Inspection on 18/01/07 for Albemarle Mews

This inspection was carried out on 18th January 2007.

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

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

Other inspections for this house

Albemarle Mews 30/03/05

Albemarle Mews 06/08/04

Albemarle Mews 23/02/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

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

CARE HOME ADULTS 18-65 Albemarle Mews Baxtergate Hedon East Riding Of Yorks HU12 8JN Lead Inspector Rob Padwick Unannounced Inspection 18th January 2007 11:45 Albemarle Mews DS0000019778.V324420.R01.S.doc Version 5.2 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 Mews DS0000019778.V324420.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 Adults 18-65. 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 Mews DS0000019778.V324420.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Albemarle Mews Address Baxtergate Hedon East Riding Of Yorks HU12 8JN 01482 890376 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 Miss Sally Ann Lowson Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Albemarle Mews DS0000019778.V324420.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd September 2005 Brief Description of the Service: Albemarle Mews provides personal care and accommodation for up to six younger adults with a learning disability. The home consists of two bungalow style properties which have recently been jointly registered as one service, and are situated next door to each other. All bedrooms are for single occupancy and there are separate lounge/dining area’s, together with a small kitchen within each of the two properties. A large garden together with a patio area is situated to the rear of the home. The gardens are well kept. The home is located on Baxtergate in Hedon, a town east of the city of Hull. The location of the home provides service users with easy access to a variety of local shops, pubs, services and local transport. Albemarle Mews is owned and operated by Humberside Independent Care Association Ltd (HICA) which is a not for profit organisation. The standard fees charged by the home range from £447 to £493 with additional charges made for hairdressing, chiropody, toiletries etc. Albemarle Mews provides information about the home to residents in its Statement of Purpose and Service User Guide. Albemarle Mews DS0000019778.V324420.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit for this service lasted for 5 hours and included a tour of the building and checking the progress in implementing the requirements from the previous inspection. During the visit, time was spent with the residents, observing their daily lives and talking with them. Other time was spent reading care plans and files and talking to staff. A Pre-Inspection Questionnaire asking for information about the home was sent to the manager before this visit and information from this was included as part of the inspection process. Other information that was used, included reports from monthly visits carried out by a senior manager from the parent company and notifications received by the Commission for Social Care Inspection about serious incidents that had taken place in the home. Questionnaires were sent out to residents, relatives and Health and Social Services staff associated with the home. Three replies were received from the group of relatives that were contacted and all of these commented favourably about the home. The replies from the three Health and Social Services staff made similarly positive comments. The views from residents who completed questionnaires as part of the inspection process have been included within this report. What the service does well: What has improved since the last inspection? Since the last inspection the manager for Albemarle Mews has formally been registered with the Commission for Social Care Inspection and this has helped make improvements for the benefit of the residents. The Provider organisation has also carried out the previous requirement that staff records are available, in order that they can be officially inspected. Albemarle Mews DS0000019778.V324420.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Albemarle Mews DS0000019778.V324420.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Albemarle Mews DS0000019778.V324420.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3 Quality in this outcome area is excellent. The residents had been provided with good information to help them make a decision about the home and they had been involved in decisions about moving into it. Residents had been assessed, in order to ensure that the home could meet their needs appropriately. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussion with residents and inspection of case files indicated that they had been involved about moving into the home. Case files inspected contained admission agreements which had been developed in pictorial format for ease of understanding, together with assessments of individual resident’s needs and support plans and other relevant information. The file of the most recently admitted resident indicated that the staff had completed his individual assessment before he had moved in, in order to ensure that the home was able to meet his needs satisfactorily. Albemarle Mews DS0000019778.V324420.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. The residents’ needs were being appropriately supported, in order that they could make decisions and make choices about their lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussion with residents indicated they were aware of their care “support” plans and the three of these that were inspected, contained clear information for staff about how the resident’s individual needs were to be met. The support plans had been developed in a pictorial format to help the residents understand them and most of them had been signed by the individual residents to indicate that they were in agreement with them. Information contained within the case files indicated that a person centred approach to meeting need was being followed by staff and the recording contained within these was of a good standard, with regular daily entries to show how the residents had been, together with monthly summaries and reviews of the support plans, in order to ensure that they were continuing to be appropriate Albemarle Mews DS0000019778.V324420.R01.S.doc Version 5.2 Page 10 to meet identified needs. Questionnaires returned from members of Social Services staff indicated that they were happy with the level of care provided at Albemarle Mews and discussion with residents confirmed that they had participated in review meetings about their needs. Observation of the care practices indicated that residents were able to make decisions about their lives, with support and assistance being offered from staff. Case files documented further examples of how residents had been supported to make choices and residents indicated that they were happy in this respect. Risk assessments for each of the residents were included within their case files and discussion with staff indicated that these were being sensitively applied within a framework that was consistent with individual choice and part of the residents’ everyday lives. Albemarle Mews DS0000019778.V324420.