Inspection on 21/04/09 for Alison House

This inspection was carried out on 21st April 2009.

CQC found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Alison House 01/10/08

Alison House 06/12/07

Alison House 14/05/07

Alison House 22/08/06

Alison House 13/09/05

Alison House 04/04/05

Alison House 20/09/04

Alison House 19/05/04

Similar services:

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Extracts from inspection reports are licensed from CQC, this page was updated on 16/02/2010.

Key inspection report CARE HOME ADULTS 18-65 Alison House 4 Hadleigh Road London N9 7BX Lead Inspector Jane Ray Unannounced Inspection 21st April 2009 10:00 Alison House DS0000010601.V374997.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Alison House DS0000010601.V374997.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Alison House DS0000010601.V374997.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alison House Address 4 Hadleigh Road London N9 7BX 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) 020 8805 3200 020 8211 8098 alison-house@hotmail.co.uk Mr Jessie Busenpeso Espino Mrs Angelina Linga Espino Mrs Angelina Linga Espino Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Alison House DS0000010601.V374997.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One specific service user who is over 65 years of age and has mental health needs may remain accommodated in the home. The home must advise the registering authority at such times as the specific service user vacates the home. 1st October 2008 Date of last inspection Brief Description of the Service: Alison House is a family run business with the care staff coming exclusively from family members. The homes stated aims are to provide high quality 24 hour residential care for you whilst supporting and maintaining your independence and supporting you so make your choices. The home is situated in Edmonton, just off the main Hertford Road. A range of shops and amenities is nearby and there are good public transport links. The lounge-diner, one bedroom and a toilet, are located on the ground floor. There are two other bedrooms on the first floor, and a staff bedroom, which is also the office. There is another toilet and bathroom upstairs. There is a lean-to conservatory and a garden at the rear of the building. The fees for the service range from £350 to £400 per week. A copy of this report can be obtained direct from the provider or via the CQC website (web address can be found at page two of this report) Alison House DS0000010601.V374997.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 the people who use this service experience adequate quality outcomes. The inspection took place on the 21 April 2009 and was unannounced. The inspection lasted for three and a half hours and was the key annual inspection. The inspection looked at how the home was performing in terms of the key National Minimum Standards for Younger Adults and the associated regulations. The inspector was able to observe the support given to one of the three current residents. The resident spoke to the inspector about their experiences of living in the home. The inspector was also able to spend time talking to the manager who was the only person working. The inspector did a tour of the premises and also looked at a range of records including resident records, staff files and health and safety documentation. The home had provided the inspector with a self-assessment questionnaire (AQAA) prior to the inspection. After the inspection the inspector spoke to the social worker who monitors the three residents. Three surveys completed by residents and three completed by staff were also received. What the service does well: The people living in the home benefit from a family run business, which means the same people have cared for them over a number of years. The one resident we spoke to was very happy in the service and clearly felt it was their home. They said, “we are looked after very well, I am very happy here”. The three residents have lived together a number of years and clearly are very fond of each other. The home has good working links with health care professionals including the mental health service that enables the people living in the home to be supported with their healthcare issues. The people living in the home are able to follow lifestyles of their choice, seeing friends and relatives. The home is well located to enable the people living in the service to access local shops and other amenities. Alison House DS0000010601.V374997.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. Alison House DS0000010601.V374997.R01.S.doc Version 5.2 Page 7 The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Alison House DS0000010601.V374997.R01.S.doc Version 5.2 Page 8 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 Alison House DS0000010601.V374997.R01.S.doc Version 5.2 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,2,3 and 4 were inspected. People using this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home can be assured that their individual needs will be recognised and that the staff have the skills and ability to meet these needs. Information about the home is available but would benefit from being more readable. EVIDENCE: “We provide high quality 24-hour residential care for the residents whilst supporting and maintaning their independence and choosing their choices. And the level of care we give them should be concentrated around maintaining the best possible quality of life”. (Extract from the AQAA prepared by the home) “I am very happy here, they take good