Inspection on 23/06/08 for Alderson House

This inspection was carried out on 23rd June 2008.

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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Alderson House 10/07/07

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 27/09/2008.

CARE HOME ADULTS 18-65 Alderson House Saltfleet Road Theddlethorpe Lincs LN12 1PH Lead Inspector Sue Hayward Unannounced Inspection 23rd June 2008 12:00 Alderson House DS0000002316.V368094.R01.S.doc Version 5.2 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 Alderson House DS0000002316.V368094.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.V368094.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 Care Home 18 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (18) of places Alderson House DS0000002316.V368094.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 10th July 2007 Brief Description of the Service: Alderson Ltd owns Alderson House. There have been changes to the management arrangements since the previous inspection visit. The owner has been managing the service but has recently appointed an acting manger. 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. People who use the service pay for the use of transport. They 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 care home has a statement of purpose and service users guide, which sets out the resources of the home and the facilities offered. These documents are shown to all visitors who are considering coming to stay at the home. The current range of fees is home charges £365 to £482 per week. Hairdressing, newspapers, chiropody and personal items are additional costs. Information about the day-to-day operation of the home and fees, as well as a copy of the last inspection report, is available in the manager’s office. Alderson House DS0000002316.V368094.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that people who use this service experience adequate quality outcomes. Throughout this report the terms ‘we’ and ‘us’ refer to The Commission for Social Care Inspection (CSCI). This was an unannounced visit and it formed part of an inspection, focussing on key standards, which have the potential to affect the health, safety and welfare of people who use the service. The main method used to do this was through a process we call “case tracking”. This includes following the care of a sample of three people through their records and assessing their care. We spoke to four people who use the service and saw rooms of those people who said we could. In addition we spoke to a visiting professional and two staff members. The visit started at midday and lasted 6 hours. It took into account information we already hold on our files, which was used to plan the visit and produce this report. Prior to the visit the owner had completed a questionnaire. This gave us important information about their own assessment of how well they are meeting standards and their plans to improve aspects of the service. Some specific information was included, which enabled us to send out surveys to people before we visited the service. Nine surveys were returned from people who use the service and four from staff prior to the completion of this report. Their comments are included throughout this report. The acting manager was present throughout the visit and the general outcomes of the visit were discussed with her. What the service does well: A homely environment is provided for people who use the service and they are supported and have opportunities to increase their independence. Comments were “I like it here” and “it’s been a good move”. There is a staff team who are committed and well trained. People who use the service made positive comments about their relationships with staff and generally felt that staff listened to them and comfortable to raise any matters. Alderson House DS0000002316.V368094.R01.S.doc Version 5.2 Page 6 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 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Alderson House DS0000002316.V368094.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.V368094.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): 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are satisfactory systems in place to introduce and assess people who use the service to ensure their care needs are identified and can be at the home prior to admission. EVIDENCE: Information about the home is available in the form of a statement of purpose and service users guide, which tells people about the service. The acting manager is in the process of updating this information in view of the changes to the management arrangements and also to reflect more explicitly how peoples differing needs such as religious and cultural will be met. Previous inspection reports are available in the office should people wish to see them. Comments from most people who use the service confirmed they were given sufficient information about the service to enable them to make a decision whether it was the right place for them to stay. The acting manger said that she also makes visits to people to assess whether or not the service can meet their needs before agreeing their admission. People who use the service said they had been able to visit the service prior to making a decision to stay. A person said, “It’s been a good move”. Alderson House DS0000002316.V368094.R01.S.doc Version 5.2 Page 9 Records of three people with a range of needs were checked on this occasion including one person who had been admitted within the past twelve months. Information showed that there had been an assessment made of peoples needs and information had also been obtained from other relevant people such as health professionals to contribute to the assessment. The amount of detail recorded about peoples needs varied. For example nothing had been recorded in relation to whether there was any specific cultural or religious needs of one person whose records were checked, although others contained more detailed information. No letter was seen on the file checked of the person most recently admitted to demonstrate that they had had the outcome of the assessment confirmed to them in writing. The acting manager confirmed she is aware that this is something, which needs to be done, and which she would be addressing along with ensuring that the statement of purpose is reviewed. Terms and conditions of residency however, are issued to people who use the service. Information about the service is currently available in written form. The acting manager confirmed as did the comments of people who use the service that this information is also discussed with people and they have a choice of whether to they keep a copy of the service users guide themselves or whether they choose to have it kept on their records to refer to if they wish. Staff demonstrated a good knowledge of the differing needs of people who use the service for example whether they