Inspection on 06/02/07 for Albury House

This inspection was carried out on 6th February 2007.

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

Albury House 25/11/09

Albury House 12/12/08

Albury House 09/11/05

Albury House 08/09/04

Albury House 16/06/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Albury House 17-19 Tweed Street Berwick Upon Tweed Northumberland TD15 1NG Lead Inspector Anne Urwin Brown Key Unannounced Inspection 6th February 2007 10:30 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 Albury House DS0000000512.V304351.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. Albury House DS0000000512.V304351.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Albury House Address 17-19 Tweed Street Berwick Upon Tweed Northumberland TD15 1NG 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) 01289-302768 Mrs M L Burn Mr A E Burn Mrs M L Burn Care Home 12 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (11) of places Albury House DS0000000512.V304351.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is able to provide one place for a named resident under the age of 65. Should this person leave the home, the CSCI must be notified. 9th November 2005 Date of last inspection Brief Description of the Service: Albury House provides accommodation for up to twelve older people in a twostorey town house near the centre of Berwick upon Tweed. The house is in a quiet residential area and has been converted from a family home to suit its present use. Bus and train services are available within a short walk. The home has accommodation on two floors and there is no lift fitted residents occupying the first floor bedrooms have to use the stairs. There is an emphasis on retaining the feel of a family home. Furnishings and the décor have been chosen with this in mind. Fees are £389 per week. The Statement of Purpose has been reviewed since the last inspection and is available at the home. Information for prospective residents is also available. Albury House DS0000000512.V304351.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key visit was carried out over five hours. Before the visit the Inspector used information from the pre-inspection questionnaire to assist in planning the inspection. The inspection involved talking to the Manager, six residents and three staff, an inspection of the building, case tracking and inspection of records. What the service does well: What has improved since the last inspection? What they could do better: Care plans and assessments need to be regularly reviewed and updated when there are any changes to an individual’s care. Albury House DS0000000512.V304351.R01.S.doc Version 5.2 Page 6 Two staff must sign handwritten entries in medication records to minimise the risk of mistakes being made. More information is needed in records about residents’ social care needs and how these are met. Evidence of identity checks must be kept in staff records to protect residents. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Albury House DS0000000512.V304351.R01.S.doc Version 5.2 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 Albury House DS0000000512.V304351.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 6 were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are thoroughly assessed before they move into the home and are assured that these will be met. Intermediate care is not provided. EVIDENCE: Residents’ records inspected contain assessments of need. The assessment covers the areas identified in this standard. Residents said that when they came to live at Albury House staff knew what their needs were. Staff said that they have enough information about residents’ needs when they come to live in the home. Intermediate care is not provided at Albury House. Albury House DS0000000512.V304351.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, and 10 were inspected Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health and personal care needs are identified within a care plan, but these are not always up to date. Residents’ health care needs are appropriately met. The home’s policies and procedures for dealing with medicines protect the residents, however these are not always followed. Residents are treated with dignity and respect and their right to privacy is upheld. EVIDENCE: Care plans based on residents’ assessed needs are in place; however these are not always updated when needs change. Limited information about individuals’ social care needs is available. Assessments for falls, pressure areas, nutrition and moving and handling are available for each resident, but some were not updated when changes occur. Monthly review of plans and assessments would provide better information for staff. Residents said that they were satisfied that staff knew what they needed help with and provided Albury House DS0000000512.V304351.R01.S.doc Version 5.2 Page 10 them with appropriate support. One resident said that staff were always helpful and cheerful. Residents’ health care needs and any specific treatments are clearly recorded and all contact with the doctor, district nurse and other health care professionals is available in individual records. Risks are not always regularly assessed for falls prevention, nutritional needs and skin care and systems for this need to be introduced. Residents said that the staff are aware of their health needs. They said they get support to attend appointments. Two residents said they were satisfied that they can access the health services that they need. One person said she had spoken to the general practitioner directly. There are no policies to show how staff are informed about any changes to treatment that impacts on the care staff provide when a resident speaks directly to their doctor. Guidance is in place for staff about handling medicines. Medication records are kept in good order, but hand written entries were not signed by two staff. Appropriate arrangements are in place for the storage of medicines. Staff handing out medicines have completed appropriate training. Residents said that they felt that staff respect them and treat them well. Staff were seen knocking on residents’ doors, but on two occasions a staff member did not wait for the resident to give permission to enter the room. There was a relaxed atmosphere in the home and staff spoke respectfully to residents during the inspection. Staff induction training includes reference to privacy and dignity. Staff guidance is available about privacy and dignity. People are asked what they prefer to be called by staff. Albury House DS0000000512.V304351.