Inspection on 10/07/07 for Alderson House

This inspection was carried out on 10th July 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 found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Alderson House 23/06/08

Alderson House 07/06/06

Alderson House 31/10/05

Alderson House 20/06/05

Alderson House 13/10/04

Alderson House 10/05/04

Similar services:

Thornham Grove

Thistle Hill Hall

Conifer Lodge

Westwood Lodge

Egerton Lodge Care Home

Alfred Minto House Care Home

St Matthews Unit

Trevayler Residential Care Home

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

CARE HOME ADULTS 18-65 Alderson House Saltfleet Road Theddlethorpe Lincs LN12 1PH Lead Inspector Ken Hague Key Unannounced Inspection 10th July 2007 08:30 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 Alderson House DS0000002316.V340502.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 Adults 18-65. 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. Alderson House DS0000002316.V340502.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alderson House Address Saltfleet Road Theddlethorpe Lincs LN12 1PH 01507 338584 F/P 01507 338584 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) Alderson Limited Paul Dytham Care Home 18 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (18) of places Alderson House DS0000002316.V340502.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered to provide personal care for service users of both sexes whose primary needs fall within the following category:Mental Disorder, excluding learning disability or dementia (MD) - 18 The maximum number of service users to be accommodated is 18 Date of last inspection 7th June 2006 Brief Description of the Service: Alderson House is owned by Alderson Ltd and managed by a Registered Manager. The home provides care for people with mental health needs. The building has been adapted from formal commercial premises. It is now a large detached 2-storey building with accommodation for 18 people in 16 single rooms and one double room. It is situated on the edge of the village and is set well back from the road. Ample car parking is available to the front and side of the property. As the care home is situated in a rural area, transport is provided for recreational, vocational and educational purposes. Residents pay for the use of transport. The residents attend various work and vocational placements within the area. The coastal resort of Mablethorpe and the town of Louth are within easy travelling distance. The home charges £361 to £568 per week. The care home has a statement of purpose and service users guide, which sets out the resources of the home and the facilities offered to residents. These documents are shown to all visitors who are considering coming to stay at the home. Alderson House DS0000002316.V340502.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 6.5 hours. The registered manager was provided with feedback at the end of the inspection. The main method of inspection used was called ‘case tracking’ which involved selecting three residents and tracking the care they receive through the checking of their records, discussion with them and the staff, and where more appropriate observation of interaction between staff and residents and related care practices. A sample of care records was inspected. Two members of staff were interviewed and the opinions of five residents were sought. No AQQA (Annual quality Assurance assessment document had been requested from the home prior to the site visit. The Commission for Social Care Inspection received twelve “have your say” documents completed by residents. This document asks 12 questions and invited residents to make comments regarding the care they receive from the home. The feedback and comments from the ”Have your say documents” is included within this inspection report. The inspector had lunch with the residents during the site visit. What the service does well: What has improved since the last inspection? The registered manager has consistently followed the recruitment policy in care home when recruiting new staff since the last key inspection. This means that the Care Home Regulations in respect of staff recruitment have been met at this inspection. The quality of care records has also improved since the last key inspection. Alderson House DS0000002316.V340502.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. Alderson House DS0000002316.V340502.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Alderson House DS0000002316.V340502.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There are procedures in place which are used for the assessment of all new residents. This ensures that all of their personal care needs, health care and social needs are identified and met. EVIDENCE: The individual care records of three residents being case tracked were inspected. All files contained a copy of an initial assessment made prior to the resident being admitted to the care home. This assessment identified the care and social needs of each individual resident. Risk assessments were included within the assessment where a risk was identified the management of that risk was included in the resident’s care plan. Assessments were signed and dated by the resident and the member of staff who carried out the assessment. Residents confirmed that they had been involved in the assessment. Staff confirmed that the assessment was used to ensure that the resident’s needs are fully met. The registered manager stated that no new resident is admitted to the home until an initial assessment has been completed. The information gathered at the assessment is used to write the first initial care plan. A resident states in their ‘have your say’ document “I am glad that I moved here it’s the best move I have made. “ Alderson House DS0000002316.V340502.