had any special dietary requirements. Alderson House DS0000002316.V368094.R01.S.doc Version 5.2 Page 10 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): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People benefit from being involved in the planning and review of their care, but the lack of information to show that people’s capacity to make decisions has been fully considered has the potential people may be deprived of their rights. EVIDENCE: Three peoples’ records were checked and all contained care plans. These contained sufficient information to enable staff to know about people’s individual needs and how to meet them. The acting manager is in the process of reviewing all care plans and showed us one, which had already been completed. She said she was also aware and is in the process of ensuring that where needed individual risk assessments are reviewed or completed if necessary. Little reference has been recorded as to whether people’s capacity to make decisions has been considered when drawing up care plans. This is important in view of recent legislation, which has come into force to ensure Alderson House DS0000002316.V368094.R01.S.doc Version 5.2 Page 11 there is no infringement of peoples’ rights. Training for staff has been provided about this legislation. The acting manager confirmed that the current care plan review would ensure this information is incorporated into individual care plans. Staff had a good knowledge of the needs of people who use the service and how to meet them and was noticed to deal appropriately with situations as they arose. There is a “key worker” system giving specific staff some responsibilities for specific people who use the service. Information provided prior to the site visit confirmed that there are both male and female carers employed which enables people some choice as to whether they wish to have a male or female “key worker”. All people who were spoken to on this occasion were aware of the records, which are held about them and had been involved in the development and reviews of their care plan. They made comments indicating that they made their own day-to-day decisions and felt they always or usually received the care and support they needed. There is information about advocacy services available should people who use the service need it and it was noticed that information about advocates was included as part of some of the care plans checked. Alderson House DS0000002316.V368094.R01.S.doc Version 5.2 Page 12 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): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are encouraged and supported to have control of their daily lives within their capabilities. Activity arrangements currently meet the wishes and needs of people who use the service. The meals provided are well balanced and cater for peoples individual preferences and specific dietary needs. EVIDENCE: Comments from people who use the service and records checked showed that people have the opportunity to participate in a variety of activities and leisure interests both within the community and the home. Of the surveys completed all but one thought there were always or usually activities arranged in which they could participate. One thought that “sometimes” there were. Alderson House DS0000002316.V368094.R01.S.doc Version 5.2 Page 13 Information provided in the records checked and from discussion with people who use the service confirmed that some people have attended college courses and work placements. A comment from a visiting professional indicated that people who use the service did a lot of activities. She also said that in the past people who use the service have been involved in organising events themselves such as quizzes. People who use the service also have the opportunity to put their views forward about outings and holidays in the meetings, which are held in the home. Information is also on display telling people about the planned events for the week. People who use the service said they were able to keep in touch with family and friends and have visitors. A health professional that visits the home on a two weekly basis said she was always made to feel welcome and felt that there was good communication between her and staff. She was of the opinion that peoples independence was encouraged and comments from people who use the service confirmed this. For example, people said they are able to take responsibility themselves for the cleanliness of their own rooms; they are able to lock their bedroom door and have a key if they choose and there is a kitchenette where they are able to make drinks and snacks if they wish. There have been improvements to the choice of meals. Comments from people who use the service ranged from “yes, its ok” to “its very good”. People also said that they were satisfied with the amount of food provided. Staff were aware of people who had specific dietary needs and records are kept detailing the choices of meals available although it was discussed and agreed with the chef that a record of breakfast choices will be kept in future. There were records available, which demonstrated that there is consultation with people who use the service about the meals provided. For example it was recorded that all people who use the service were “happy with the menu now they have a choice”. Staff have had training about food hygiene. Alderson House DS0000002316.V368094.R01.S.doc Version 5.2 Page 14 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): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff have a good knowledge of peoples needs and how to meet them, which contributes to ensuring peoples health and welfare. Medication is stored safely but there are instances of medication procedures not being followed sufficiently well enough to ensure peoples safety. EVIDENCE: Comments from people who use the service indicated that they are able to attend medical appointments such as visits to their general practitioner when they wish. An occupational therapist was visiting on the day and said people have opportunities to increase their independence and develop their independent living skills within the service. People who use the service confirmed that they are able to visit other health professionals such as dentists and personal records kept clearly showed when any issues had arisen and the medical appointments attended. Information provided prior to the visit showed that there are a range of policies and procedures in place for staff to refer to promote the health and Alderson House DS0000002316.V368094.R01.S.doc Version 5.2 Page 15 welfare of people who use the service. As we have been notified of an incident where a person who uses the service went missing the procedure relating to this was checked on this occasion and gave staff satisfactory information about what action to take should someone go missing. Both male and female staff are employed which enables people to have some