Inspection on 20/06/05 for Alderson House

This inspection was carried out on 20th June 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

Alderson House 23/06/08

Alderson House 10/07/07

Alderson House 07/06/06

Alderson House 31/10/05

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 Unannounced 20 June 2005 - 0900 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 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 Stationary 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 C53 C04 S2316 Alderson House V233530 20-6-05 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Alderson House Address Saltfleet Road Theddlethorpe Lincs LN112 1PH 01507 338584 01507 338584 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr T Carter Mrs Alderson-Davies Application being processed - Mr P Dytham PC Care Home Only 18 Category(ies) of MD - Mental Disorder - 18 registration, with number of places Alderson House C53 C04 S2316 Alderson House V233530 20-6-05 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 13 October 2004 Brief Description of the Service: Alderson House is owned by Alderson Ltd and managed by a Acting 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 2storey 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. Service users pay for the use of transport. The service users attend various work and vocational placements within the area. The coastal resort of Mablethorpe and the town of Louth are within easy travelling distance. Alderson House C53 C04 S2316 Alderson House V233530 20-6-05 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspection took place over a six hour period. A tour of the building was conducted, and care records and other documents were inspected. Two members of staff, four residents using the service and the acting manager were interviewed. A discussion was held with the proprietor and administrator of the care home. The inspection was concluded with feedback being given to the proprietor and acting manager in relation to the findings of the inspection. What the service does well: What has improved since the last inspection? 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 Alderson House C53 C04 S2316 Alderson House V233530 20-6-05 Stage 4.doc Version 1.30 Page 6 contacting your local CSCI office. Alderson House C53 C04 S2316 Alderson House V233530 20-6-05 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Alderson House C53 C04 S2316 Alderson House V233530 20-6-05 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,4&5 The statement of purpose does not contain sufficient detail to allow a new resident to make an informed choice regarding whether their needs can be met by the resources of the home. Residents are aware of the terms and conditions for their stay at the care home. Residents receive a full assessment before they are admitted. EVIDENCE: At the last inspection in October 2004 it was identified that information was missing from the statement of purpose. This was still the case on the day of this inspection. The acting manager confirmed that new residents are invited to visit the home before being admitted. He stated that all residents are given a full assessment including a risk assessment before they are admitted. Alderson House C53 C04 S2316 Alderson House V233530 20-6-05 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7&9 The choices and wishes of service users are not recorded on the individual care plans. Individual residents goals are not identified and recorded on care plans. Risk assessments are not carried out consistently to ensure that service users are supported in taking a risk as part of maintaining a choice of lifestyle. EVIDENCE: A resident seen on the day of this inspection had a personal goal to move back into the community. This detail was not recorded in his care plan. There was no indication on his care plan or records that he is to move on 17th July 2005 to another home. This is to allow him to further develop his independent skills and provide a bridge into independent living in the community. Two other files seen contained no goals or residents wishes for their future. There was no evidence of service users being involved in the decision-making process on care records. A service user stated that he was taking driving lessons ready for his return to living independently in the community. There was no evidence of a risk assessment in relation to this training. A service user was selfmedicating and no risk assessment was in place and the GP had not been consulted. One service user had two care plans one dated June 2000 and a second dated August 2004. It was unclear which was the current care plan. Alderson House C53 C04 S2316 Alderson House V233530 20-6-05 Stage 4.doc Version 1.30 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15&17 Activities are held at the home and in the local community. Staff enable and encourage residents to maintain links with their family. A varied menu is provided which offers, choice and meets the dietary needs of all residents. EVIDENCE: The care files contains details of activities offered to individual residents. The residents confirmed that these activities do take place and stated that they make choices as to which activities they participate in. Staff gave details of individual residents choice of activities and these details corresponded with the information recorded on care records. A member of staff explained the importance of family contact to one resident and stated the actions being taken to ensure contact was maintained. Five residents stated they were happy with the menu being provided and confirmed choice was offered. The likes and dislikes of individual residents were recorded on their personal files. Alderson House C53 C04 S2316 Alderson House V233530 20-6-05 Stage 4.doc Version 1.30 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20 The home has not consistently followed its own medication policy. EVIDENCE: The home was allowing a resident to self-medicate without following the homes procedure on the administration of medication. There was no risk assessment on their file to demonstrate that he was able to safely selfmedicate. There was no confirmation from a GP or consultant that this action was appropriate. Alderson House C53 C04 S2316 Alderson House V233530 20-6-05 Stage 4.doc Version 1.30 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Not inspected on this visit EVIDENCE: Alderson House C53 C04 S2316 Alderson House V233530 20-6-05 Stage 4.doc Version 1.30 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Not inspected on this visit EVIDENCE: Alderson House C53 C04 S2316 Alderson House V233530 20-6-05 Stage 4.doc Version 1.30 Page 14 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,34&36 Staff are being recruited in accordance with the National Minimum Standards. The home is staffed with competent qualified staff . Staff supervision is not taking place in accordance with the National Minimum Standards. EVIDENCE: A member of staff recruited since the last inspection described her recruitment which provided evidence that the recruitment policy of the home was being followed. Her personal file contained the documentation required by the Care Home Regulations before a new member of staff is employed. The acting manager gave details of NVQ training for care staff. At the present time 43 hold NVQ two in care or above. There are plans in place for additional staff to achieve NVQ training to meet the 50 recommended figure by 2005. A written training plan was seen to be in place. Annual appraisals had been carried out and the training needs of staff identified. Staff stated that they had received supervision at the frequency set out in the National Minimum Standards, but added that no formal record is being kept of the supervisions. Alderson House C53 C04 S2316 Alderson House V233530 20-6-05 Stage 4.doc Version 1.30 Page 15 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39&42 The care records do not indicate the choices and wishes of residence. The care plans are not been reviewed as required by the Care Home Regulations. The management of the home ensures the health and safety policy the home is followed. EVIDENCE: There was no evidence of the review of individual residents care plans. There was evidence found of changes in assessments and service users wishes but these were not transferred onto their care records There was no health and safety issues identified at this inspection. Alderson House C53 C04 S2316 Alderson House V233530 20-6-05 Stage 4.doc Version 1.30 Page 16 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 x 3 3 Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 x 3 x 3 Standard No 31 32 33 34 35 36 Score x 3 x 3 x 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Alderson House Score x x 2 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 3 x C53 C04 S2316 Alderson House V233530 20-6-05 Stage 4.doc Version 1.30 Page 17 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. 2. 3. Standard 1 6 7 Regulation 4 -1 (c} 15-1 15-1 (c} Requirement The home is required to ensure its statement of purpose meets and national minimum standard. Residents care plans must include their personal goals and future plans. Residents care records must provide evidence that their decisions and wishes are included in their care plan The registered person must complete a risk assessment if a residents requests to be allowed to self Medicate. Staff must be provided with supervision in accordance with the National Minimum Standards Residents care records and care plan must be reviewed at the frequency set out in the National Minimum Standards Timescale for action 20/10/05 20/10/05 20/10/05 4. 20 13 -1 (2) 20/10/05 5. 6. 36 39 18-2 15-2 20/10/05 20/10/05 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 C53 C04 S2316 Alderson House V233530 20-6-05 Stage 4.doc Version 1.30 Page 18 Alderson House 1. none Alderson House C53 C04 S2316 Alderson House V233530 20-6-05 Stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection noney House, The Point Weaver Road off Whisby Road Lincoln LN6 3QN 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 Alderson House C53 C04 S2316 Alderson House V233530 20-6-05 Stage 4.doc Version 1.30 Page 20 - 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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