care of me” (Quote from a resident) Alison House DS0000010601.V374997.R01.S.doc Version 5.2 Page 10 The service has a combined statement of purpose and service user guide and this was inspected. The document has been amended since the last inspection to include all of the information needed. Whilst the guide states that the home recognises the “importance of maintaining the uniqueness of each and every person”, it does not give examples of how the equality and diversity needs of the residents will be met. The AQAA provided by the home recognised that work is needed to develop a policy for the home that addresses these issues. In addition the statement of purpose does not include photos or other means of making the document readable and interesting for the residents. The need to address this is also reflected in the AQAA prepared by the home. We looked at the assessments for the three current residents. These have all been updated since the last inspection and provide a useful summary of each person’s needs. The assessments include details of each person’s race, culture and religion. Since the last inspection there have been no changes in the residents living in the home. The service user guide includes details of how admissions would be handled in the home and says that potential residents would be offered visits as part of this process. The current needs of the people who live in the home were discussed with the manager. The three residents are all being supported appropriately in terms of their mental health. The manager has a good understanding of each person and how to support them when they are feeling anxious or distressed. Since the last inspection the staff have updated their mental health awareness training. Alison House DS0000010601.V374997.R01.S.doc Version 5.2 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7,8 and 9 were inspected. People using this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people living in the home have a care plan that they have discussed with their key worker. The residents would benefit from having care plans that are more person centred and risk assessments that fully reflect their individual needs. EVIDENCE: “Staff here at Alison House are excellent with supporting all residents with their daily activities of living. If residents are self caring, staff are there to provide support and continue to encourage service users to become Alison House DS0000010601.V374997.R01.S.doc Version 5.2 Page 12 independent. The staff at Alison House are professional at all times, they treat all service users with respect and maintain the service users dignity with their daily care”. (Extract from the AQAA prepared by the home) “I have read this before.” (Quote from a resident looking at their care plan) We inspected care plans for the three people currently living in the service. These documents had been updated since the last inspection and reflected some of the issues that arose at the last inspection such as supporting a resident to practice her religion. There was a record of these care plans being reviewed although in some cases the goals had not been achieved and there was no revision of the goal or alternatives. The residents had signed their care plan and the one person who was at home recognised this document. The care plans were not very person centred and did not provide an opportunity for each person to express their likes and dislikes and say what was important to them. The manager has not used the person centred planning training provided by Enfield Social Services. The last review with a social worker had taken place for the three residents in January 2009. The manager said she had not yet received a record of these meetings and could not remember any agreed outcomes, other than the residents remaining in the home. We read the risk assessments for the same three people who live in the service. These were completed using a standard format. Whilst these documents had been updated they still did not reflect the individual areas of risk relevant to each of the residents, such as loosing too much weight, being anxious about going out, overspending personal monies and having an unsettled sleeping pattern. All areas of risk must be included in the risk assessments including details on how these are being addressed by the staff team. From talking to the resident and the manager it was evident that as the home is very small the residents are able to express their wishes. What is not clear is whether they are offered enough choices with the support needed to fulfil these choices. Alison House DS0000010601.V374997.R01.S.doc Version 5.2 Page 13 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): This is what people staying in this care home experience: Standards 11,12,13,14,15,16 and 17 were inspected. People using this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the homes are supported to develop their daily living skills and are also enabled to follow their own routine. The residents go out in the local community but could be supported to access a wider range of resources. The residents are not eating a healthy and nutritious diet at all times. EVIDENCE: “Staff at Alison House are trained to support all residents and encouragement them to act an independent lifestyle and participate with daily tasks and Alison House DS0000010601.V374997.R01.S.doc Version 5.2 Page 14 activities”. (Extract from the AQAA prepared by the home) “The manager prepares all the evening meals.” (Quote from a resident) “When we go out the manager usually drives rather than using the bus.” (Quote from a resident) The