Inspection on 09/11/05 for Albury House

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

Albury House 25/11/09

Albury House 12/12/08

Albury House 06/02/07

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 Announced Inspection 9th November 2005 09:00 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 Albury House DS0000000512.V249253.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. Albury House DS0000000512.V249253.R01.S.doc Version 5.0 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 albury@vodafone_net 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.V249253.R01.S.doc Version 5.0 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. 12th April 2005 Date of last inspection Brief Description of the Service: Albury House provides accommodation for up to twelve elderly 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. Albury House DS0000000512.V249253.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one day and involved discussion with the manager, six residents, four staff and one relative, a tour of the building and inspection of records. Questionnaires were distributed among residents and relatives prior to the inspection and there were nine relatives’ and eight residents’ questionnaires returned. Comments were very positive about the quality of the service and individual support provided. What the service does well: What has improved since the last inspection? What they could do better: The practice of leaving a person who is not aged 21 years or above in charge of the home must cease. The initial assessment needs to include more information about individual residents needs so that the home’s management is clear that these needs can be met by the home. Albury House DS0000000512.V249253.R01.S.doc Version 5.0 Page 6 Information about residents’ social and emotional needs and how these will be met must be included in the care plan. Risk assessments for pressure areas and moving and handling must be regularly updated. Training must be provided for staff in dealing with allegations of abuse. An annual development plan must be drawn up using information collected as part of the quality assurance audit. 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. Albury House DS0000000512.V249253.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 Albury House DS0000000512.V249253.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): 3, 6 No resident moves into the home without having had his/her needs assessed, however more information should be recorded to show that his/her needs can be met. Residents are not admitted for intermediate care. EVIDENCE: Records showed that an assessment is carried out, but more information is needed. The manager described an appropriate assessment process that is completed before a resident moves into the home. The records showing the assessment would benefit from more information being recorded about individual needs. The manager confirmed that intermediate care is not provided. Records confirmed this. Albury House DS0000000512.V249253.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): 7, 8, 9, 10 Residents’ health, personal and social care needs are set out in an individual plan that would benefit from more information in some areas. Residents’ health care needs are met, although some risk assessments need updating. Residents are protected by the home’s policies and procedures for dealing with medicines. Each person is treated with respect and his/her right to privacy is upheld. EVIDENCE: Each person has a care plan prepared, however in some plans more information is required about how individual needs are met. In some plans little information was available about social and emotional needs. One plan needed more detail about how physical needs are met by staff. Some risk assessments were not regularly updated and the moving and handling risk assessments require more information. Evidence of regular reviews of the care plans was available. Residents said that staff were aware of their needs and that arrangements are in place to meet these. Albury House DS0000000512.V249253.R01.S.doc Version 5.0 Page 10 Residents said that they felt satisfied that their health care needs are met. Records showed that health care needs are identified. One pressure area risk assessment had not been updated. Records showed that advice about continence is sought from district nurses. Residents said that they were satisfied that they had retained or registered with the doctor of their choice. They said that staff were aware of their health care needs. Residents have access to dental, optical, chiropody services and records confirm this. Written guidance is in place for the administration of medication. Staff training has been provided in administering medicines and records confirmed this. Arrangements for the storage of medicines are satisfactory. Records of administration of medicines were kept in appropriate order. Residents said that they were satisfied that they were treated with dignity and respect. Staff were seen knocking on doors and speaking respectfully to residents. Albury House DS0000000512.V249253.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 Residents find the lifestyle of the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. Contact with family, friends, representatives and the local community is encouraged and maintained. EVIDENCE: Residents said they are happy with their lifestyle. They are able to decide upon their own daily routine and are able to express their own preferences. Staff confirmed that residents are able to make choices about routines, leisure and social activities, relationships and religious observance. Recording about residents’ interests is sometimes limited, but residents said they feel satisfied with the arrangements in place for activities. Residents said that they were able to have visitors at any time and that they have regular visitors. Relatives confirmed this in questionnaires. The manager and records confirmed that there are no restrictions on visiting. Information is available for relatives about maintaining links with residents. Relatives’ questionnaires showed that they are satisfied with the arrangements for visiting. Albury House DS0000000512.V249253.R01.S.doc Version 5.0 Page 12 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): 18 Residents are protected from abuse, but training for staff is needed in dealing with allegations of abuse. EVIDENCE: Written guidance is in place for dealing with suspicion or evidence of abuse. No allegations have been made at Albury House. The manager is aware of the steps to be taken when an allegation of abuse is made. Staff training has not been provided in dealing with an allegation of abuse. Albury House DS0000000512.V249253.R01.S.doc Version 5.0 Page 13 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): 