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Inspection on 21/08/06 for Albion Park House

Also see our care home review for Albion Park House for more information

This inspection was carried out on 21st August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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.

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

The home provides a warm and homely atmosphere for residents. The home has created a family type atmosphere that all of the residents spoke about. The menu in the home provides a well-balanced and varied diet for residents. The kitchen was well stocked, clean and well maintained. Albion Park House has a strong caring staff team, and has a low staff turnover; staff that have left have done so for genuine reasons. The staff group at the home are enthusiastic, well trained and skilled. The resident spoken with on the day stated that the manager and staff were `kind and caring` and the home was `very nice`. The resident reported that relatives and visitors are welcomed into the home at all times. The staff were observed to chat continually with the residents and involve them as they went about their work through out the day. The home has close links with the health care team in the area, and works with both professionals and residents to promote and maintain the residents health. The home promotes the rights of the residents and staff provide care that ensures privacy and dignity. The residents interacted comfortably with the staff. Staff treat residents with dignity and respected their privacy.

What has improved since the last inspection?

The registered person has ensured that the home informs the CSCI of formal complaints made by residents and relatives. The registered person has ensured that pre-admission assessments contain appropriate information that is relevant to the setting. The registered person has ensured that the advocacy service used in the home is displayed for the residents.

What the care home could do better:

The home does not have care plans that provide evidence that all appropriate information is recorded. Care plans do not contain appropriate risk assessment required to provide a detailed and accurate daily plan of care. The home does not accurately record the administration of medication and this shortfall has the potential of placing service users at risk. The home does not provide enough time for social activities. The money and financial records held in the home are not accurate. The home has not implemented the quality assurance procedure to measure the quality of life of the residents. The home does not have a robust recruitment policy. The issues identified above are important as the lack of sufficient information in care plans could ultimately impact on the quality and standard of care that service users receive. The lack of accurate recording of medication may impact on the safety of residents. The poor recruitment process in the home mayresult in the lack of protection of service users. This report contains six requirements linked to the above issues and may be found at the end of this report.

