Inspection on 07/06/06 for Alderson House

This inspection was carried out on 7th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 1 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 10/07/07

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 Mr Ken Hague Unannounced Inspection 7th June 2006 10:00 Alderson House DS0000002316.V299166.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.V299166.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.V299166.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alderson House Address Saltfleet Road Theddlethorpe Lincs LN12 1PH 01507 338584 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.V299166.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That Mr Dytham is provided with training in respect of the 1983 Mental Health Act That Mr Dytham is provided with additional training in Adult Protection That Mr Dytham is provided with training in employment law Date of last inspection 31st October 2005 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. Alderson House DS0000002316.V299166.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place between 08.15am & 11.30am. A site visit was made as part of the inspection. Care records were inspected, staff and the registered manager was interviewed The main method of inspection used is called ‘case-tracking’; this involved ; reading the individual care records for residents being case tracked and discussions with staff and the registered manager. Observations are made of the manner in which care and help is provided throughout the inspection. Discussions were held with the residents being case tracked to ensure that their care plans were being followed and their choices and wishes were considered in the day-to-day management of the care home. The home has supplied the Commission for Social Care Inspection with 15 copies of the “have your say document”. This document ask 10 questions to the residents and invite them to pass comments which reflect their views on the resources been offered by the care home. All 15 documents were studied, the and the comments and opinions are reflected within this report. A sample number of 10 we used to generate percentage figures for the responses to the 10 questions. The Registered Manager was present throughout the inspection. What the service does well: What has improved since the last inspection? What they could do better: The home must ensure supervision is provided in accordance with the national minimum standards. The home has failed at the last two inspection to meet this standard. The recruitment process must be monitored to ensure that no staff are employed before the information required by the care home Alderson House DS0000002316.V299166.R01.S.doc Version 5.2 Page 6 regulations has been obtained. The home must address has failed to meet this standard on several inspections. 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. Alderson House DS0000002316.V299166.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.V299166.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is Excelent. This judgement has been made using the available evidence including a visit to this service. The home completes an assessments prior to admitting a resident to the care home ensuring that all their needs are identified and the care home has the resources to meet individual residents needs. EVIDENCE: A new residents file was inspected and found to contain a full assessment which set out the identified needs of the resident and his goals for the future. The registered manager confirmed that he had been invited to visit the home on two occasions prior to be admitted into the care home. The resources in the care home could meet the residents needs identified in his initial assessment. Alderson House DS0000002316.V299166.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 &9 Quality in this outcome area is Excellent. This judgement has been made using the available evidence including a visit to this service. Care plans contain comprehensive information, which identify the care needs and personal preferences of the residents. Risk assessments are of a good quality, providing management strategies that enable residents to be as independent as possible EVIDENCE: A resident admitted since the last inspection had a comprehensive care plan which set out identified needs resulting from the initial assessment. His wishes and choices in respect of the way care is provided was recorded. The shortterm goals for this resident had been identified but as he had only been in the home under two months long-term goals at this point had not been completed. The care plan had been reviewed since the resident was admitted. The registered manager stated there were no risk factors to take into account with this resident. He did however give an example of one resident’s care plan where identified risks had been balanced against the wishes of the resident. Resident’s feedback forms confirmed that all residents have a copy of the Alderson House DS0000002316.V299166.R01.S.doc Version 5.2 Page 10 terms and conditions for their stay at the care home. The registered manager confirmed that residents are given a copy of the terms and conditions, which is explained to them by staff. The individual files of the residents being case tracked all contained care plans, which had been reviewed since the last inspection and was signed by the residents. Alderson House DS0000002316.V299166.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 &17 Quality in this outcome area is Good. This judgement has been made using the available evidence including a visit to this service. Residents are encouraged to keep in contact with their family and friends. All visitors are made welcome by staff at the care home. Catering arrangements for the home reflects the residents choices, preferences and personal dietary needs. Residents with a special diet are provided with a menu which takes their personal needs into account. EVIDENCE: The home has a comprehensive activity programme. Activities are organised in the care home on a daily basis or away from the care home in the community . On the day of the site visit residents travelled into Cleethorpes for the day. The registered manager provided the Inspector with a detailed written copy of the activity programme. In the “have your say document” completed by residents there was confirmation that activities are organised and this included a choice of activities. A resident being case tracked confirmed that family visit him at the home and are made very welcome. He Alderson House DS0000002316.V299166.R01.S.doc Version 5.2 Page 12 stated that he went home for visits on a regular basis. A second resident stated that he took a holiday this year with his family. There were two residents in the care home who have their own cars. They often go out into the community. These two resident stated they were working towards independent living. The pre-inspection questionnaire supplied by the home contained a menu planner which provided evidence that choice of food is offered to residents. The individual likes and dislikes of residents were found on their care plans. Resident stated all of their dietary needs were being met by the care home. A residents feedback form stated “the chefs usually does a good meal”. A second residents, commented that “the chef supplies a good meal every day. ”A third resident wrote “ being a vegetarian I prefer the vegetarian meals. Maybe the more exotic vegetarian meals should be available?” Residents spoken during the site visit stated they were very satisfied with the choice of food provided by the home. Alderson House DS0000002316.V299166.