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7 & 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Care plans identify all areas of need and provide detailed care instructions for staff; this enables them to provide appropriate care and ensures residents’ health needs are met. EVIDENCE: The care plan of three residents being case tracked was studied. The information obtained at the initial assessment had been used to complete an initial care plan. This identified the care and social needs of each resident. The choices, wishes and goals of each resident were recorded on their own individual care plan. Risk assessments had been completed. The management of any identified risk was included in the resident’s care plan. Individual residents being case tracked confirmed that they have been involved in the writing of their care plan. Residents stated that their individual goals matched those recorded on Alderson House DS0000002316.V340502.R01.S.doc Version 5.2 Page 10 the care plan. There was evidence found of care plans being reviewed with the resident on a monthly basis with a full formal review at every 6 months. The registered manager stated that two residents had left the home since the last key inspection moving into a more independent setting within the community. Residents in discussions stated that the home encourage them to maintain their individual skills and assists them to look towards independence in the community. Recordings within individual resident’s care records and observations on the day of the site visit provided evidence that residents are encouraged to maintain their social skills and to develop new skills. Alderson House DS0000002316.V340502.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,15,16 &17 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. A range of activities are provided for residents which enables them to have an active and interesting social life. Residents rights are respected by staff which ensures their privacy and dignity is maintained. The home’s menu does not offer choices and this restricts the diet and choices for residents. EVIDENCE: A document supplied by the care home to the Commission for Social Care Inspection after the site visit sets out a number of activities offered to residents. Residents confirmed in discussions that these activities do take place. The “have your say” documents completed by residents make reference to activities, the majority of the residents being satisfied with the activities provided. Residents were observed to be taking part in craft and cooking activities during the site visit. One “have your say” documents states, “I enjoy swimming, tennis and playing games. I like to go out of the home to the local fish shop”. Alderson House DS0000002316.V340502.R01.S.doc Version 5.2 Page 12 Care plans contained details of the individual activities of each individual resident. The registered manager stated that additional activities are organised outside the care home when the weather permits. Throughout the time of the site visit all residents were occupied and were enjoying the social activities. Observations on the day and discussions with staff and residents produced evidence that the residents live as a small community. Family and friends visit the home on a regular basis. Residents go home for family breaks. Residents form friendships and relationships within the care home as would happen in any community. It was noticeable that residents get on well as a community group even though they have different needs and different ambitions. The staff and the registered manager stated that the privacy and dignity of residents are always respected. “Have your say” documents completed by residents supported this statement. On the day of the site visit residents were not offered a choice of lunch. Residents could only obtain a hot drink at set times throughout the day. A discussion was held with the registered manager and agreement reached for the home to address these issues. Alderson House DS0000002316.V340502.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19 &20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Health care needs and emotional needs are recorded on up-to-date care plans, which instructs staff how to ensure that residents’ needs are met. The medication policy the care home is being followed, ensuring the safe administration and storage of medication. EVIDENCE: Care plans outlined the choices and wishes of individual residents and the manner in which personal support should be provided. Staff were able to discuss the choice wishes and feelings of the people being case tracked. The registered manager has an overview of the personal support being given to all residents in the care home. Residents stated that they are satisfied with the manner in which care was being provided at the time of a site visit. “Have your say” documents provided further evidence of residents being satisfied that their needs are being identified and met by the care home. The health care needs of residents were recorded in their individual care records. This Included Eye care, chiropody and Dental care. Visits by health care community professionals were recorded in individual records. The Alderson House DS0000002316.V340502.R01.S.doc Version 5.2 Page 14 residents being case tracked confirmed that their health care needs are being met. Evidence was seen of emotional support being given to residents during the site visit. The registered manager described the support being given to residents and explained how residents were encouraged to work, developing their personal and social skills and where are appropriate look towards independent living. Staff have been trained by outside agencies in the administration and storage of medication. Medication records are being completed in accordance with national guidelines. Drugs were found to be stored correctly. The registered manager confirmed that the boots pharmacist visits on a regular basis to give advice and to monitor the medication practice of the care home. Alderson House DS0000002316.V340502.