CARE HOMES FOR OLDER PEOPLE Albion Park House 7 Albion Hill Loughton Essex IG10 4RA Lead Inspector Sharon Thomas Key Unannounced Inspection 21st August 2006 09:30 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 Park House DS0000017746.V309592.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 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 Park House DS0000017746.V309592.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Albion Park House Address 7 Albion Hill Loughton Essex IG10 4RA 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) 020 8508 4172 020 8508 4172 Mr Mark Bowman Michelle Maxine Wimpress Care Home 19 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (19) of places Albion Park House DS0000017746.V309592.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Persons of either sex, aged 65 years and over, who require care by reason of old age (not to exceed 19 persons) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 10 persons) The total number of service users accommodated must not exceed 19 persons No more than three persons may attend the home on a daily basis in addition to those 19 accommodated The registered provider must consult with the existing service users and staff every three month on the daily attendance at the home of non-resident persons. The registered provider must respond according to the wishes and feelings of service users in respect of non-resident persons attending the home daily. Copies of the minutes of these meetings must be forwarded to the Commission 8th November 2005 Date of last inspection Brief Description of the Service: Albion Park House is a detached, two story, older style property, situated in a residential area near to Loughton town centre in Essex. The home is registered to provide residential care for 19 Older People (over the age of 65, 10 beds for residents with dementia), the home does not provide nursing care. The residents live in one double and seventeen single bedrooms. The communal rooms include two dining areas, and two lounge areas. The grounds around the property have been developed to provide additional access and facilities for residents. The home has wheelchair access via the extension. Due to the location of the house: on a steep hill, only the front garden is accessible to residents at present. The home provides 24-hour personal care and support to residents with varying levels of need. The home is well decorated and offers a homely atmosphere to the residents living there. The home is well designed to meet the needs of the current residents. The cost per week is £444.00. Albion Park House DS0000017746.V309592.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 21 August 2006 and the overall inspection of the home took five hours. Twenty-one of the thirty-eight National Minimum Standards were inspected: fifteen were met, and six were nearly met. For the purpose of this report the individuals living in the home will be referred to as residents. The inspection process included: discussion with the manager, the acting manager, two members of staff, the cook, and one resident. The tour of the premises included observation of four bedrooms, the bathrooms and toilets, the communal areas, the kitchen and the laundry. There was an opportunity to spend a considerable period of time observing the care being provided by the staff. The inspection included the examination of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). During the inspection, the resident spoken to appeared content with their life at Albion Park House, and were positive about the care and assistance they received from staff. What the service does well: The home provides a warm and homely atmosphere for residents. The home has created a family type atmosphere that all of the residents spoke about. The menu in the home provides a well-balanced and varied diet for residents. The kitchen was well stocked, clean and well maintained. Albion Park House has a strong caring staff team, and has a low staff turnover; staff that have left have done so for genuine reasons. The staff group at the home are enthusiastic, well trained and skilled. The resident spoken with on the day stated that the manager and staff were ‘kind and caring’ and the home was ‘very nice’. The resident reported that relatives and visitors are welcomed into the home at all times. The staff were Albion Park House DS0000017746.V309592.R01.S.doc Version 5.2 Page 6 observed to chat continually with the residents and involve them as they went about their work through out the day. The home has close links with the health care team in the area, and works with both professionals and residents to promote and maintain the residents health. The home promotes the rights of the residents and staff provide care that ensures privacy and dignity. The residents interacted comfortably with the staff. Staff treat residents with dignity and respected their privacy. What has improved since the last inspection? What they could do better: The home does not have care plans that provide evidence that all appropriate information is recorded. Care plans do not contain appropriate risk assessment required to provide a detailed and accurate daily plan of care. The home does not accurately record the administration of medication and this shortfall has the potential of placing service users at risk. The home does not provide enough time for social activities. The money and financial records held in the home are not accurate. The home has not implemented the quality assurance procedure to measure the quality of life of the residents. The home does not have a robust recruitment policy. The issues identified above are important as the lack of sufficient information in care plans could ultimately impact on the quality and standard of care that service users receive. The lack of accurate recording of medication may impact on the safety of residents. The poor recruitment process in the home may Albion Park House DS0000017746.V309592.R01.S.doc Version 5.2 Page 7 result in the lack of protection of service users. This report contains six requirements linked to the above issues and may be found at the end of this report. 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 Park House DS0000017746.V309592.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Albion Park House DS0000017746.V309592.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an appropriate pre-admission process that ensures that the home has assessed the needs of the prospective resident. EVIDENCE: One of the four care plans examined was that of the newest admission into the home. This resident was funded by the local social service department and their file contained the home’s pre-admission assessment. There was evidence that the resident and their family were involved in the care planning process. The home had used its own pre-admission assessments, which were comprehensive and contained an appropriate assessment of need. Albion Park House DS0000017746.V309592.R01.S.doc Version 5.2 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 & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Health and personal care needs were set out in individual care plans, but these did not satisfactorily cover all key needs and provide sufficient details of the action required by staff. Health care needs are well met within the home, but as before care plans did not adequately set out residents’ health, personal and social care needs. Overall the medication procedures protected residents, although some aspects of recording were not satisfactory. Staff treated residents with dignity and respected their privacy. EVIDENCE: Four care plans were examined on the day of this