20, 21, 22, 24, 25, 26 Residents have access to safe and comfortable indoor and outdoor communal facilities. Residents have sufficient and suitable lavatories and washing facilities. One bathroom needs redecoration. Residents have the specialist equipment they require to maximise their independence. Residents’ rooms are safe and comfortable. All residents have their own possessions around them. The home provides safe, comfortable surroundings. EVIDENCE: The sitting room is well decorated, homely and comfortably furnished. A new carpet was laid during the inspection. The dining room is appropriately furnished. A patio area and small area of lawn is available to the rear of the home. Lighting is adequate. There are six bedrooms with en-suite accommodation. There are sufficient toilets and one bathroom on each floor. One bathroom needs refurbishing. Aids and adaptations are provided to suit the residents’ needs. Albury House DS0000000512.V249253.R01.S.doc Version 5.0 Page 14 Records show evidence of individual assessments for aids and adaptations. All public rooms are on the ground floor. There is no lift fitted. There is a risk assessment in place for one resident who is unable to use the stairs. This risk assessment needs to show the action to be taken if emergency evacuation is necessary. A system for regularly assessing residents’ ability to manage occupying upstairs rooms should be put in place. A call system point is fitted in each room. 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 are naturally ventilated. 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.V249253.R01.S.doc Version 5.0 Page 15 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 Residents’ needs are met by an appropriate number and skill mix of staff. Staff aged less than twenty-one years of age should not be leading shifts. Residents are supported and protected by the home’s recruitment policy and procedures. EVIDENCE: Rotas show that two staff are on duty throughout the day. One waking night staff and one person sleeping in are on duty throughout the night from 9pm to 8am. The rota showed that it is current practice for one person to undertake every sleep in from 9pm. This is not practicable and should be reviewed. A cook is on duty each morning and there is a domestic each weekday morning. This level of staffing is adequate to meet the needs of the current resident group. It is current practice for a person under twenty-one years of age to be the senior member of staff on duty at times. This practice must cease to comply with National Minimum Standards. Residents said that there are enough staff on duty at all times. Staff records contain evidence of two written references and a Criminal Records Bureau check. The manager confirmed that there is an appropriate recruitment procedure in place. All staff receive a statement of terms and conditions of employment. Albury House DS0000000512.V249253.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): 32, 33, 35, 38 This home is run almost as a domestic home and this is much appreciated by the residents. The management style is very informal and this is reflected in the aims and objectives of the home. There needs to be more effective systems in place to record how the management enable residents, staff and others to affect the way in which the service is delivered. The home is run in the best interests of the residents, but there is a need to prepare an annual development plan. Residents’ financial interests are safeguarded. The health, safety and welfare of residents are promoted and protected. EVIDENCE: Staff confirm that the manager presents a clear sense of direction and leadership. They said that they feel able to make their views known about the way the service is provided. The manager said that formal staff meetings are not held except for the daily hand over meeting at the change of shift. Staff said that they felt that the handover provided an appropriate forum to discuss Albury House DS0000000512.V249253.R01.S.doc Version 5.0 Page 17 issues. There are no systems in place to record how residents, staff and others are able to affect the way in which the home is run. Questionnaires are used to collect the views of residents, relatives and others who regularly visit the home about the service provided. The results of these are not published or made available to residents or prospective residents and their representatives. There is no annual development plan prepared for the home or annual audit carried out. No money is held on behalf of residents. The manager reported that residents are assisted by their relatives to manage their money. Each resident has a lockable storage facility in his/her room. Written guidance is provided for staff on Health and Safety and Control of Hazardous substances. Fire records are maintained in an appropriate form. Records seen are kept up to date and show regular tests and servicing of the alarm system and fire equipment. Fire safety training is provided for day staff at appropriate intervals. Night staff require more frequent fire training. Accident records are kept in an appropriate form. Training for staff at appropriate intervals included Moving and Handling, First aid, Infection Control and Food Hygiene. Albury House DS0000000512.V249253.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X 3 3 3 X 3 3 3 STAFFING Standard No Score 27 2 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 2 X 3 X X 3 Albury House DS0000000512.V249253.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 OP3 Regulation 15 Requirement The system for recording the initial assessment must be reviewed to ensure sufficient information is available about each resident’s needs. Information about residents’ social and emotional needs must be included in the care plan. Risk assessments for pressure areas and moving and handling must be regularly updated. Training must be provided for staff in dealing with allegations of abuse. Staff left in charge of the home must be at least aged 21 years. The current practice of having only one identified person sleep in the home each night from 9pm to 8am must be reviewed. An annual development plan must be drawn up using information collected as part of the quality assurance audit. Timescale for action 31/01/05 2 OP7 15 31/01/05 3 4 OP18 OP27 13 18, 19 28/02/06 31/12/05 4 OP33 24 28/03/06 Albury House DS0000000512.V249253.R01.S.doc Version 5.0 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP31 Good Practice Recommendations The manager should undertake recognised training in management and care. Albury House DS0000000512.V249253.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Albury House DS0000000512.V249253.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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!