Inspection on 31/05/07 for Alderlea Care Home

This inspection was carried out on 31st May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Alderlea Care Home 01/12/05

Alderlea Care Home 06/09/05

Alderlea Care Home 14/12/04

Alderlea Care Home 16/07/04

Alderlea Care Home 15/01/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Alderlea Care Home St Thomas Close Humberston Grimsby North East Lincs DN36 4HS Lead Inspector Rob Padwick Key Unannounced Inspection 31st May 2007 12:50 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 Alderlea Care Home DS0000002814.V308597.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. Alderlea Care Home DS0000002814.V308597.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alderlea Care Home Address St Thomas Close Humberston Grimsby North East Lincs DN36 4HS 01472 812588 01472 816118 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) Humberside Independent Care Association Limited Position Vacant Care Home 40 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (40) of places Alderlea Care Home DS0000002814.V308597.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st December 2005 Brief Description of the Service: Alderlea provides personal care and accommodation for up to forty people aged 65 and over, including thirty people who may have dementia care needs. The home is a large two storey building with access to the top floor via a passenger lift. The majority of bedrooms are for single accommodation. The home is in the process of undergoing an extensive programme of refurbishment and rooms on the top floor have been upgraded as part of this process. There are pleasant gardens surrounding the home and ample car parking facilities. The home is close to the local church and village shop and is situated on a bus route to Cleethorpes and Grimsby. Alderlea is owned by Humberside Independent Care Association, which is a not for profit organisation. The standard fees charged by the home range from £329.00 to £440 with additional charges made for hairdressing, chiropody, toiletries etc. Alderlea provides information to people living in the home about its facilities in its Statement of Purpose and Service User Guide. Alderlea Care Home DS0000002814.V308597.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A Pre Inspection Questionnaire asking for information about the home was sent to the manager before a visit to the home and information from this was included as part of the inspection process. Other information used included reports from monthly visits carried out by a senior manager from the parent company and notifications received by the Commission for Social Care Inspection about serious incidents that had taken place in the home. Questionnaires were sent out to relatives and professional staff who know the service well and all of those that were returned expressed high levels of satisfaction with the home. The inspection visit for this service lasted for 7.5 hours and during this period, time was spent talking with people living in the home and observing their daily lives. Other time was spent looking at their care plans and other records and talking to staff. The inspection visit also included a tour of the building. What the service does well: What has improved since the last inspection? No requirements or recommendations were made at the last inspection, and the home’s quality assurance systems had continued to monitor the standard of service against its aims in order to improve things. Continued progress to upgrade the building had been made and this had resulted in bedrooms on the top floor being enlarged and improved bathing and toilet facilities being installed elsewhere. A hairdressing salon had been developed as part of the home’s refurbishment and further work had been started to implement the next stage of development on the downstairs areas of the home. Alderlea Care Home DS0000002814.V308597.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Alderlea Care Home DS0000002814.V308597.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 Alderlea Care Home DS0000002814.V308597.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): 3 and 6 People who use this service experience good outcomes in this area. People living in the home had been involved in the assessment of their needs, in order to ensure that the service was able to meet these satisfactorily. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The case files of three people recently admitted to the home that were inspected all contained evidence that their individual needs had been assessed prior to them moving in, so that the manager could ensure that the service was able to meet these satisfactorily. Evidence was seen that the manager had undertaken her own assessment of their needs and for an individual who was funded via the Local Authority, an up to date Community Care Assessment had been obtained, in order to inform this process. Relatives and people living in the home confirmed that they had made an active choice about moving in to Alderlea and that they had been involved in decisions about this. Alderlea Care Home DS0000002814.V308597.R01.S.doc Version 5.2 Page 9 The manager confirmed that the service does not admit people for intermediate care. Alderlea Care Home DS0000002814.V308597.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10 People who use this service experience good outcomes in this area. The health and personal care needs of people living in the home were being met, although the levels of dependency experienced meant that the ability of staff to meet these adequately could on occasions be compromised. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Feedback received from both relatives and professionals in the community concerning the quality of the staff was universally positive in nature. Discussion with staff on duty confirmed that they were committed to meeting the needs of people living in the home and observation of their interactions indicated them to be friendly, approachable and respectful towards the people living in the home. Support plans relating to various aspects of health and personal care were contained within case files that were inspected together with information to staff on how these were to be delivered. A good standard of daily recording was contained within the case files that were inspected, and evidence was seen that support plans were being were being appropriately Alderlea Care Home DS0000002814.V308597.R01.S.doc Version 5.2 Page 11 reviewed and updated as required. Whilst aspects relating to the personal history and individual strengths and needs of people living in the home were included within the support plans that were inspected, recommendations are made in these respects, in order that the social needs and interests of people living in the home are better met. (See daily life and social activities) People living in the home indicated that their health needs were being met and on the day of this inspection visit, a chiropodist was attending the service to assist in this regard. Comments received from a Community Psychiatric Nurse indicated that the staff in