Inspection on 26/09/06 for Alfreton Residential Home

This inspection was carried out on 26th September 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 13/03/06

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 26th September 2006 08:55 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.V306989.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 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.V306989.R01.S.doc Version 5.2 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.V306989.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th March 2006 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. It is part of a family owned business 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 was shared when the inspector made the site visit for this inspection. Residents have a TV lounge, dining room, a ‘music’/quiet lounge and a conservatory that overlooks the back garden. There is no separate visitors room, but the range of communal spaces means that residents can see visitors in private if they want to. The home has a spa bath, an assisted Apollo bath and a shower room. All floors can be reached by a shaft lift. Alfreton Residential Home DS0000018857.V306989.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit for this inspection was unannounced and the inspector spoke to several residents, the Registered Manager and three members of staff. He toured the building, including all bedrooms and examined records concerning activities, care plans, staff recruitment, assessments, fire safety, medication and accidents. The Registered Manager completed a CSCI Annual Quality Assurance Assessment (AQAA) as part of the inspection and the inspector collected it on the morning of the site visit. AQAAs had not yet been introduced nationally at the time of this inspection and the Registered Person had kindly agreed to take part in a trial which was running in four areas. What the service does well: What has improved since the last inspection? What they could do better: The conservatory would be more homely – in keeping with the rest of the home - if the chest freezers were moved to an appropriate location. The home needs to continue with its efforts to achieve 50 of care staff with NVQ2 or above. A staffing review could help to address some staffing issues in relation to one night shift, cooking and the organisation of activities. Alfreton Residential Home DS0000018857.V306989.R01.S.doc Version 5.2 Page 6 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.V306989.R01.S.doc Version 5.2 Page 7 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.V306989.R01.S.doc Version 5.2 Page 8 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): 1, 2, 3, 4, 5. Quality in this outcome area was good. The home’s pre-admission assessment procedures ensure that residents are appropriately placed and therefore receive care that meets their needs. EVIDENCE: There is a comprehensive service user guide but it needs to be reviewed to ensure that all of the information in it is up to date. Residents are assessed by the Registered Manager before being admitted and the assessment for the most recent resident was on file. One resident is the subject of a Guardianship Order and the relevant form was on the file. Alfreton does not provide intermediate care so Standard 6 does not apply. Alfreton Residential Home DS0000018857.V306989.R01.S.doc Version 5.2 Page 9 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, 10, 11. Quality in this outcome area was good. 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 generally 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. The daily reports are made both in a hard backed ‘daily report book’ and on loose leaf sheets which can be transferred to individual files. The ‘daily report book’ is in effect a handover or staff communications book. Some of the entries refer to confidential matters such as toileting of individuals and are therefore inappropriate. This sort of information must be recorded on the individual sheets for each resident. 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 Alfreton Residential Home DS0000018857.V306989.R01.S.doc Version 5.2 Page 10 needs to be refrigerated is kept in a newly purchased, dedicated fridge which is not lockable but is kept in a secure environment. Medication is generally well organised and accurately recorded though on the day of the site visit there was one minor error, where the administration of one tablet for one resident had not been recorded for three days. The senior care assistant described how administration is normally recorded, with the Medication Administration Record (MAR) sheets taken to the resident along with the medication and completed on the spot. The Registered Manager must remind staff of the need to record all medication administration as soon as it is given or witnessed. Residents’ wishes in respect of what will happen in the event of their death are recorded on the file. Alfreton Residential Home DS0000018857.V306989.R01.S.doc Version 5.2 Page 11 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. Quality in this outcome area was good. 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, the Registered Manager and the staff have developed a full programme of activities. The senior carer is designated as the ‘Activities Organiser’ though this runs alongside her normal duties. The appointment of a part time, dedicated Activities Organiser would allow some activities to be carried out without impinging on care staff’s direct caring duties. A timetable is on display for each month and lists at least one activity of some sort every day. These include bingo, chair exercises, board games, music activities, cooking, gardening and clothing sales. The senior carer had carried out some research on activities and had purchased equipment for a floor game and some musical activities. There was a musical activity on the morning of the site visit though the playing of ‘Jingle Bells’ was perhaps premature. The management also arranged some excursions in the summer, including a trip on a canal narrowboat; several residents told the inspector how much they had enjoyed this trip. There were photographs