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. The residents were being supported to take part in a range of daily activities, in order to ensure that that their lifestyle wishes and needs were appropriately met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the start of this visit most of the residents were out attending a daycentre. Discussion with staff indicated that all of residents had a day off from their chosen programme of activities, in order to ensure that they had quality time at home with their key worker, to do everyday tasks such cleaning their rooms, going shopping and developing their skills of daily living. Case files documented a range of opportunities that the residents were able to take part in and discussion with them confirmed that they enjoyed taking part in these. Residents said they enjoyed “going shopping” or “going to the pub with staff” and questionnaires returned from relatives confirmed that they were encouraged to take part in the life of the home. Policies were in place in respect of visitors and maintaining relationships and case files contained Albemarle Mews DS0000019778.V324420.R01.S.doc Version 5.2 Page 12 evidence of how staff had supported residents in this, with social events being held, to which friends and family members were invited. Information submitted by the manager as a part of the inspection process, indicated that a course on the importance of social care values was planned for staff and observation of the care practices confirmed that residents’ rights were being upheld, with individuals choosing to do activities and spend their lives as they chose. Staff indicated that residents were supported to prepare their own meals if they wanted, and case files contained evidence of the residents’ dietary intake being monitored, in order to ensure that their nutritional needs were met, with entries for individual weight being recorded appropriately. Albemarle Mews DS0000019778.V324420.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. The residents’ health, emotional and personal care needs were being met with appropriate support being given from staff, in order to meet these. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents confirmed that staff were supporting their health and personal care needs in a way that they were happy with. Observation of the residents indicated that they were largely independent in relation to their personal care, and discussion with staff revealed that a system of prompts and encouragement was generally adopted, in order to ensure that these needs were appropriately met. Case files contained copies of good quality health action plans, which documented liaison with other professionals as required, together with appropriate monitoring in respect of the residents’ needs. A relative questionnaire returned confirmed the above and stated that “ My sister is very happy living at Albemarle Mews …… I feel that all her needs (both physical and emotional) are met…...The standard of care has improved very much over the past 5 years”. Views contained in another relative comment Albemarle Mews DS0000019778.V324420.R01.S.doc Version 5.2 Page 14 card stated the senders relative had “never been happier” and commented that “staff are excellent and treat him with great understanding”. Information submitted as part of the inspection process indicated that all of the staff were responsible for the administration of medication to the residents and discussion with individual members of them confirmed that they had received training in this aspect of practice. A random inspection of the homes medication systems confirmed that these were being maintained appropriately with accurate records accurately kept. Albemarle Mews DS0000019778.V324420.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. Complaints and adult protection policies and procedures were in place and followed by staff, in order to ensure that residents are safeguarded from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had policies in place in respect of complaints about the service and regarding the protection of vulnerable adults. Information about the using the complaints procedure had been developed in a pictorial form, in order to make it easier for the residents to understand. However, despite these efforts by the Provider organisation, discussion with the staff and observation indicated that owing to some of the residents limited verbal skills and the levels of understanding experienced by them, most of them were not able to able fully grasp how to use these. Residents spoken to said that they “like living here” and that “it is a nice home”. Questionnaires returned from relatives were positive in their comments about the home and confirmed that they knew how to make a complaint, if this was required. The manager has obtained some specialist skills using Makaton, in order to assist in communicating with residents and observation of the staff and discussion with them indicated that they had a good understanding of the residents needs and were able to interpret if anything was wrong or upsetting them. The home’s inspection log contained no entries since the previous inspection and confirmed that appropriate action had been taken by the manager to resolve any issues that had previously arisen. Albemarle Mews DS0000019778.V324420.R01.S.doc Version 5.2 Page 16 The home’s staff induction process includes training in Protection of Vulnerable Adults procedures and discussion with the manager and staff confirmed that they were aware of these and that they would take appropriate action if this was needed. The manager indicated that the all of the residents had individual bank accounts and inspection of the associated records for these, confirmed that robust systems were in place, in order to ensure that their financial interests were being satisfactorily safeguarded. Albemarle Mews DS0000019778.V324420.