Inspection on 09/11/05 for Albion Lodge Retirement Home

This inspection was carried out on 9th November 2005.

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 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

Albion Lodge Retirement Home 04/10/06

Albion Lodge Retirement Home 05/05/05

Albion Lodge Retirement Home 18/11/04

Albion Lodge Retirement Home 09/07/04

Albion Lodge Retirement Home 24/05/04

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Ravenhurst

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Inspirations

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

CARE HOMES FOR OLDER PEOPLE Albion Lodge Retirement Home Hanley Swan Worcester Worcestershire WR8 0DN Lead Inspector Y South Unannounced Inspection 9th November 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 Albion Lodge Retirement Home DS0000018623.V261898.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. Albion Lodge Retirement Home DS0000018623.V261898.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Albion Lodge Retirement Home Address Hanley Swan Worcester Worcestershire WR8 0DN 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) 01684 310626 Mr Colin Darwent Mrs Jean Mary Darwent, Mr Mark Robert Darwent, Mr Andrew John Darwent, Mrs Helen Ruth Smith Mr Andrew John Darwent Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36), Physical disability over 65 years of age of places (36) Albion Lodge Retirement Home DS0000018623.V261898.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may accommodate one named person under the age of 65 years. The home to be staffed as per the sample rosters and the levels are increased when necessary to meet the changing needs of the service users. 5th May 2005 Date of last inspection Brief Description of the Service: Albion Lodge is a large house in the village of Hanley Swan in Worcestershire. It is surrounded by a beautiful, well-maintained garden. This home is registered to provide care for a maximum of 36 older people with mild to moderate physical dependency needs. There are 32 single bedrooms and 2 double bedrooms. All rooms are fitted with en-suite facilities. Currently each double room is occupied by a service user who does not wish to share. The size of all bedrooms meets or exceeds the National Minimum Standards. The communal rooms comprise a spacious lounge / dining room, a bar lounge, a library and a conservatory. In addition there are assisted bathrooms, toilets and two shaft lifts. The Darwent family comprising Mr Colin Darwent, Mrs Jean Darwent, Mr Mark Darwent, Mr Andrew Darwent and Mrs Helen Smith own the home. Mr Andrew Darwent is the registered manager. Albion Lodge Retirement Home DS0000018623.V261898.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine unannounced inspection took place over three hours between 9.50am and 12:oomd The inspector was assisted by the registered manager Mr Andrew Darwent and also spoke to three staff and three service users. A partial tour of the home was undertaken and a range of files were assessed. The manager was asked to complete and return a service questionnaire, and distribute questionnaires to service users, relatives and health care professionals that sought their views on the quality of the service that was provided by the home. The responses that are received will be analysed and included in the next inspection report if appropriate. What the service does well: What has improved since the last inspection? Since the last inspection the written information available on the home has been improved and the pre admission assessments of needs are being more thoroughly documented. Improvements have been made to the gardens so that people are able to use level pathways and enjoy the newly developed courtyard. Handrails will soon be fitted. Inside the house there has been a lot of progress in redecoration and refurbishing rooms and corridors. Albion Lodge Retirement Home DS0000018623.V261898.R01.S.doc Version 5.0 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. Albion Lodge Retirement Home DS0000018623.V261898.R01.S.doc Version 5.0 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 Albion Lodge Retirement Home DS0000018623.V261898.R01.S.doc Version 5.0 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): EVIDENCE: These standards were not fully assessed during this inspection. However requirements had been made following the last inspection relating to standards 1 and 3. One requirement was that there must be an up to date Statement of Purpose and Service Users Guide and Terms and Conditions of Residence that includes all elements listed in the regulations and standards. This requirement had been met. A second requirement was made that pre admission assessments must be undertaken in sufficient detail to enable an initial service users plan to be compiled. Two assessment records were seen to be acceptable. Therefore this requirement had been met. Albion Lodge Retirement Home DS0000018623.V261898.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not fully assessed during this inspection but two requirements were made following the previous inspection and compliance with these was checked. Neither had been met. Care was being provided but the care plan that was assessed still lacked sufficient detail to guide and assist staff in providing the care that the individual needed. Full assessments were not being undertaken in relation to pressure area care and nutrition therefore there was insufficient information available on which to judge if a care plan was needed. It was observed that an over flow of medication stock was stored in a general store cupboard. This was not acceptable. It was recommended a medication cupboard that meets the criteria be secured in the cupboard for this purpose. Albion Lodge Retirement Home DS0000018623.V261898.