choice of who assists them if they need help with personal care. A pharmacist visits the home periodically to check the medication and storage arrangements in place. The report of the most recent visit made on 26th March 2007 indicated there were no problems. There are opportunities for people who use the service to take responsibility for their own medication after they have been assessed as safe to do so. A staff member was observed for a time dispensing the lunchtime medicines. She confirmed as did records that she had had training about how to administer medications and was noted to follow a safe process ensuring that records were checked, medication dispensed correctly and records signed after each person had taken their medication. It was however noted that the records of a person who was prescribed medication on an as required basis was not always indicating whether 1 or 2 tablets were given. Furthermore, it could not be demonstrated that there is clear guidance in place for staff to follow about this. This has the potential that people who use the service may not be satisfactorily protected. Storage arrangements for the current medications, which were checked, were satisfactory. Alderson House DS0000002316.V368094.R01.S.doc Version 5.2 Page 16 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): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service are comfortable to raise concerns and complaints but procedures are not being implemented rigorously enough to ensure that people are fully protected from any potential risks of harm. EVIDENCE: The home has a satisfactory complaints procedure, and people who use the service said they had been given a copy of it. Some people were noticed to have copies of it on display in their bedrooms. Comments from people who were spoken to and who had completed surveys were generally positive in they knew how to make a complaint and felt that staff listened and acted on what they said. A person who uses the service said when referring to staff “they do listen” and “they do help”. Meetings are also held at which people who use the service can attend if they wish and raise any issues and matters. Records kept of the last meeting held on 13th June 2008 showed there had been the opportunity to discuss whether they were happy with the current menu for example. They were also reminded about the complaints procedure and advocacy service. Alderson House DS0000002316.V368094.R01.S.doc Version 5.2 Page 17 People who use the service said they would feel comfortable to raise any issues with staff and it was observed that a person using the service brought a matter to the attention of the manager, which she dealt with promptly. There are policies and procedures in place in relation to the protection of people such as safeguarding adults procedures. Comments from people were generally positive indicating they felt safe in the home. One person said she did not always feel safe and this was discussed with the manager who agreed to look into the matter. Comments confirmed that staff know of their responsibility to report any safeguarding matters and have had training relating about this. However, an incident was noted where it could not be ascertained whether it had been referred for social services to decide whether an investigation under local procedures was necessary. This is important to ensure people are properly protected. The acting manager agreed to refer the matter retrospectively and is requested to notify us of the outcome. There are satisfactory arrangements in place for people who wish to have their money or valuables kept safely by in the home. However, whilst the records of money of one person corresponded to the amount in safe keeping one did not as it was in excess of the amount, which was recorded as being held. (See recommendations in relation to auditing). Alderson House DS0000002316.V368094.R01.S.doc Version 5.2 Page 18 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): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a safe and comfortable environment that is suitable for their needs. EVIDENCE: The bedrooms of three people whose care was being followed on this occasion was checked as well as the lounges, dining room, kitchen, kitchenette, laundry and a sample of the bathrooms which people use. People said they found their rooms to be comfortable and were able to arrange them to their liking and make them more personal with items of their own choosing. Questionnaires completed by people who use the service indicated that they were satisfied with the cleanliness of the home. Information provided on the pre-inspection questionnaire demonstrated that there is an ongoing programme of redecoration and refurbishment and over the last year Alderson House DS0000002316.V368094.R01.S.doc Version 5.2 Page 19 some of the improvements have included the external window frames and down pipes being repaired and repainted, a new electrical installation fuse board and fire detection and alarm system being installed, new flooring to the laundry room and conservatory and a bathroom has been refurbished and redecorated. People who use the service have opportunities to assist in some domestic tasks to increase their independence and receive support from staff if necessary to do so. For example a client said she cleaned her own room. Others were seen to be using the kitchenette to make drinks when they wished. The service has visits periodically from an environmental health officer and fire safety officer. The last visit of the Environmental Health officer on 23rd August 2007 raised a number of matters, which needed attention. Although these were not checked in detail on the day of the visit discussion with the chef and with the acting manager confirmed that most matters had been addressed. For example, new fly screens have been installed. The chef also confirmed, as did records kept that there are checks made to ensure that the cleaning of kitchen equipment and surfaces takes place regularly. Information provided prior to the visit confirmed that there are policies and procedures in place for staff to refer to to ensure they know about good hygiene and infection control practices. It was observed that a staff member ensured she washed her hands prior to administering medicines and there is equipment available such as gloves for staff to use if needed. Alderson House DS0000002316.V368094.R01.S.doc Version 5.2 Page 20 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): 32, 33, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are not consistently maintained to ensure they are adequate to meet the needs of people who use the service. Staff have training to ensure they have the skills needed to carry out their roles and are committed to the work they do but the recruitment procedure is not sufficiently robust to ensure that people who use the service are protected. EVIDENCE: The sample of rotas checked on this occasion showed that there