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Inspection on 06/06/06 for Albert House

Also see our care home review for Albert House for more information

This inspection was carried out on 6th June 2006.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Residents said they liked living at Albert House, which was in a good location near the town centre and easy for people to visit. Several residents said Albert House is a "friendly" home and visitors are made welcome. The home was warm and nicely furnished. Residents said they were very comfortable and more than one person remarked that the home was always "spotlessly clean". Everyone spoken with had something positive to say about the meals. Over half the staff have NVQ qualifications and residents praised several staff for being "kind" and "patient".

What has improved since the last inspection?

A new management team member had been appointed, to provide sufficient staff supervision at all times and help the manager improve the quality of care at Albert House. A good start had been made in improving care planning and conducting risk assessments, so that everyone at the home will know how to properly care for each person according to their needs and wishes. Thorough checks had been carried out before appointing workers, and care workers had received health and safety and `principles of care` training, so residents can be sure that they are safely cared for by staff who are competent and of good character.The manager had put thermometers in every room, so temperatures can be monitored and adjusted to suit individuals.

What the care home could do better:

In order that prospective residents have the information they need to make sure Albert House is the right place for them to live, the manager should give everyone a copy of the service user`s guide; and make the home`s Statement of Purpose, complaints procedure and CSCI reports available to residents. So each person`s needs and wishes are met and their quality of life is constantly improved, the manager should ensure that residents are consulted about and included in discussions about their care plans. Every resident must have a detailed care plan, so that everyone knows what his or her needs are and how these are to be met and staff should be reminded of resident`s rights to privacy in bedrooms. Residents were keen to re-establish the programme of outings and improve choices of tea and supper meals. To protect everyone`s safety, privacy, choice and independence the management team should make a commitment to meet the requirements and recommendations made in previous reports: These include improving medication risk assessment; providing a report based on residents` views about improving the quality of care; properly supervising staff; recording staff induction training and giving staff training in the specialist needs of residents; carrying out hot water safety checks and Control Of Substances Hazardous to Health (COSHH) risk assessments; and holding regular fire drills with staff and residents.

CARE HOMES FOR OLDER PEOPLE Albert House 22 Albert Road Colne Lancashire BB8 0AA Lead Inspector Mrs Keren Nicholls Key Unannounced Inspection 6th June 2006 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 Albert House DS0000061635.V291190.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. Albert House DS0000061635.V291190.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Albert House Address 22 Albert Road Colne Lancashire BB8 0AA 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) 01282 862053 Albert House Residential Home Ltd Mr Peter Alan Perris Care Home 17 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (15) of places Albert House DS0000061635.V291190.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Within the overall total of 17, a maximum 15 service users may be accommodated requiring personal care who fall into the category of OP (either sex) Within the overall total of 17, a maximum of 2 (named) service users may be accommodated requiring personal care who falls into the category of DE(E) 24th January 2006 Date of last inspection Brief Description of the Service: Albert House is a residential care home providing 24-hour accommodation and personal care to 15 older persons and two (named) older persons who have a dementia. The registered provider Mr Perris, is also the manager. The home has a ‘service users’ guide’ and a Statement of Purpose, which give information about the services offered by Albert House and contacting the CSCI. The fees charged at May 2006 ranged from £315.00 to £360.00 per week (depending on need). There are additional charges for hairdressing, incontinence pads and private chiropody. Personal effects (such as toiletries and clothing etc.) are not included in the fee. The home is an extended detached house located on the main road in Colne town centre, within easy reach of shops, library, market and other amenities. There is time-limited on-street parking at the side of the home and across the main road. A public car park is a short walk away. The home has some parking in the garden courtyard at the rear of the home. There are steps (with handrails) and a ramp to the main front door. There are steps (with handrails) to the back door (accessed through the enclosed courtyard. There is a garden at the front and a private garden at the rear of the home. The home has two ground floor lounges (one with adjoining dining room accessed by two steps) and a separate dining room (adjoining the kitchen), which is the designated smoking area. There is one double bedroom with ensuite and 15 single bedrooms on the ground and first floors. There is a passenger lift to access upstairs and mobility adaptations such as handrails and disabled toilet facilities. Albert House DS0000061635.V291190.