the home “work well with families” whilst one from a relative indicated that “the home provides very good care and is well responsive to day to day care, especially bearing in mind the levels of dementia”. Case files that were inspected provided further evidence that matters affecting health were being closely monitored, together with documentation relating to actions taken in these respects. Areas of concern relating to the management of known risks to people living in the home were included in the case files, as well as guidance to staff on what they should look out for and do. The home has a high proportion of people with dementia and a significant number of incidents relating to injuries following falls, had been notified to the Commission as required under the Care Home Regulations. Safety gates had been installed on the stairways to minimise risk in this respect. However whilst praising the qualities of the staff, two people living in the home indicated the ability of the staff to meet the needs of everyone living at Alderlea was sometimes constrained by the increasing frailty and dependency of others. The inspector observed an example of this in the evening of this visit, when a number of people living in the home became unsettled, resulting in the staff having difficulties in managing their behaviours. Requirements and recommendations are made in these matters (See Staffing) Policies and procedures were available to safeguard the people living in the home in respect of their medication needs and discussion with staff indicated that they were aware of these. Only the senior staff are responsible for this aspect of practice. Discussion with a newly promoted senior staff member confirmed her to be knowledgeable regarding her role and responsibilities in this regard and that she was undertaking a college course on the safe use and handling of medication. Alderlea Care Home DS0000002814.V308597.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use this service experience good outcomes in this area. People living in the home were being provided with support to enable them make decisions and choices, in order that their lifestyle needs and wishes could be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Observation and discussion with people living in the home indicated that they were able to choose to take part in a variety of appropriate social activities that were geared to meeting their needs and wishes. On the day of this inspection visit, a group of people living in the home were getting ready to go away on a holiday with staff, whilst discussion with others indicated they had previously been given the opportunity to go away on a similar trip. People living in the home indicated that their spiritual needs were met by visits from 2 different church denominations and staff recording in the case files inspected documented evidence of support given in relation to meeting their lifestyle needs and social activities. The home produces a newsletter that is distributed every 2 months and information included in the most recent version, included articles and photos of recent parties to celebrate Valentine’s Day and Easter, together with requests for suggestions and ideas about a forthcoming summer Alderlea Care Home DS0000002814.V308597.R01.S.doc Version 5.2 Page 13 fayre. The home has an open visiting policy and discussion with relatives confirmed that they were welcome to visit and be involved in the life of the home. Relatives spoke very positively about the caring qualities of the staff, however one person indicated that sometimes staff experienced problems associated with the complexities and joint needs of the people living in the home and the numbers who were on duty. The home has an activities organiser, and inspection of her training file highlighted that she had not undertaken dementia skills training and a recommendation is made in this matter. The case files that were inspected together with the minutes of meetings held in the home indicated that wherever possible, people living in the home were consulted about their needs and wishes. People confirmed they could chose when to get up or go to bed, however some indicated uncertainties and confusion about not being able to access their bedrooms, owing to problems associated with their capacity to make personal decisions about their safety. A recommendation is made about this matter (See Environment). People living in the home stated that the food was of high standard and evidence was seen that a good variety of healthy and nutritious meals were being provided. Discussion with the chef confirmed that special diets were accommodated and observation of meals times indicated that sensitive support was provided to those requiring assistance in this regard. Case files contained evidence that people living in the home had been assessed in relation to their nutritional needs as appropriate, as well as documentation concerning the monitoring and actions taken in respect of these matters. Alderlea Care Home DS0000002814.V308597.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use this service experience good outcomes in this area. The concerns and complaints of people living in the home were being taken seriously and they were being safeguarded from abuse by staff that had received training in the protection of vulnerable adults. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service had satisfactory policies and procedures in order to ensure that concerns and complaints could be raised and dealt with appropriately and discussion with people living in the home and their relatives, indicated they were aware of these and that staff took their views seriously. The home’s complaints log contained evidence of action taken by the manager, in order to resolve the two complaints received since the last inspection. Following issues recently highlighted as part of the home’s quality assurance process, evidence was seen of an action plan, which had been developed in these respects. Policies and procedures were in place relating to the protection of vulnerable adults and discussion with staff indicated that they knew about these and would take appropriate in these matters if the was needed. A complaint about the service received by the Commission for Social Care Inspection since the last inspection, had resulted in a referral being made to the Local Authority to consider investigating under its safeguarding duties. Discussion with a Social Services team leader about this confirmed that this was not substantiated and that she had “no concerns” about the home. A random check of the associated Alderlea Care Home DS0000002814.V308597.R01.S.doc Version 5.2 Page 15 financial records of money held on behalf of the people living in the home was satisfactory and indicated that these were being accurately maintained. Alderlea Care Home DS0000002814.V308597.