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 &20 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The home provides personal support in the manner preferred by each individual resident. Residents physical and emotional health needs are being met. Staff have been trained to ensure they can administer and manage the storage of medication for residents. EVIDENCE: The have your say feedback documents provided evidence that residents receive the care and support they need. There were no negative statements received from residents only positive comments were made. The physical and emotional needs of each resident, being case tracked was found to be recorded on their individual file. Residents confirmed these details were accurate. The details of input from community health care services were recorded on all files seen during the site visit. All staff who administer medication have received training in the Administration and storage of medication. This evidence comes from the pre-inspection questionnaire and staff training files. The evidence from observations and discussions with residents was that the medication policy of the home is being followed. Alderson House DS0000002316.V299166.R01.S.doc Version 5.2 Page 14 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 the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The home listens to resident’s views and wishes and acts on them. They are procedures in place to protect residents from any possible abuse. Staff have received appropriate training to protect residents from being harmed. EVIDENCE: The homes policy and procedures manual contains policies and procedures to protect residents from any possible abuse. Staff confirmed that training had been providing in adult protection. The staffing records confirmed this statement to be correct. The residents surveys state provided evidence that staff listen to resident’s comments and act on their request. The complaints policy is displayed in public area of the care home. Staff were able to discuss this with Inspector during the site visit. There have been no complaints received by the home since the last inspection. Alderson House DS0000002316.V299166.R01.S.doc Version 5.2 Page 15 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 the following standard(s): 24 & 30 Quality in this outcome area is Good. This judgement has been made using the available evidence including a visit to this service. Residents live in a well maintained clean environment . Staff follow the infection control policy of the care home. EVIDENCE: The home was found to be clean and tidy and smelt fresh. There has been two new air extractors fitted in the social area of the care home to improve the air quality after residents have used this as a smoking area. No health and safety or infection control issues were identified at this site visit Alderson House DS0000002316.V299166.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 &36 Quality in this outcome area is poor. This judgement has been made using the available evidence including a visit to this service. The home is staffed with appropriate numbers of care staff who are sufficiently trained to be able to answer the needs of residents who fit within the registration category of the care home. The managers of the care home are not following the home’s recruitment policy consistently and residents therefore could be placed at risk. staff supervision is not being carried out in accordance with the National Minimum Standards. EVIDENCE: Staffing levels have not been reduced from that set in 2002. The registered manager stated that staffing levels are under review and the home is considering employing another member of staff. Resident spoken to during the site visit confirmed they were happy with present staffing levels. The registered manager confirmed that staffing hours are increased if residents needs change. The inspection of recruitment records for a new member of staff contained only one written reference. This does not meet the Care Home Regulations. The recruitment records have been improved in terms of the organisation of information a checklist is now in placed at the front of every file. It a source of Alderson House DS0000002316.V299166.R01.S.doc Version 5.2 Page 17 concern to the Inspector that the sheet on the staff member who had only one reference clearly showed a second reference was outstanding. This had not been acted upon by the proprietor or the registered manager. The failure to follow the recruitment policy of the care home could place residents at risk. This requirement was an outstanding requirement from the last inspection . The registered manager was unable to demonstrate that supervision was being carried out at the frequencies set out in the National Minimum Standards. A member of staff stated they had received one supervision in the last 3 1/2 months. The National Minimum Standards state that staff should be supervised six times per year. Alderson House DS0000002316.V299166.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Residents live in a care home, which is safe and free of any health and safety hazard. Staff listen, and take into account the wishes of residents when planning the development of the care home. The register manager offers positive leadership to all staff EVIDENCE: There were no health and safety issues identified from the tour of the care home or discussions with residents and staff. Resident stated that staff do listen to them and they feel that they are actively involved in discussions relating to the day to day running of the care home. The home is managed by an experienced registered manager who staff state is very supportive. Alderson House DS0000002316.V299166.R01.S.doc Version 5.2 Page 19 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 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 X Alderson House DS0000002316.V299166.R01.S.doc Version 5.2 Page 20 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 YA34 Regulation 19-1 Requirement The registered person must obtained the information set out in schedule 2, Paragraphs 1to7 before employing a new member of staff Timescale for action 01/08/06 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.V299166.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Lincoln Area Office Unity 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 DS0000002316.V299166.R01.S.doc Version 5.2 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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