated with respect and their privacy is upheld. Albemarle Care Home DS0000026406.V261821.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Not assessed during this inspection. Albemarle Care Home DS0000026406.V261821.R01.S.doc Version 5.0 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): 18 Service users are protected from abuse, however this may be compromised due to the remaining criminal records checks and references for current staff that are required. EVIDENCE: Appropriate policies and procedures were in place with regards to adult protection and staff spoken with were able to discuss these. All staff have criminal record bureau checks in place, however for those who work at other establishment further criminal record checks are underway, outstanding references are also still required for some staff. Service users are able to deposit money in to an individual account, these were checked and correct. Appropriate records were maintained to demonstrate transactions. On speaking with service users and relatives no concerns were expressed. Albemarle Care Home DS0000026406.V261821.R01.S.doc Version 5.0 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): 19,26 Service users live a safe, well-maintained, clean and pleasant environment. EVIDENCE: There are sufficient staff employed to maintain the cleanliness of the home. There were no unpleasant odours on the day of inspection and the home was clean and tidy. Additional hand washing facilities have been installed and the carpet replaced as required. The proprietor is intending to continue to work toward improvements and replacing flooring as required. Service users and relatives stated that the home is well maintained and homely. Albemarle Care Home DS0000026406.V261821.R01.S.doc Version 5.0 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 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): 28 Service users are in safe hands, however further consideration is required to commencing current staff onto the National Vocational Qualification to consolidate and evidence learning. EVIDENCE: One staff member has attained the National Vocational Qualification level two in care; another is due to commence level three. All staff have completed a training analysis and are working towards completing all mandatory training prior to commencing a National Vocational Qualification. Staff stated that training was sufficient and they felt supported in their development. The home follows a recognised induction programme to meet this requirement. Service users stated that staff are nice, efficient, and tend to their needs, no complaints or concerns were voiced. Albemarle Care Home DS0000026406.V261821.R01.S.doc Version 5.0 Page 16 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): 31,35 Service users live in a home, which is run and managed by a person who is of good character, and able to discharge her responsibilities, she is awaiting completion of her application for registered manager. Service users financial interests are safe guarded. EVIDENCE: The manager has been in post since May of this year. She is a qualified nurse and has experience in management. She has worked at the home previously with an agency and remains up to date with practices and training. She is currently awaiting completion of her registered managers application. Staff when spoken with stated that she is working towards improvements; there was evidence of this during the inspection. Three service users personal allowances were checked and corresponded to the account. Receipts were in place and reasons for transactions. Two signatures
Albemarle Care Home DS0000026406.V261821.R01.S.doc Version 5.0 Page 17 were available for all transactions. A new system has been introduced to address previous difficulties. The proprietor is not responsible for any individual personal finances. Albemarle Care Home DS0000026406.V261821.R01.S.doc Version 5.0 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 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 X 28 1 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X X Albemarle Care Home DS0000026406.V261821.R01.S.doc Version 5.0 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 OP1 Regulation 4(1,2) Sch4 Requirement The responsible individual is required to ensure a statement of purpose is available for inspection, this has been partly met, further information is now required to ensure all appropriate information is available. Service user / relatives involvement during the preassessment procedure is to be documented. This is an outstanding requirement from March 2005 and must be addressed to avoid enforcement action. Risk assessments are required to demonstrate risk management. This has been partly met, however further development is required to ensure a management plan is in place. Service users reviews are required to be individualised and service user focused. This is an outstanding requirement from the previous inspection and must be addressed to avoid enforcement action.
DS0000026406.V261821.R01.S.doc Timescale for action 20/12/05 2 OP3 14 (1c) 25/10/05 3 OP7 13(4c) 15/12/05 4 OP7 15(1b) 13/11/05 Albemarle Care Home Version 5.0 Page 20 5 OP29 19 Sch2 6 OP30 18(c1) 7 OP33 24(1,a,b) All staff employed are required to have the appropriate documentation and relevant checks in place. Staff employed must not work without a POVA 1st in place and under supervision whilst awaiting a criminal records bureau check. This is an outstanding requirement and must be addressed to avoid enforcement action. 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. This had been partly met, however evidence of all training is now required. The responsible individual is required to ensure a formal quality assurance system is in place. This had been in part met, however further documentary evidence is required. 26/10/05 16/01/06 26/01/06 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. 2 Refer to Standard OP14 OP26 Good Practice Recommendations Information and contacts to be displayed with regards to advocacy services. Supervision sessions are held at least sis times a year. Albemarle Care Home DS0000026406.V261821.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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