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 723 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home’s up to date complaints procedure is known and understood by residents and staff. Residents can therefore raise concerns with the management and staff. Staff, have received training in the identification and management of abuse. Staff, therefore know how to protect residents from any potential abusive situation. Residents feel they live in a safe environment. EVIDENCE: The home’s adult protection policy is in line with current local guidelines. A copy of the Lincolnshire County Council adult protection procedure was included in the home’s policy and procedures manual. The registered manager and staff were able to give details of how they would report any suspected abuse to the Commission for Social Care Inspection and Social Services. Staff comments and training records demonstrated that staff had received appropriate training in this subject which would help them to recognise and take appropriate action should the need arise. The home’s complaints procedure was discussed in the formal interviews. Staff are familiar with this policy and stated it is displayed in the foyer of the care home. Alderson House DS0000002316.V340502.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 & 30 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 comfortable, homely, clean environment with a choice of communal areas and personalised bedrooms. The up-to-date infection control policy is followed and maintains a safe environment. EVIDENCE: The home was found to be well maintained throughout. There is a garden area and sitting area outside the care home, set back from the road and safe to be used by all residents. Residents are encouraged to bring possessions into their rooms and to make them homely. Each bedroom seen during the site visit was individually furnished. There are enough bathrooms and toilets to meet the needs of the residents. Staff interviewed confirmed that fire alarms are tested weekly, and were able to describe the appropriate action they would take in order to maintain residents and staff safety in the event of a fire. They confirmed a fire drill had been carried out recently. Alderson House DS0000002316.V340502.R01.S.doc Version 5.2 Page 17 All areas of the home were clean and smelt fresh. Discussions with staff members and the registered manager identified no health or safety or infection. Residents stated that they are very happy with the facilities provided by the Company. Alderson House DS0000002316.V340502.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,34 & 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff are appropriately trained to meet the needs of residents, and are safely recruited. EVIDENCE: The inspection of recruitment records for new members of staff who have commenced employment since the last key inspection provided evidence that the recruitment policy of the home is being followed. All appropriate documents were on individual members’ staff personal files. This included criminal record bureau checks (CRB), two written references, proof of staff members’ identity and a POVA check (protection of vulnerable adults). All documentation had been obtained prior to employment being offered and the new member of staff commencing employment. New staff confirmed that they had filled in application forms, had been formally interviewed and provided with an induction programme. The care home has a long-term training programme in place, which is linked into the appraisals and supervision process. Staff confirmed that NVQ training is being provided. Staff interviewed during the site visit confirmed that the Alderson House DS0000002316.V340502.R01.S.doc Version 5.2 Page 19 training records were accurate in respect of courses they had taken since last inspection. Staff stated they felt competent to be able to meet the needs of residents with the training provided to date. Residents stated that staff were sensitive, helpful and have the skills to help them. Alderson House DS0000002316.V340502.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,39 & 42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Leadership, guidance and direction are provided to staff to ensure that residents receive a good standard of care and the home operates safely. Residents are happy with the service they receive. EVIDENCE: The care home has a registered manager in post, who staff stated provides leadership and is approachable. The registered manager stated that he provides all staff with individual supervision and the yearly appraisals. Staff confirmation of this statement to be correct, provided a further support for the statement. Residents stated that they felt that the registered manager does ensure their care needs are met. No residents stated they had any complaints or problems in relation to the registered manager or the proprietor. No health and safety issues or infection control issues were identified during the site visit. The home’s manager has failed to inform the Commission for Social Care Alderson House DS0000002316.V340502.R01.S.doc Version 5.2 Page 21 Inspection of discipline action taken against two employees, which resulted in their dismissal. Alderson House DS0000002316.V340502.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 Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Alderson House DS0000002316.V340502.R01.S.doc Version 5.2 Page 23 no 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 YA17 Regulation 16-2 (i) Requirement The care home must provide a menu which offers choices and meets the dietary needs of all residents The registered person must give notice to the commission of any allegation of misconduct by a member of staff. Timescale for action 01/09/07 2 YA43 37-1 01/09/07 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 Alderson House DS0000002316.V340502.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 - 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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