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit took place over 2 days. A total of 11.40 hours were spent at the home, when the inspector talked to residents, a relative, staff, the manager and deputy. She looked at records and care plans; observed care practice; lunched with residents and toured the home. Consideration was given to written information provided by the manager prior to the site visit. All key and additional National Minimum Standards were assessed. None of the 17 service user or 10 relatives comment cards sent to the home prior to the site visit were returned to the Commission. What the service does well: What has improved since the last inspection? A new management team member had been appointed, to provide sufficient staff supervision at all times and help the manager improve the quality of care at Albert House. A good start had been made in improving care planning and conducting risk assessments, so that everyone at the home will know how to properly care for each person according to their needs and wishes. Thorough checks had been carried out before appointing workers, and care workers had received health and safety and ‘principles of care’ training, so residents can be sure that they are safely cared for by staff who are competent and of good character. Albert House DS0000061635.V291190.R01.S.doc Version 5.1 Page 6 The manager had put thermometers in every room, so temperatures can be monitored and adjusted to suit individuals. 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. Albert House DS0000061635.V291190.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 Albert House DS0000061635.V291190.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): 1, 2, 3 and 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service: Residents and their representatives were consulted about needs and wishes prior to admission, but not everyone had a care plan, to ensure that staff knew how to meet these needs. Not every resident had been given information about the home (to enable them to make an informed decision about whether Albert House was the right place for them to live). EVIDENCE: The home had a service user’s guide, which was given to relatives, but not residents. Copies of the guide and the home’s Statement of Purpose were not readily available to residents in the home. One person said she knew about Albert House, having visited a resident in the past but another said they knew nothing about the home, other than what they had been told by their Social Worker. Neither person had a clear understanding of procedures, such as for making complaints. The guide was under review and the manager explained it would be reproduced as a ‘brochure’. Albert House DS0000061635.V291190.R01.S.doc Version 5.1 Page 9 Contracts (terms and conditions of residence) that adequately described the rights and responsibilities of all parties were available, but little progress had been made since the last inspection in ensuring that everyone had an up to date contract. Although there were good systems for assessing needs prior to people moving into the home, the plans of care for daily living were still lacking in the detail necessary for staff to understand how to meet some short-term and longer term needs (see also Standard 7). Several new residents did not have a care plan and therefore staff did not have full knowledge of needs. For example, staff had difficulty in obtaining immediate medical care for one service user admitted for ‘respite’ care. The home does not offer intermediate treatment (rehabilitation) care. Albert House DS0000061635.V291190.R01.S.doc Version 5.1 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, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service: Not everyone’s needs were fully met as some people did not have a care plan, and some people’s plans did not sufficiently detail how needs were to be met and by whom. Medication practices could improve to ensure safety. EVIDENCE: Inspection of a selection of care plans and discussion with those residents showed that generally care planning had improved and there were new systems for detailing social needs and reviewing and monitoring risk assessments. Daily diary records had continued to improve and described the care and attention given, although responses to identified problems were not always carried forward. Residents spoken with thought staff adequately met their general care and personal needs; “we are looked after very well”. However, the deputy manager had not had time to review all plans; some newer residents did not have a care plan, and some plans still did not identify how special needs, especially mental health, psychological, emotional and sensory needs were to be met. Residents thought that some staff had Albert House DS0000061635.V291190.R01.S.doc Version 5.1 Page 11 insufficient knowledge of their personal situation to meet such needs; “ I don’t think staff always understand, some staff explain and others don’t – its hard if you can’t, say hear or see properly”. Providing medicines protocols for variable dose and ‘when required’ medicines should reduce the risk of under or over medication, especially for residents those who buy their own ‘homely remedies’. Risk assessments and plans to minimise risk of harm should be completed for people who routinely refuse medication. Staff were observed to treat people with dignity and respect privacy when assisting with personal care and helped residents with their appearance. Residents had access to a pay telephone in the dining room. As this was not a private area, residents could use the mobile handset, although this did not work in all bedrooms. Residents said they used their bedrooms for private conversations with others, but during the visit there were three occasions when staff did not knock on doors and wait for a reply before entering. One resident commented it was “not nice” for one care worker to be pleased that personal care, such as bathing was completed quickly. Albert House DS0000061635.V291190.R01.S.doc Version 5.1 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): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service: The home enabled residents to choose preferred lifestyles and to take charge of personal affairs. Residents enjoyed social activities within and outside the home and were offered nutritious and varied meals. EVIDENCE: Several people said that they had chosen to live at the home because of its location. It was “handy”, near to shops and other amenities and easy for visitors to ‘pop in’. One person said he liked sitting out at the front and seeing people passing by and others said they felt as though they were still part of the community. Residents were happy that staff helped them to go out and were willing to run errands. Several people were pleased that staff brought them cooling ice creams on one hot day. Residents and a visitor said visitors were always made welcome and offered hospitality. Several people commented that the home was “friendly”. Residents said they could “please themselves” about rising/retiring times, using their rooms when they wanted and joining in with activities - “someone comes every other week and she does things like massage your hands and sometimes we have a singsong”. Residents also liked playing cards and other Albert House DS0000061635.V291190.R01.S.doc Version 5.1 Page 13 games and the home provided local newspapers. Several people said they enjoyed going out for coffee and other trips, but the manager had been so busy, there had been no outings for several weeks. They were very keen that these should be restored. There was an expectation that everyone would handle their own financial and personal affairs, as far as they were able. Residents said they had help from families with personal finances. One person said she was waiting for the manager to take her to her bank. Lunch meals shared with residents were nicely presented and well cooked, with an alternative for anyone not liking the menu. Residents’ comments included “very nice”, and “the food is good”. Menus, provided by the trained and experienced cook, were balanced and catered for health needs and residents’ preferences. Residents could choose to have meals in their bedrooms. Residents, the cook and staff agreed that teatime meals could be improved in terms of variety and consistency of cooking (care staff were responsible for teas). Also supper content was variable depending on who was on duty. The manager said varied foodstuffs were available, and this was an area he intended to improve with staff. Albert House DS0000061635.V291190.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service: Complaints were taken seriously and Albert House had a complaints procedure, which was followed. The procedure to protect vulnerable adults from harm was appropriate, and staff understood how to respond effectively to suspicion or allegations of abuse. EVIDENCE: The home had an adequate complaints procedure, but this was not well known in the home. The procedure was in the Service User’s Guide (which not every resident had a copy of – see Section ‘Choice of Home’) and in the staff procedures file. A record was kept of formal complaints. The manager had complied with requirements and recommendations made by CSCI following complaints. Most residents said they had no current concerns or complaints. Most had no clear idea of the procedure, but thought they would speak to staff or Mr Perris if they had any problems and these would be dealt with. Staff explained minor concerns were sorted out as they arose. Some residents were discussing their problems with the deputy manager. As previously recommended, improving the care planning system should help to give residents another forum for discussing individual worries (see Standard 7). Residents were protected by good financial practices and there was a procedure based on ‘No Secrets’ guidance, which if followed, should help to Albert House DS0000061635.V291190.R01.S.doc Version 5.1 Page 15 protect residents from harms. Staff had received recent training in protection issues and improved recruitment practices protected residents from harm. Staff spoken with had a good understanding of how to prevent and respond to suspicion or allegation of abuse and residents told the inspector they felt safe at Albert House. One resident said she liked to reward staff for the small extra kindnesses they showed (such as running errands). The deputy manager was asked to ensure that this did not contravene the home’s policies and procedures regarding acceptance of gifts and gratuities. Albert House DS0000061635.V291190.R01.S.doc Version 5.1 Page 16 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, 20, 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service: The home had an excellent standard of cleanliness. Residents enjoyed living in a safe, comfortable and ‘homely’ environment. EVIDENCE: Residents said the home was always “spotlessly clean”. They were happy with and comfortable in their bedrooms, which they used at any time they wished and could keep secure and private with a door lock. Residents personalised bedrooms with their own belongings and rooms were rooms were comfortably furnished, nicely decorated and carpeted. So temperatures suit individuals, the manager had provided room thermometers. Maintenance issues and refurbishment were attended to promptly. New commodes and mattresses had been purchased and residents appreciated the new dining chairs. There were no obvious hazards to safety. Infection control was appropriately managed, although adequate supplies of gloves and aprons should be ensured. Albert House DS0000061635.V291190.