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The lifestyle in the home suits residents’ preferences and expectations, but care plans do not have sufficient information about their social needs and how these are met. Residents keep in contact with family, friends and the local community. Residents have control over their lives. The dietary needs of residents are well catered for with a balanced and varied selection of food. EVIDENCE: Residents said that they are able to make choices about their daily routines, like when they get up and go to bed. Individual routines are identified within care plans, but information about residents’ wishes about social activities is in sufficient. Communal activities are not regularly organised, staff said that they spend time on an individual basis with residents. Residents said that they are happy with the support provided by staff. The atmosphere is homely and residents are encouraged to make choices about how they spend their time. There are videos, music tapes, newspapers and books available. Two residents said they enjoyed spending time in their rooms, with television, jigsaws and in Albury House DS0000000512.V304351.R01.S.doc Version 5.2 Page 12 one person’s case their radio. One resident has her dog living with her and staff help her to look after it. Residents said that they have regular visitors and this was evident from the Visitors Book. Residents said that they could see visitors in their own rooms or in the public areas of the home. Information is available for relatives about visiting and this is made available before a resident is admitted. Residents are encouraged to continue to manage their finances for as long as they are able. One person is paid her personal allowance by the home who receive this from the local authority. A record is kept of this. All other residents manage their own money or are assisted by their relatives or representatives. Residents are encouraged to bring in furniture, ornaments and pictures from their previous homes. Rooms are personalised and reflect residents’ interests and taste. The menu is varied and residents said that they are very satisfied with the quality and quantity of food. Staff are aware of residents’ likes and dislikes. Choices are available if residents do not like what is on the menu, at the evening meal there is a good selection of items for residents to choose from. Residents are able to eat in the dining room or in their own rooms. Food is available throughout the day to suit residents’ needs and preferences. The kitchen is to be refitted shortly. Staff have completed food hygiene training. Albury House DS0000000512.V304351.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. 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. Complaints are listened to and acted upon. Residents are protected from abuse and they feel confident about raising issues. EVIDENCE: Guidance is available for dealing with complaints. Residents said that they knew how to make a complaint and that they felt able to speak to the owner or the staff if they have any concerns. No complaints have been made in the past year. Appropriate systems are in place for recording and dealing with complaints. Clear guidance is in place for dealing with allegations of abuse. Staff were clear about the procedures to be followed if an allegation is made. Staff training has been provided in Protection of Vulnerable Adults. Albury House DS0000000512.V304351.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 21, 24, and 26 were inspected. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, well-maintained homely environment. There is no lift to the first floor. There are comfortable and safe indoor and outdoor communal facilities. There are sufficient lavatories and washing facilities that are equipped to suit residents’ needs. In the upstairs bathroom an edging strip on the flooring needed fixing to the floor. Residents have safe, comfortable bedrooms with their own belongings around them. The home is clean, pleasant and hygienic. EVIDENCE: Maintenance systems are in place and records are available of work carried out. The house is well decorated and furnished in a homely style. A patio area and small area of lawn is available to the rear of the home. These areas are tidy and safe. The access to the first floor is by the stairs and is not Albury House DS0000000512.V304351.R01.S.doc Version 5.2 Page 15 accessible to residents with physical disabilities. There is not sufficient room to fit a stair or shaft lift. One resident who is in an upstairs room is unable to manage the stairs. There is a comprehensive risk assessment in place for this person that has been agreed with the fire officer. All public areas of the home are well furnished and decorated. The arrangements for lighting are appropriate to residents’ needs with low level lighting available for reading in sitting and bedrooms. There are six bedrooms with en-suite accommodation. There are sufficient toilets and one bathroom on each floor. Appropriate aids and adaptations are available to suit residents’ needs in bathrooms and toilets. Residents’ rooms are appropriately furnished and highly personalised. Lockable storage is available in each room and a door key is available. Residents have a key supplied unless a risk assessment suggests this is not appropriate. Residents said that they were satisfied with their rooms and that they had been encouraged to bring in items from their previous homes. All rooms have windows for ventilation. Central heating is fitted and the temperature can be adjusted. Radiator guards are fitted. Lighting levels are appropriate. Thermostatic controls are fitted to all hot water outlets. Emergency lighting is fitted. The laundry is sited in a shed at the back door. Washing machines have appropriate washing cycles for dealing with soiled linen. Written guidance is in place for the control of infection. Albury House DS0000000512.V304351.