Inspection on 13/03/06 for Alfreton Residential Home

This inspection was carried out on 13th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Alfreton Residential Home 26/09/06

Alfreton Residential Home 07/06/05

Alfreton Residential Home 17/01/05

Alfreton Residential Home 02/08/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Alfreton Residential Home 6 Reservoir Road Prenton Birkenhead Wirral CH42 8LJ Lead Inspector Peter Cresswell Unannounced Inspection 13th March 2006 9:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Alfreton Residential Home DS0000018857.V286389.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Alfreton Residential Home DS0000018857.V286389.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Alfreton Residential Home Address 6 Reservoir Road Prenton Birkenhead Wirral CH42 8LJ 0151 608 6863 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) Weatherstones House Care Limited Sandra Elizabeth Phillips Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Alfreton Residential Home DS0000018857.V286389.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th June 2005 Brief Description of the Service: Alfreton is a detached three-storey house with a large and attractive back garden. The home is in a quiet residential area of Birkenhead just off a main road and within a mile of local shops. The home is part of a family owned company that operates a small group of care homes and a domiciliary care agency. The home has a registered manager and the owners and their family play an active part in the week to week running of Alfreton, which was their first care home. Alfreton is registered to accommodate 16 elderly persons who are accommodated in three shared and ten single bedrooms, four of which have en suite toilets. Only one of the rooms is shared at the moment. Residents have use of a TV lounge, a music/quiet lounge and a conservatory that overlooks the back garden. There is not a separate visitors room, but the range of communal spaces means that residents can see visitors in private if they wish to do so. The home has a spa bath, an assisted Apollo bath and a shower room. All floors are served by a shaft lift. Alfreton Residential Home DS0000018857.V286389.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and the inspector spoke to five residents (including a new resident), the Registered Manager, three members of staff and, briefly, to the owners. He toured part of the building and examined records concerning activities, care plans, staff recruitment, assessments, fire safety medication and accidents. 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 contacting your local CSCI office. Alfreton Residential Home DS0000018857.V286389.R01.S.doc Version 5.1 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Alfreton Residential Home DS0000018857.V286389.R01.S.doc Version 5.1 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4, 5. The home’s pre-admission assessment procedures ensure that residents are appropriately placed and therefore receive care that meets their needs. EVIDENCE: One resident has been admitted to Alfreton since the last inspection. There was a detailed care plan in place and assessment documents had been completed by the Registered Manager before admission. The resident’s family were fully involved in the assessment and admission process. She had rapidly become involved in the activities in the home. Alfreton does not provide intermediate care so standard 6 does not apply. Alfreton Residential Home DS0000018857.V286389.R01.S.doc Version 5.1 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 11. Care planning is good and the manager’s regular informal reviews ensure that staff are aware of residents’ current needs. The system for organising medication is sound, protecting the welfare of the residents. EVIDENCE: Detailed care plans set out how residents’ needs are to be met. Each element is regularly reviewed by the Registered Manager or the senior care assistant, though not much detail is recorded either in the reviews or the daily reports. One resident has had a number of falls recently and she is due to be assessed for new mobility aids soon, which it is hoped will help her to retain her much cherished independence. Residents have access to the full range of community, and if necessary specialist, health services and this is recorded on the files. Alfreton uses a monitored dosage system for medication, with most medication being delivered by the dispensing pharmacist in blister packs. Medication that needs to be refrigerated is kept in a normal fridge in locked containers but following a recent visit the Environmental Health Officer has told the Registered Person that this is not acceptable. That being so the home should provide a ‘separate, secure and dedicated refrigerator for the storage of medicines requiring cold storage’ (The Administration and Control of Medicines Alfreton Residential Home DS0000018857.V286389.R01.S.doc Version 5.1 Page 9 in Care Homes and Children’s Services - Royal Pharmaceutical Society of Great Britain). Residents’ wishes in respect of what will happen in the event of their death are recorded on the file. One resident has died since the last inspection and a number of staff attended her funeral, though no residents chose to do so. Alfreton Residential Home DS0000018857.V286389.R01.S.doc Version 5.1 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. The home arranges a wide range of activities to enhance the lives of its residents. The menu provides choices and meets the dietary needs of the residents. EVIDENCE: The senior care assistant and the Registered Manager have developed a full programme of activities. A timetable is on display for each month and lists at least one activity every day. These include ball games, manicures, music, painting, cooking, gardening, clothing sales and letter writing. The management also arranged a number of excursions in the summer, including a trip on a canal narrowboat. There were photographs on display of this trip and recent parties, including a Halloween party that was attended by about 50 children. The residents enjoyed having the youngsters in their home. The activities programme is well documented so staff are able to identify those which had been especially successful and who takes part in which activity. During the inspection many of the residents gathered in the conservatory to see a snowman being built and one resident was able to join in. An Easter party is being planned. The main meal is served at lunchtime but the evening meal (‘supper’) includes substantial cooked options. Salads and sandwiches are always available as Alfreton Residential Home DS0000018857.V286389.R01.S.doc Version 5.1 Page 11 options and other choices are available at each mealtime. Tea and cakes are served in mid afternoon. Alfreton Residential Home DS0000018857.V286389.