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service: The recruitment and selection process had improved and adequately safeguarded the welfare of the residents. However, in order to meet the health, welfare and safety needs of residents, the induction programme for new staff should be followed. EVIDENCE: Sufficient numbers of staff were on duty to meet the needs of residents and residents said that they liked and got on well with most of the staff, describing individual staff members as “couldn’t be nicer” and “lovely”. Rotas indicated that the one person on waking watch at night was supported by a person ‘sleeping-in’. The recruitment process had improved: Discussion with new staff and inspection of the files of four people appointed since the last inspection showed that appropriate pre-employment checks had been made. However, induction programmes had not been completed and there was no evidence of new staff being given copies of the GSCC codes of conduct. According to records and discussion with staff, the home had a good foundation and on-going training programme, with 61 of care workers being qualified to NVQ level 2 or above and the majority having completed recent principles of care and health and safety related training. Albert House DS0000061635.V291190.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service: The manager was experienced, but had not completed his NVQ level 4 training in care and management. Health and safety training had improved, but staff supervision and quality assurance processes had not progressed. This resulted in practice that did not promote health, safety and welfare improvement for the people using the service. Good financial systems and records safeguarded residents. EVIDENCE: The registered manager had made limited progress in meeting requirements and recommendations from previous inspections to ensure residents will receive consistent and improving good quality care: Albert House DS0000061635.V291190.R01.S.doc Version 5.1 Page 19 The manager explained that his registration on a NVQ level 4 course had lapsed and he had to re-start with a different training provider. However, the shortfall in management time and skills level had been alleviated by the recent employment of a trained deputy manager. Several residents were pleased with the new appointment and thought that the management of the home was “improving” with more consistent oversight of care practice on a day-to-day basis. More than one person said the deputy had “time to talk and listen to me”. Limited progress had been made with developing a quality assurance system to monitor outcomes for residents. The manager said survey questionnaires had been given to residents and their representatives, but none had been returned. Consultation with residents was informal, with the manager and staff chatting to individuals. Residents reported that whilst they found the manager and staff approachable, some minor concerns were not formally noted and therefore “forgotten” or took some considerable time. The manager and deputy said they were going to start some formal consultation strategies, such as residents meetings and producing a newsletter for everyone at the home. A staff meeting had been recently held. In order that the quality of care at Albert House is properly monitored and improved, the registered person must provide a written report in accordance with the Care Homes Regulations. The home should also review the aims and objectives with residents and staff; publish the results of satisfaction surveys and ensure each person (and their representative if appropriate) is consulted about and has input to his or her care plan. Staff were still informally and sporadically supervised, so residents were not confident that every staff member was competent and promoted the home’s aims and objectives. Staff spoken to thought that having the deputy manager to speak to, in the absence of the manager was a positive move. The manager should make sure that as well as the annual appraisal, every member of staff has formal supervision at least 6 times a year. This should cover all aspects of practice, the philosophy of care at Albert House and career development needs. This is so residents have care and support from a staff team who know what the care values are, are competent to do their job and that residents can be sure that care work is overseen by the manager. The home had sound policies and procedures regarding service users money and other financial arrangements. The certificate of liability insurance was displayed and there was up to date insurance cover in respect of loss or damage to the assets of the business. The manager had submitted a business and financial plan, including a training plan and budget. ‘Case tracking’ showed that written records of financial transactions and fee payments were kept. Residents spoken with about finances said that they or their families managed their own monies, kept their own personal allowances and paid fees. The manager helped residents to access their bank accounts if they so desired Albert House DS0000061635.V291190.R01.S.doc Version 5.1 Page 20 but policy otherwise was for residents to manage their own personal finances. Although secure facilities provided for the safe storage of valuables and monies, policy encouraged residents not to store such items at the home. The majority of staff had completed recent training in health and safety issues (such as moving and handling, fire safety, basic food hygiene), which minimised risk of harm for everyone at the home. Fire alarms were tested regularly and equipment had been renewed but drills and practices that ensured that everyone knew how to respond in the event of a fire (especially new staff) had not been held. To further minimise risk of harm to residents, the manager should progress recommendations made at the last inspection: i.e. to regularly test hot water (to prevent risk from scald) and carry out COSHH risk assessments. Albert House DS0000061635.V291190.R01.S.doc Version 5.1 Page 21 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 2 2 2 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 X X X 3 X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 Albert House DS0000061635.V291190.