on display of this trip and the summer garden party which had been attended by families as well as staff and their children, raising money for further activities. One of the residents had enjoyed doing much of the replanting of one of the garden Alfreton Residential Home DS0000018857.V306989.R01.S.doc Version 5.2 Page 12 borders. The activities programme is well documented so staff are able to identify those which are especially popular and who takes part in which activity. The main meal is served at lunchtime but the evening meal (‘supper’) includes substantial cooked options. The cook and the Registered Manager put a great deal of emphasis on using fresh ingredients. Most of the residents said that they enjoyed their meals and one said that suggestions for some changes to the menu had been taken up. The cook now only works three hours a day, three days a week, with the other meals prepared by the manager or other staff. This is not a good use of the manager’s time and the Registered Person should seek to employ an additional part time cook. Salads and sandwiches are always available as options and other choices are available at each mealtime. Tea and cakes are served in mid afternoon. Alfreton Residential Home DS0000018857.V306989.R01.S.doc Version 5.2 Page 13 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, 17, 18. Quality in this outcome area is good. 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.V306989.R01.S.doc Version 5.2 Page 14 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. Quality in this outcome area is good. 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 in shared spaces. There were odours in three rooms and the Registered Manager said that the reasons for this were being addressed. All of the bedrooms were inspected and were well furnished and personalised. Only one bedroom is shared at the moment. The Registered Manager said that residents would only use a shared room if they had made a positive choice to share with each other (a different matter to ‘agreeing to share’). The home has a main TV lounge, a ‘quiet’ room (known as the ‘music room’) and a conservatory that overlooks the garden. The conservatory is used more in warmer weather and was used on the day of the site visit for some activities. There are still two large chest freezers in the conservatory which does not contribute to a homely atmosphere, in contrast to the rest of the home. New carpets have been bought to replace some of the hall carpeting and several bedrooms. Some of the carpeting does look rather Alfreton Residential Home DS0000018857.V306989.R01.S.doc Version 5.2 Page 15 ‘tired’ and its replacement needs to be kept under review. The carpet in the main lounge needs to be stretched to avoid it developing into a trip hazard. The garden is large and well maintained. One of the borders has been largely replanted as a strip of land was lost to the development next door and one of the residents had helped to plant some of the shrubs. Alfreton Residential Home DS0000018857.V306989.R01.S.doc Version 5.2 Page 16 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, 30. Quality in this outcome area was good. Sufficient staff are generally employed to meet the needs of the residents but a review is needed to make sure that sufficient staff are always on duty. The home’s recruitment procedures protect the residents against the employment of unsuitable people. EVIDENCE: Four care staff are working towards their NVQ2 and five have NVQ2 or above. Alfreton therefore falls short of the standard of 50 of care staff with at least NVQ2, though this may now be achieved later in the year. 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 (Protection Of Vulnerable Adults) had been received before the member of staff started work and a CRB (Criminal Records Bureau) check had been applied for. As reported in an earlier section, the home employs a cook for three hours a day, now only three days a week and at other times the care staff do the cooking. The manager also cooks, sometimes several days a week, which is not the best or most appropriate use of her skills and time. The rota provides for at least two carers to be on duty at all times. At night there is one waking member of staff and one on sleep in. However, there is currently no member of staff sleeping in on Sunday nights and the home relies on staff and the owners being available nearby by telephone. In view of this, the cooking situation and the dual role of a senior carer as the Activities Organiser it is suggested that the Registered Person should review the staffing structure. Alfreton Residential Home DS0000018857.V306989.R01.S.doc Version 5.2 Page 17 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, 33, 35, 36, 38. Quality in this outcome area was good. 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. Alfreton’s internal QA includes written questionnaires to residents but there was no evidence of this being done since 2003, so the Registered Person should review the QA procedure. 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. Staff are supervised and the Registered Manager keeps a record of this though those records were not inspected on this occasion. Alfreton Residential Home DS0000018857.V306989.R01.S.doc Version 5.2 Page 18 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 3 X 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 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 X 3 X 3 Alfreton Residential Home DS0000018857.V306989.R01.S.doc Version 5.2 Page 19 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. 2. 3. Refer to Standard OP1 OP10 OP20 Good Practice Recommendations The service user guide should be reviewed. Daily reports containing confidential or sensitive information should be made on the individual service user’s file, not in a communications book. 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. 4. OP28 Alfreton Residential Home DS0000018857.V306989.R01.S.doc Version 5.2 Page 20 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.V306989.R01.S.doc Version 5.2 Page 21 - 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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