is usually a minimum of 2 care staff on duty plus the acting manager. There were eighteen people residing at the home on the day of the visit, some who have needs associated with challenging behaviour and need one the one to one support of staff. At the time of arrival care staff were not easy to locate. The acting manager in the service was dealing with an admission and it was later confirmed that the second staff member was out of the building, which only left the acting manager on the premises and the administrator for approximately three Alderson House DS0000002316.V368094.R01.S.doc Version 5.2 Page 21 quarters of an hour. There were however, no adverse comments from people who use the service about staffing levels affecting the quality of their care. The records of recruitment of two staff were checked on this occasion. It was noticed that only one written reference had been obtained for one person, although the acting manager confirmed a second one was being pursued. In addition, whilst it could be confirmed that staff are not employed prior to a satisfactory protection of vulnerable adults check, a member of staff who was awaiting the return of a criminal records bureau check was working unsupervised. Verbal confirmation has been provided since the site visit that a satisfactory criminal records bureau check has now been received. Comments from people who use the service were positive about their relationships with staff. They said they “liked” the staff and were noticed to have a good rapport with them. People who use the service were noticed to seek the company of staff who treated them in a kind and friendly manner. Records and comments from staff confirmed there is a range of training provided to enable them to have the knowledge and skills to provide appropriate care for people. This includes training to introduce them into the work and some which relates to more specific areas such as fire safety, safeguarding adults, health and safety and ethical control and restraint. Some staff have also achieved a nationally recognised vocational award in care. Staff comments indicated that they were well supported in their work. Alderson House DS0000002316.V368094.R01.S.doc Version 5.2 Page 22 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): 37, 39, 41 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The interim arrangements for managing the service are satisfactory and there are opportunities to ensure people’s views about the service are sought in order to monitor and develop the quality of the care provided. EVIDENCE: The registered manager has left the service since the previous visit and an acting manager has recently been appointed. People who use the service knew who was in charge. Staff said they felt well supported and communication was good. There are records in place to demonstrate when staff meetings and meetings for people who use the service have taken place and comments from people living at the home confirmed that they participated in them and felt comfortable to raise matters with staff. Alderson House DS0000002316.V368094.R01.S.doc Version 5.2 Page 23 There are other quality monitoring systems in place such as questionnaires, which are used periodically with people who use the service and quality audits of the premises and grounds. Discussion with the acting manager indicated that she has started to carry out further audits of different aspects of the service such medication to ensure the quality of the service There is a range of policies and procedures for staff to refer to relating to health and safety issues such as, first aid and missing persons. There are also certificates and records kept to show how health and safety matters are monitored. For example, records kept in relation to fire safety demonstrated that weekly checks are made of the alarm system and that a fire risk assessment had been reviewed in May 2008. Information provided prior to the visit demonstrated that equipment and appliances are satisfactorily maintained and the sample of records checked on the day showed that the fixed electrical wiring and portable electrical appliances were tested and inspected in January 2008. Most of the records that are required to be kept were in place however an incident had occurred which had resulted in a person requiring hospital treatment. This matter had not been notified to us as is required by law. There were some records in place to show that risk assessments relating to individuals and the environment had been undertaken. It was noticed that one assessment had indicated that a window restraint was needed although there was no confirmation that this had been provided. This matter was discussed with the acting manager who has since confirmed in a telephone call that it has been addressed. Alderson House DS0000002316.V368094.R01.S.doc Version 5.2 Page 24 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 3 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 2 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 2 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X 2 3 X Alderson House DS0000002316.V368094.R01.S.doc Version 5.2 Page 25 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 YA3 Regulation 14[1] d Requirement Written confirmation of the outcome of the assessment as to whether the service is suitable to meet the peoples needs must be sent to people before they move into the home to assure them whether or not their needs can be met. Reviews of care plans must be carried out and must take into consideration the Mental Capacity Act 2007 in order to ensure people are not deprived of their rights. Staff must adhere to policies and procedures when giving out medicines to ensure that safe procedures are followed. There must be sufficient staff employed at all times to ensure the welfare and safety of people who use the service. In order to ensure people who use the service are properly protected staff must not work in an unsupervised capacity until all satisfactory checks, which must include Criminal Records Bureau register check. In order to ensure peoples DS0000002316.V368094.R01.S.doc Timescale for action 31/08/08 2. YA6 15[2] b & c Mental capacity Act 2007 13[2] 31/08/08 3. YA20 31/08/08 4. YA33 18[1](a) 31/08/08 5. YA34 19[1] 31/08/08 6. YA41 37[1] (c) 31/08/08 Page 26 Alderson House Version 5.2 health and welfare is properly monitored the commission must be notified of significant events including hospital admissions of people who use the service. 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 YA41 Good Practice Recommendations It is recommended that an audit of all money held in safekeeping is undertaken to ensure that any balances are accurately reflected in the records kept. Alderson House DS0000002316.V368094.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Alderson House DS0000002316.V368094.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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