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP1 OP7 Regulation 5(2) 15 Requirement The manager must give every service user a copy of the service user’s guide. Every service user must have a care plan, which sets out in detail how physical and mental health; personal; psychological; emotional and social care needs are to be met. Each service user must be consulted about his or her plan and plans must be regularly reviewed and revised with each person. (Timescale of 31/3/06 not met). The manager must ensure that all staff receive training appropriate to their role. For example, this may include care of older people; dementia care; assessed special care needs of individuals (such as sensory impairment and emotional care). (Timescale of 30/4/06 not met). The registered persons must establish and maintain a system, (which provides for consultation with service users and their representatives) for reviewing and improving the quality of care DS0000061635.V291190.R01.S.doc Timescale for action 14/07/06 14/07/06 3. OP30 18(1)(c) 30/09/06 4. OP33 24(1)(3) 14/07/06 Albert House Version 5.1 Page 23 5. OP33 24(2) 6. OP36 18(2) 7. OP38 23(4)(e) at Albert House. (Timescale of 31/3/06 not met). The manager must supply a copy 31/07/06 of the report of the quality improvement review to the Commission and make a copy available to service users. (Timescale of 30/4/06 not met). The manager must ensure that 31/07/06 all staff are appropriately supervised. (Timescale of 31/3/06 not met). Fire drills and practices must be 30/06/06 held at suitable intervals and that staff and (as far as practicable service users) are aware of the procedure to be followed in the event of a fire, including the procedure for saving life. (Timescale of 5/2/06 not met). 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 OP1 OP2 Good Practice Recommendations The manager should make sure that every resident has access to the home’s Statement of Purpose (1.1). This recommendation carried forward from the inspection on 24/1/06: The manager should ensure that every resident has agreed a contract (statement of terms and conditions of residence) with the home (2.1). Recommendation carried forward from inspections on 23/4/04, 9/3/05, 25/7/05 and 24/1/06: That needs assessments and care plans are fully completed with all service users (3.4). Recommendation carried forward from inspections on 23/4/04, 9/3/05, 25/7/05 and 24/1/06: That service users care plans should set out in detail the action that needs to be taken by care staff to ensure that DS0000061635.V291190.R01.S.doc Version 5.1 Page 24 3. OP3 4. OP7 Albert House all aspects of the health, personal and social care needs of the service user are met (7.2) and Plans should be agreed and signed by residents whenever capable and/or their representative (if appropriate and with the agreement of the service user) and recorded in a style accessible to the service user (7.6). Resident’s psychological health should be monitored regularly and preventive and restorative care provided (8.7) This recommendation carried forward from inspection on 24/1/06: a) The criteria for ‘when necessary’ and variable dose medicines should be clearly defined and recorded for all service users using such items (9.3) b) a signature list of people accredited to administer medication should be maintained The home should have a procedure for instances where individuals consistently refuse prescribed medication, which includes a risk assessment and plan to minimise harm (9.1) Staff should be reminded of resident’s rights and needs for privacy and dignity when; a) entering private bedrooms (10.1) b) regarding personal giving, including bathing (10.1) That the manager re-establishes the programme of activities, especially trips outside the home (12.3) That the home works towards improving the variety and content of the tea and supper meals (15.1) The manager should ensure the complaints procedure is accessible to everyone in the home (16.1) Recommendation carried forward from inspections on 25/7/05 and 24/1/06: That induction training specific to role is carried out within the first 6 weeks of employment (30.1) Recommendation has been brought forward from previous inspections: That the registered provider/manager completes his NVQ level 4 course in care and management (31.2) Recommendation carried forward from last four inspections: That the registered provider/manager evidences how management planning and practice encourages innovation, creativity and development (32.5). Recommendation brought forward from several previous inspections: That the arrangements for reviewing the quality of care at DS0000061635.V291190.R01.S.doc Version 5.1 Page 25 5. 6. OP8 OP9 7. OP9 8. OP10 9. 10. 11. 12. OP12 OP15 OP16 OP30 13. OP31 14. OP32 15. OP33 Albert House 16. OP36 17. OP38 the home are maintained, by for example, publishing the results of the service users questionnaires (33.4); using feedback from service users to inform planning decisions (this may be from formal and informal meetings) (33.6); seeking the views of staff, family, friends and other stakeholders about how the home is achieving goals for service users (33.7); and progressing action to implement the requirements and recommendations identified in inspection reports (33.10) Recommendation carried forward from the last three inspections: That the registered persons implement a programme of staff supervision sessions, at least 6 times a year, which covers all aspects of practice, the philosophy of care at Albert House and career development needs (36.2 and 36.3). Recommendations carried forward from previous inspections: a) That regular recorded tests are undertaken to ensure pre-set hot water valves are working correctly (38.3) b) that COSHH risk assessments are carried out (38.4) Albert House DS0000061635.V291190.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 Albert House DS0000061635.V291190.R01.S.doc Version 5.1 Page 27 - 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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