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not assessed during this inspection. Albion Lodge Retirement Home DS0000018623.V261898.R01.S.doc Version 5.0 Page 11 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): EVIDENCE: These standards were not assessed during this inspection. The manager said that he had received no complaints since the last inspection. Albion Lodge Retirement Home DS0000018623.V261898.R01.S.doc Version 5.0 Page 12 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 are able to live in a comfortable, well-maintained home that suits their needs. Staff need to receive training to effectively reduce the risks of cross infection. EVIDENCE: A partial tour of the home was undertaken. It was clean, well maintained, furnished and decorated and free from unpleasant odours. Recently the exterior of the building had been painted and the courtyard landscaped with raised flowerbeds and paved paths. Inside corridors, the dining room and the lounge had been redecorated and carpeted Improvements were underway in the laundry. Walls were to be tiled in the laundry and in the adjacent dry storeroom. Albion Lodge Retirement Home DS0000018623.V261898.R01.S.doc Version 5.0 Page 13 The contents of the storeroom were being sorted and the non-food items were being moved to another area. Improved shelving was to be provided. Acceptable laundry and sluice equipment was provided and personal protective equipment was readily available. An infection control policy and procedure was available but staff had not received training in infection control. Albion Lodge Retirement Home DS0000018623.V261898.R01.S.doc Version 5.0 Page 14 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, 29, 30. The number and skills of staff on duty enable the current needs of the service users to be met. Some staff do not value training and there is a risk that they will become deskilled and unable to perform their duties in a manner that benefits the service users. EVIDENCE: The manager said that there were no staff vacancies. A maintenance man had recently been appointed and was proving of great benefit. In addition to maintenance and repairs, decoration and development work was also now being undertaken. Extra staff were rostered to work during the evenings and this had benefited the service users with their personal hygiene management. The records of a recently appointed member of staff were assessed as acceptable. Care must be taken that new staff receive their copy of the GSCC Code of Conduct and Practice. There was a total staff team of 30 people. Of this number 14 had qualified in NVQ levels 2 or 3, and 2 other staff were undertaking the course. Albion Lodge Retirement Home DS0000018623.V261898.R01.S.doc Version 5.0 Page 15 The manager considered that there was reluctance among some of the staff team to attend training courses and keep their knowledge up to date. 50 of the staff had undertaken training in moving and handling, 70 had undertaken training in health and safety. Other course training was needed such as food hygiene training and infection control. It is required that staff need to be trained to enable them to keep their skills updated in order to provide the service in the home in a manner that is acceptable, understanding and safe. Training is not a matter of choice and courses should not be missed without valid reasons. This should be addressed through supervision and if necessary through the disciplinary process. Albion Lodge Retirement Home DS0000018623.V261898.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): 33 A quality assurance system is in use that is proving beneficial in identifying areas for improvement and development. Financial systems are in use that protects the service users’ monies. EVIDENCE: The manager continues to be on the NVQ 4 course but is not making progress due to the pressure of other work. He said that now a maintenance man is in post this will reduce his own workload and it is hoped progress will be achieved in other areas. There was no annual development plan drawn up for the home but a plan of improvements for the building was available and being worked on. The quality assurance system has identified areas and challenges for improving the service that is provided. Albion Lodge Retirement Home DS0000018623.V261898.R01.S.doc Version 5.0 Page 17 A quality assurance survey was undertaken with the service users and feedback was given through a Service Users’ meeting. Meetings are now held regularly and minuted. Service users’ monies that were held in safekeeping were stored securely and appropriately documents. A full and continuous supervision programme was not in use. This had been a requirement in the two previous reports and remains unmet. Training was needed in core health and safety subjects such as first aid, food hygiene, and infection control. Fire safety checks were being undertaken and 50 of the staff had received training updates for this quarter. Albion Lodge Retirement Home DS0000018623.V261898.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 3 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 X 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 x 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 2 X 2 Albion Lodge Retirement Home DS0000018623.V261898.R01.S.doc Version 5.0 Page 19 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. 1 Standard OP7 Regulation 15 Requirement The service users plans and reviews, based on detailed assessments, must be drawn up with the involvement of the service users and set out in detail the action which needs to be taken by care staff to ensure all aspects of the health, personal and social care needs of the service user are met. Service users must be assessed by a person trained to do so, to identify those people who are at risk of developing pressure sores in order that appropriate intervention can be recorded in their care plans and implemented. 3. OP8 14 Nutritional screening must be undertaken on admission and subsequently on a periodic basis, a record maintained of nutrition, including weight gain or loss and appropriate action taken. 01/04/06 Timescale for action 01/04/06 2 OP8 12, 13, 14 01/04/06 Albion Lodge Retirement Home DS0000018623.V261898.R01.S.doc Version 5.0 Page 20 4 OP38OP30 OP26 13,18, Staff must receive training updates as necessary in core health and safety matters; specifically in infection control, first aid and food hygiene 01/04/06 5 OP36 18 Care staff must receive formal 01/04/06 supervision at least six times a year. Supervision must include all aspects of practice, philosophy of care in the home and career development needs. (Previous timescale of 31st December 2004 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. Refer to Standard Good Practice Recommendations Albion Lodge Retirement Home DS0000018623.V261898.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Albion Lodge Retirement Home DS0000018623.V261898.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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