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use this service experience good outcomes in this area. A major programme of refurbishment of the building was being carried out in a planned manner, in order to minimise the disruption to the comfort of people living in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As part of a major refurbishment of the home, work was being carried out to modernise and upgrade the downstairs areas of the home. A similar programme of work has recently been completed to the upstairs facilities and the bedrooms that were inspected were decorated to a good standard. In order to minimise the disruption to the people living in the home, work is being carried out on a planned basis, with each corridor being completed separately, before the commencement of further work. Whilst discussion with people living in the home affected by these changes, indicated that they were happy Alderlea Care Home DS0000002814.V308597.R01.S.doc Version 5.2 Page 17 with the temporary move to other bedrooms that this has entailed, a requirement is made in this matter. Despite the significant work that the above refurbishment has involved, the home’s domestic staff were observed working hard to ensure that the comfort and cleanliness of the home was maintained. Alderlea Care Home DS0000002814.V308597.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use this service experience adequate outcomes in this area. The homes recruitment and selection procedures ensure that staff have been checked to make sure that they are safe to work with people living in the home. However, the numbers and skill mix of staff in the home should be reviewed, in order to ensure that the needs of people living in the home are met at all times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Observation throughout this inspection visit indicated that the staff took their responsibilities seriously and that they were committed to doing their jobs. Positive comments regarding their qualities were received from both people living in the home and their relatives, and a Community Psychiatric Nurse expressed “respect for the staff”. However, some comments were received from both people living in the home and their relatives that indicted that owing to the levels of dependency experienced, staff sometimes had difficulties in managing their collective needs on occasions and this was observed towards the end of the inspection, when a number of people living in the home became somewhat confused and agitated. A requirement is therefore made that the staffing levels be reviewed, in order to ensure that there are sufficient numbers on duty to meet the needs of the people living in the home. Alderlea Care Home DS0000002814.V308597.R01.S.doc Version 5.2 Page 19 The provider organisation has developed a strong programme of induction and mandatory training and inspection of the home’s training records confirmed that staff had undertaken a variety of courses relevant to the needs of the people living in the home. Further analysis of this however highlighted some gaps in this programme and a recommendation is made that a staff training analysis needs is undertaken which is linked to the needs of the people living in the home and the home’s aims and objectives. Information provided by the manager indicated that 30.7 of the staff had obtained an NVQ level 2 qualification in care and that a further six staff members were due to commence undertaking a such a course in the near future. A further recommendation is made in this matter. The service had a recruitment policy and procedure to ensure that staff employed were safe to work with the people living in the home. Inspection of the files of three of the most recently employed staff members, indicated that this was being appropriately followed, with evidence of Criminal Records Bureau and Protection of Vulnerable Adults (POVA First) checks being carried out and references obtained. Checks confirming the staff member’s identity were also present in the files that were inspected. Alderlea Care Home DS0000002814.V308597.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, and 38 People who use this service experience good outcomes in this area. Effective administrative procedures were being maintained to ensure that the home was well run. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection visit, a new manager had been appointed who was in the process of being registered with the Commission for Social Care Inspection. Staff indicated that the manager was open in her approach and the minutes of meetings held provided evidence of effective communication, in order to ensure that the views of people living and working in the home could be heard and acted upon. The provider organisation has developed robust systems for quality assuring its services and inspection of these confirmed that they were being maintained well and kept up to date. A random inspection of Alderlea Care Home DS0000002814.V308597.R01.S.doc Version 5.2 Page 21 the records of money held on behalf of the people living in the home confirmed that accurate records were being kept in these respects and information provided by the manager indicated staff had undertaken training on a variety of health and safety issues. A random sample of the home’s staff and maintenance records confirmed these to be satisfactory and that regular safety checks were being carried out. Alderlea Care Home DS0000002814.V308597.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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Alderlea Care Home DS0000002814.V308597.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 OP27OP27 Regulation 18 (1a) Requirement The registered person must review the home’s staffing numbers, in order to ensure that sufficient numbers of suitably qualified, competent and experienced staff are working at the care home at all times. Timescale for action 31/07/07 Alderlea Care Home DS0000002814.V308597.R01.S.doc Version 5.2 Page 24 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 OP7OP7 Good Practice Recommendations The registered person should consider developing the support plans in order that they can maximise the interests and hobbies of the individual people living in the home. The registered person should ensure that the activities organiser has received dementia care training in order to ensure that social activities of people living in the home are better met. The registered person should consider the use of the down stairs bedrooms for people living in the home with dementia needs, in order to enable them to have better access to their rooms. The registered person must formally notify the Commission for Social Care Inspection of the programme of refurbishment for the home. The registered person should ensure 50 of the staff have achieved an NVQ 2 in care, in order to ensure that they are equipped with the skills to do their job. The registered person should ensure that a staff training analysis is undertaken in order to ensure that staff members development needs reflect individual roles and the aims of the home. 2 OP12OP12 3 OP14OP14 OP19OP19 4 5 6 OP19OP19 OP28OP28 OP30OP30 Alderlea Care Home DS0000002814.V308597.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Alderlea Care Home DS0000002814.V308597.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. 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!