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. The residents’ environment was clean and generally well maintained, but some repairs were needed to improve the decoration of the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Albemarle Mews consists of two separate properties that have since the last inspection, been jointly registered as one service. The two properties are situated next door to each other and each has similar facilities. The home provides ground floor accommodation with easy access for people who may have a disability and all rooms are single occupancy. On the day of this inspection visit, the home was warm, bright and clean with no offensive smells detected. Inspection of a range of the home’s records indicated that satisfactory checks were being carried out, in order to ensure the environment was safe for the residents and a handyman was observed undertaking a weekly check of the home’s fire equipment. Some parts of the Albemarle Mews DS0000019778.V324420.R01.S.doc Version 5.2 Page 18 home were showing some signs of a need of decoration, with a wall in one of the home’s lounges requiring repair, resulting from a leak in the adjoining bathroom that had caused a damp patch to appear. However, discussion with the homes manager confirmed plans were in place to carry out work on these matters in the near future. A recommendation is made in these respects. Residents indicated that they had been encouraged to personalise their bedrooms and inspection of these confirmed that they were appropriate to meet their needs and chosen lifestyles. The home’s laundry areas were clean, tidy and appropriate for use. Albemarle Mews DS0000019778.V324420.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is good. Staff had been safely recruited and training provided for them, in order that the needs of the residents were met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Observation of the care practices indicated that positive relationships existed within the home and that residents obtained support and assistance from staff as required. Discussion with staff indicated that they knew the residents well and that they were knowledgeable about the individual needs of those accommodated. Information supplied by the manager indicated that 66 of the staff team had obtained an NVQ in care at level 2 or above, and this is commended as it exceeds the national minimum standard. The Provider organisation has developed an extensive training programme to ensure that staff are equipped with the skills required, in order to meet the residents’ needs. One staff member was enthusiastic about the specialist accredited Learning Disability Award Framework (LDAF) training that she had completed and a recommendation is made that similar training is provided for all new staff employed in the home. Inspection of the home’s records Albemarle Mews DS0000019778.V324420.R01.S.doc Version 5.2 Page 20 confirmed that whilst a good range of the topics within this had been completed by staff, a recommendation is made that the training programme is further developed, in order to ensure that staff are equipped with the necessary skills to work with residents that present challenging behaviours, since the home’s accident book recorded a number of incidents relating to this aspect of practice. A recruitment policy and procedure was in place to ensure that staff are safe to care for the residents. The files of the two most recently employed staff were inspected and indicated that this was being followed appropriately, with copies of Criminal Records Bureau checks and two written references being taken before staff could start work. Discussion with staff members indicted that the staff team was largely a long standing and stable one, however, a recommendation is made that the Provider takes steps when recruiting, to consider addressing the current gender imbalances within this, in order to ensure that these reflect the needs of those accommodated. Albemarle Mews DS0000019778.V324420.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. Appropriate checks were being carried out, in order to ensure the welfare of residents and staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussion with residents and staff indicated that Albemarle Mews was being well run. Since the last inspection, the manager had been registered with the Commission and discussion with her confirmed that she was undertaking an NVQ level 4 qualification in care and management. Staff indicated that the manager was open and approachable in her style and inspection of the home’s quality assurance systems confirmed that regular and thorough checks were being made of various aspects of the service, in order to ensure that it was meeting its stated aims. The minutes of meetings confirmed that the manager Albemarle Mews DS0000019778.V324420.R01.S.doc Version 5.2 Page 22 was consulting with residents and staff about the home and indicated that they were involved in decisions affecting them. Inspection of the home’s records indicated that the health, safety and welfare of residents and staff were being promoted and protected. Maintenance records inspected were up to date and in good order and the home’s training plan indicated that staff had covered a variety of health and safety issues or that these been identified as a future development need. Albemarle Mews DS0000019778.V324420.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 4 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 3 X 3 X X 3 X Albemarle Mews DS0000019778.V324420.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 YA24YA24 Good Practice Recommendations The registered person should ensure that the plans to repair the lounge wall and decorate the home are implemented as soon as possible, in order to improve the standard of the residents’ environment. The registered person should takes steps when recruiting, to consider that staff in day to day contact with residents include staff of both genders wherever possible, in order to ensure that these reflect the needs of the residents accommodated. The registered person should ensure that the homes training plan is further developed in order to ensure that staff are equipped with the necessary skills to work with residents that present challenging behaviours and that new staff undertake accredited Learning Disability Award Framework (LDAF) training. 2 YA33YA33 3 YA35YA35 Albemarle Mews DS0000019778.V324420.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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