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Procedures for complaints and adult abuse allegations are in place, providing protection for residents. EVIDENCE: The home has appropriate policies in respect of complaints and the prevention of abuse. No complaints have been received since the last inspection. Alfreton Residential Home DS0000018857.V286389.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25, 26. The home provides a comfortable and clean environment for its residents though the storage of freezers in the conservatory detracts from the generally homely environment. EVIDENCE: Alfreton was clean and well maintained on the day of this unannounced inspection and there were no offensive odours. Only one bedroom was inspected (chosen at random) and it was well furnished and personalised. Only one bedroom is shared at the moment. When new residents are admitted the Registered Person should bear in mind that rooms should only be shared if the residents ‘have made a positive choice to share with each other’ (National Minimum Standard 23.6) and that when a shared place becomes vacant the remaining resident should have ‘the opportunity to choose not to share’ (Standard 23.7). The home has a main TV lounge, a ‘quiet’ room (known as the ‘music room’) and a conservatory, overlooking the garden. The conservatory is used more in warmer weather but on the (very cold) day of this inspection many of the residents sat there to watch the staff build a Alfreton Residential Home DS0000018857.V286389.R01.S.doc Version 5.1 Page 14 snowman in the garden. There are still two large chest freezers in the conservatory despite a recommendation from the last inspection that they should be moved. It would create a much more homely atmosphere if they were moved. The garden is large and well maintained. Part of the garden has been lost to the converted coach house next door but this has not resulted in any significant loss of amenity as the garden is still very large and the newly built fence is quite an attractive feature. Alfreton Residential Home DS0000018857.V286389.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29. Sufficient staff are employed to meet the needs of the residents but more NVQ training is needed to meet the National Minimum Standard. The home’s recruitment procedures protect the residents against the employment of unsuitable people. EVIDENCE: Three care staff are working towards their NVQ2, four staff already have NVQ2 one new member of staff is due to start one and two others are unlikely to start a course of study. Alfreton therefore falls short of the standard of 50 of care staff with at least NVQ2, though some progress continues to be made. One new member of staff has been taken on since the last inspection and all of the relevant checks had been carried out. A POVAFirst had been received before the member of staff started work and a CRB check had been completed, though it is retained at the owners’ headquarters, not in the home. The application form did not contain a CV or employment history and this should always be obtained so that the applicant’s employment history can if necessary be verified. The home employs a cook for three hours a day, five days a week and at other times the care staff do the cooking. The manager also cooks, sometimes several days a week, which does not seem to be the best use of her skills and time. Sufficient staff are employed to meet the requirements made by the previous registering authority though care assistants carry out domestic tasks such as cleaning as well as care duties. The rota provides for at least two carers to be on duty at all times. Alfreton Residential Home DS0000018857.V286389.R01.S.doc Version 5.1 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 38. The home is efficiently managed and staff morale is good, helping to promote a homely and welcoming atmosphere. EVIDENCE: The Registered Manager is continuing to study for her Registered Managers’ Award. The home has the Investors in People Award, which requires it to maintain a quality assurance system. Fire safety records were up to date. Accidents are reported appropriately to the Commission for Social Care Inspection and recorded in accordance with the Data Protection Act but the numbers need to be entered on to the forms when they are removed from the Accident Book for filing. Alfreton Residential Home DS0000018857.V286389.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X X X X X 3 Alfreton Residential Home DS0000018857.V286389.R01.S.doc Version 5.1 Page 18 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. Standard Regulation Requirement Timescale for action 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 OP9 Good Practice Recommendations In the light of the Environmental Health Officer’s view that medicines should not be stored in the main fridge, the Registered Person should provide a dedicated fridge for the storage of medicines, in accordance with the Royal Pharmaceutical Society of Great Britain’s publication The Administration and Control of Medicines in Care Homes and Children’s Services. The Registered Person should make more suitable arrangements for the location of the chest freezers that are currently in the conservatory. More care staff need to obtain NVQ2 to meet the standard of 50 of care staff with NVQ2. 1. 2. OP20 OP28 Alfreton Residential Home DS0000018857.V286389.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Alfreton Residential Home DS0000018857.V286389.R01.S.doc Version 5.1 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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