inspection. The home has started to develop the new care plan format and this has been used on one resident file. The new care plan format contained detailed and comprehensive information the new document sets out the resident’s need, the action to address the need, and the aim of the care being provided. The new care plan also contained a range of additional assessments including a satisfactory risk assessment. The remaining care plans examined needed to be developed into Albion Park House DS0000017746.V309592.R01.S.doc Version 5.2 Page 11 the new format. The manager should delegate some of this work to the senior carers in the home to enable the schedule to be complete. There was little evidence of regular reviews, and most care plans had not been updated to reflect the changed needs of the individuals. Two of the four care plans had not been reviewed since September 2005. Residents spoken to and observed during the inspection looked well cared for. Staff were seen to be gentle and caring in their dealings with residents, and a member of staff demonstrated patience and care during their dealings with the residents. Staff spoken to showed a good understanding of residents’ needs, and both residents and relatives spoken to were positive about the care provided at Albion Park House. The health care needs of the residents were not well recorded. The care plans contained vague pieces of information of health issues, pressure care issues and continence issues. The needs of residents with personal care needs are documented and where an individual is able to self-care this is recorded and encouraged by staff. The care plans contained assessments that would not guarantee the carer ’s ability to deliver appropriate care. There was evidence from the records that referrals are made to GP’s, district nurses and other health care professionals. The home continued to receive support from local health care agencies with continence, dementia and pressure care issues. The home does not provide adequate exercise for the residents living there. The home has appropriate storage facilities for medicines held on behalf of residents. Medication administration records (MAR) are pre-printed by the pharmacy, or handwritten by staff when a new resident is admitted. The MAR sheets were generally well completed, although there were a number of gaps where medication administration was not recorded. The quantity of each medication received by the home was generally recorded on the MAR, although, for someone recently admitted to the home, the quantities of medication had not been recorded on admission. Albion Park House DS0000017746.V309592.R01.S.doc Version 5.2 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 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home now provides an appropriate range of activities for residents. Routines in the home are flexible and residents are somewhat enabled to exercise choice. Overall the residents are treated with dignity and respect. The home provides the residents with a varied, nutritional and well-balanced diet that addressed specific individual need. EVIDENCE: Albion Park House has a dedicated activity programme that provides activities for one hour a day, seven days a week. The activity programme offered a variety of social activity that was appropriate to the needs of the residents including reminiscence for those residents with dementia. The care plans sampled did not detail the social and recreation needs of the residents. The residents were observed spending time in various parts of the home, communal areas and in their bedrooms. The residents spoken with confirmed that the home provided a variety of activities in line with their preferences. Albion Park House DS0000017746.V309592.R01.S.doc Version 5.2 Page 13 Two residents reported that although they did not participate in the activities that were provided, the staff always “invited me to join in”. Staff spoken with confirmed that residents see relatives and professionals in private. Visitors to the home are welcomed at any time and there are no restrictions on visiting time. External entertainment is provided in the home at various times throughout the year. The staff confirmed that residents choose who they wish to see and when. The staff and residents confirmed that the home encouraged residents to have contact with family, friends and the community at large. Daily routines in the home appeared flexible, with people being able to chose when to get up, where to spend their day and whether to join in with activities. The deputy manager reported that the home had focused on activities this year, and felt that there had been significant improvements in the activities taking place within the home. The manager confirmed that the home does not act as appointee for any of the residents living there. The residents spoken with on the day were aware of the advocacy service, and this information was displayed in the home. The deputy manager confirmed that arrangements for residents to bring in personal items were discussed prior to admission. Routines observed in the home were flexible and residents’ individual choices were addressed. Staff encouraged residents to leave the home with relatives and friends when and where possible. The menus examined reflected that the home provided residents with a variety of well- balanced, nutritional meals. The kitchen was clean and well organised, and the food stocks were high and of good quality. Meals are freshly prepared and cooked by the chef. The meal presented on the day was appealing and the residents stated that the quality of food in the home was “good”. Residents confirmed that the meals provided in the home were “always tasty” and “well prepared”. Fresh fruit and snacks were available throughout the day, and residents confirmed that they could have a drink or snack at any time. When required, meals are liquidised and special dietary needs are catered for. Albion Park House DS0000017746.V309592.R01.S.doc Version 5.2 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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had systems in place that enable residents to make complaints. The home protects its residents through the Protection of Vulnerable Adults policies and procedures. EVIDENCE: Albion Park House has a complaint procedure, and this was found to be clear and concise. The document directed the individual how and to whom, to make a complaint. It contained timescales for action, and the details of the CSCI. It was written in plain language and was user friendly. The residents spoken with reported that they had no cause to complain. They commented that they felt confident that their concerns would be dealt with immediately. The complaint log was examined and was accurate and well maintained; there had been no recorded complaints since the previous inspection. The staff spoken with confirmed that they were aware of the importance of enabling residents to make complaints. The home has a comprehensive and clear set of the Protection of Vulnerable Adult Abuse policies and procedures. The home had clear guidelines for staff to follow should an allegation of abuse be made. Copies of the relevant national guidelines were available to staff. Two members of staff spoken with on the day were aware of the guidelines and all of these had been on training courses that deal with this issue. One resident stated that they “felt very safe in the Albion Park House DS0000017746.V309592.R01.S.doc Version 5.2 Page 15 home” and “trusted the staff”. All of the staff in the home had received training with regard to the issue of safeguarding vulnerable people. Albion Park House DS0000017746.V309592.R01.S.doc Version 