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 26, 27, 28, and 29 were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff numbers are appropriate to the assessed needs of the residents, size, layout and purpose of the home. Staff have the skills to meet residents’ needs. Residents are supported and protected by the home’s staff recruitment procedures, although proof of identity was not available in individual records. Staff are trained and competent to do their jobs. EVIDENCE: The minimum staffing during the day is two care staff. At night there is one waking member of staff and one person sleeping in on the premises. These levels of staffing are adequate to meet the needs of the residents living at Albury House. Residents said that they felt there are enough staff on duty in the home and that staff respond promptly to their needs. One resident said “they are very kind and know what I need help with.” Two staff members said there were enough staff to meet the needs of the residents living at the home. Seven staff have completed national qualifications in care. Staff have achieved a level of sixty two per cent of qualified staff, which is above the minimum requirements. Staff are committed to training and recognise the importance of gaining qualifications. Albury House DS0000000512.V304351.R01.S.doc Version 5.2 Page 17 Recruitment procedures are in place and records show these are followed. Appropriate reference and Criminal Records Bureau checks are carried out before staff start work at Albury House. Staff records do not contain evidence of identity checks and the Manager is aware of the need to do this. Training provided in the past year included Protection of Vulnerable Adults, Dementia, and National Vocational Qualifications at Level 2, 3 and 4. A staff training plan is in place. Individual training records are kept. Staff said that new staff receive appropriate induction training and records confirmed this. Albury House DS0000000512.V304351.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, and 38 were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is run and managed by a person who is appropriately experienced in caring for older people. The home is run in the best interests of residents and an annual development plan was available. Residents’ financial interests are safeguarded. Systems are in place to protect residents and staff from health and safety hazards. EVIDENCE: The manager is also one of the owners of the home, which is well established and family run. She has considerable experience of providing care services for older people. She does not intend to complete the Registered Manager Award, Albury House DS0000000512.V304351.R01.S.doc Version 5.2 Page 19 but her son is currently undertaking this with a view to applying to become the Registered Manager. The manager undertakes regular updating training. This is a small family run home that has started to use questionnaires for residents as part of the quality assurance system for the home. An annual development plan has been drawn up since the last inspection and will be reviewed on a regular basis. Guidance is in place for staff about handling residents’ money. The home has a policy that is does not take responsibility for handling residents’ money. One person receives their personal allowance from the manager and appropriate records are kept of these transactions. Training in moving and handling, first aid, fire safety, food hygiene and infection control is provided at regular intervals. Records showed this and staff said that they receive this training. Records showed that regular checks are made of electrical equipment and the central heating system. Risk assessments are in place for safe working practices. Staff said that they receive appropriate induction training and records are in place to confirm this. Records of fire alarm tests, servicing of fire equipment and the alarm, fire training and emergency lighting are kept in an appropriate manner. Full details of accidents are kept. Albury House DS0000000512.V304351.R01.S.doc Version 5.2 Page 20 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 2 X X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Albury House DS0000000512.V304351.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? 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 OP9 Regulation 15 Requirement Systems need to be in place to ensure that care plans and assessments are regularly reviewed or updated when there are any changes to an individual’s care. Two staff must sign handwritten entries in medication records. More information is needed in records about residents’ social care needs and how these are met. Evidence of identity checks must be kept in staff records. Timescale for action 31/03/07 2. 3 OP9 OP12 13 15 31/03/07 31/03/07 4 OP29 19 31/03/07 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 Albury House DS0000000512.V304351.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Albury House DS0000000512.V304351.R01.S.doc Version 5.2 Page 23 - 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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