5.2 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a safe environment, with systems in place for repairs and maintenance. The home provides service users with sufficient personal and communal space, which was suitably furnished; EVIDENCE: On the day of the inspection, the home appeared safe and well maintained. The home had a maintenance person who was responsible for maintenance and decoration. Some furniture in the home was becoming worn and in need of replacing, and some carpets were marked. A sample of bedrooms viewed were mostly in a reasonable state of decoration. Rooms generally had sufficient and suitable furniture, subject to space constraints in some cases. Not all bathrooms were inspected on this occasion, but those viewed provided assisted bathing facilities in pleasant environments, and were clean and tidy. There were systems in place to monitor hot tap water temperatures (re risk of Albion Park House DS0000017746.V309592.R01.S.doc Version 5.2 Page 17 scalding), and for monitoring central hot water temperatures (re risk of Legionella). On the day of the inspection the home was clean and tidy and generally free from unpleasant odour. The home had general guidance on Infection Control for Care Homes, and disposable protective gloves and aprons were available to staff. The home had a laundry room that was located away from areas where food was prepared or stored. Albion Park House DS0000017746.V309592.R01.S.doc Version 5.2 Page 18 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 & 30. Quality in this outcome area adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels (number and competence) met the needs of current residents. There is a stable and loyal staff team, which ensure consisitency in the delivery of care. The home provided appropriate training to give staff the skills necessary to do their job. The recruitment procedure in the home was not robust and did not provide the safeguards to ensure that appropriate staff were employed, potentially putting the residents at risk. EVIDENCE: The staff rota examined reflected that the home was providing the agreed levels of staff. The home had an appropriate number of day care and night care staff and additional numbers were on duty during busy periods. Records confirmed that 10 of the 15 members of staff in the home had achieved the NVQ Level 2 qualification. The home provided the staff with a full and comprehensive programme of training. The programme included: First Aid, Fire Safety, Moving & Handling, Food Hygiene, infection Control, Medication, Continence, Pressure care prevention, and Falls Prevention The staff spoken with reported that the training provided was relevant to their roles in the home and helped them to do their job better. Albion Park House DS0000017746.V309592.R01.S.doc Version 5.2 Page 19 The two staff personnel files examined did not contain information necessary to ensure the safety of residents through the recruitment process. One file did not contain the two required references. Neither of the staff files contained a Criminal Reference Bureau check and the references attached did not contain enough information regarding the skills and knowledge of the individual. The file for the maintenance man who occasionally covers for the cook did not have a personnel file and he should not be allowed to work in the home until all of the appropriate checks are completed. There is a requirement made regarding this issue and this may be found below. Albion Park House DS0000017746.V309592.R01.S.doc Version 5.2 Page 20 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 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home appears well run by a competent manager. Overall the home has a secure system to safeguard the residents’ financial interests. Quality assurance processes are not in place and service users are not consulted on issues relating to their day-to-day lives. There were comprehensive health and safety systems in operation to ensure the ongoing welfare of both residents and staff. EVIDENCE: The manager has been registered with the CSCI since the previous inspection visit. Albion Park House DS0000017746.V309592.R01.S.doc Version 5.2 Page 21 The home has not implemented a quality assurance system. Three resident personal allowance records were sampled. Two sets of records were accurate and well maintained, while the third was found £9.00 under the amount recorded. The deputy manager confirmed that the money had been taken out to buy toiletries and did stated that once the goods had been bought and the change returned that the record would be changed. The inspector suggested that any money taken from an account should be recorded immediately to avoid discrepancies. The money held in the home for residents is held in a safe in a locked room. The home does not act as appointee for any resident living there. The residents’ families are responsible for the financial matters of individual resident. The home provided staff with appropriate Health and Safety training. Risk assessments of the premises were not undertaken and regular Health and Safety checks of facilities and equipment were not undertaken. The manager was aware of relevant Health and Safety legislation and was committed to the welfare of both the residents and staff group. Hot water, fire alarm and equipment checks were accurate and up to date. The staff spoken with are committed to the safety of the residents and are able to discuss the potential hazards in the home. The staff stated that they would report any safety hazard to the manager who would take the appropriate action. The staff also confirmed that they would use the resident risk assessment to ensure the safety of the residents. Staff are aware of Health and Safety issues around the home and wore personal protection clothing when needed. Albion Park House DS0000017746.V309592.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 3 Albion Park House DS0000017746.V309592.R01.S.doc Version 5.2 Page 23 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 13(4) 15 (1)&(2) Timescale for action The registered person must 31/10/06 ensure that resident care plans contain information on all aspects of care. The care plans must include a complete and comprehensive risk assessment. The care plans must be reviewed on a monthly basis. This is a repeat requirement. (03.11.04 & 19.04.05) The registered person must 31/10/06 ensure that care plans contain detailed and clear information for staff with regard to risk The registered person must 21/08/06 ensure that the administration of medication is accurately recorded to ensure the safety of residents. The registered person must 31/10/06 ensure that the home provides suitable and appropriate social activities for all residents. The registered person must 31/10/06 ensure that no one is employed in the home before all of the required checks are undertaken. The home must ensure the DS0000017746.V309592.R01.S.doc Version 5.2 Page 24 Requirement 2 OP7 13(4) 15 (1) 3 OP9 14 (1) 4 OP12 14 (1) (a) 5 OP29 7, 9, 19 Schedule 3 Albion Park House 6 OP33 18 (6) 7 OP35 !4 (1) (a) (c) safety of the residents through a robust recruitment procedure. The registered person must 31/10/06 ensure that the home implements the quality assurance process and sends the results to the commission. The registered person must 31/10/06 ensure that the money and records held in the home on behalf of residents is accurate. 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 Park House DS0000017746.V309592.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Park House DS0000017746.V309592.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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