manager talked about how they are supporting the residents to develop their independent living skills. Everyone is encouraged to clean their room with support as needed and help with their laundry. The manager acknowledged that she usually cooks the evening meal and was seen making drinks for the resident who was at home, rather than encouraging her to do this for herself. The residents are all able to go out independently and use public transport, however the manager explained that two can be anxious about going out on their own. The resident who was at home was able to show her freedom pass that she can use on the buses and trains. None of the residents attend any structured activity. At the time of the inspection one resident was out with a friend and another was spending the day with a relative. The manager explained that they have encouraged one resident to do a computer-training course at college but she has not attended. There is no evidence of the residents participating in any new activities since the previous inspection. The residents have not been on holiday, but the manager explained that they go out once a month and the preferred activity is shopping and lunch out. When asked when they last went out, the manager explained that they had been out to the coffee shop at the end of the road, but there was no record available of this activity. At the last inspection one resident said she would like to practice her Jewish religion. The manager explained that they have offered to take her to synagogue but she refuses at the last minute. When asked no other opportunities such a volunteer visitor or attendance at a social club had been explored as an alternative. Contact with family and friends are encouraged by the home. One resident has a long-standing boyfriend who is made welcome in the home, staying for meals and overnight visits if requested by the resident. It was observed and from talking to resident and manager that everyone has their own routine and that this is flexible and reflects their preferences. One resident said “sometimes I don’t sleep very well so I have a lie in, in the morning”. Alison House DS0000010601.V374997.R01.S.doc Version 5.2 Page 15 When we arrived at the home, there was no evidence of fresh food being available. In the fridge there was bread, margarine, milk, sliced ham and a cucumber that was rotten. The manager was phoned to say we were here and when she arrived brought some fresh fruit into the home. The resident was asked what she ate for lunch and said she had fried egg. The manager was separately asked what the resident would be eating for dinner and she replied fried egg. When it was pointed out that this would be two meals of fried egg in a day, she said that she thought the resident would go out for lunch but she had refused. She also said it was the “residents choice” to eat fried eggs. The record of food eaten was inspected and looked healthier than last time with less obvious convenience food, but this did not reflect what was available in the home itself. The inspection did not finish until eight in the evening and the resident was not offered supper during this time, although she did eat a packet of crisps. Alison House DS0000010601.V374997.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19 and 20 were inspected. People using this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people living in the home are supported in a manner that protects their privacy and dignity. Each person is supported to access professional healthcare input based on their individual needs. EVIDENCE: “The medication policy now contains guidance about self-medication and there is a system for recording the administration of medicines”. (Extract from the AQAA prepared by the home) The manager explained that the residents are able to attend to their own personal care, with a little prompting if needed. Since the last inspection there Alison House DS0000010601.V374997.R01.S.doc Version 5.2 Page 17 has been a discussion with one resident about accessing a beautician service but she has declined. It was observed that the resident who was at home was wearing rather stained looking clothing and her hair needed attention. The manager explained that she tends to spill her food and drinks and refuses to go to the haidresser so the staff help with her haircuts. This needs to be addressed through her care plan to ensure she is able to be well presented. We looked at the healthcare records for the people living in the home. Everyone was registered with the GP and had regular health checks. Everyone had been encouraged to visit the dentist and optician. All the residents had input from the local mental health care professionals. The staff understand the importance of monitoring each persons mental health and contacting the care professionals if there are any issues to address. One resident who has issues with her weight is now being supported to monitor this and has received medical input to address the issue. We looked at the medication procedure and staff training records. Two of the residents only have a prescribed depot injection and the home keeps a record of when they have attended an appointment for this. The third resident selfadministers her medication and this is approved in writing by her GP. One resident uses a homely remedy to help her sleep at night. This has been approved in writing by her GP. The staff training records show all the staff have received medication training from Boots. Alison House DS0000010601.V374997.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 were inspected. People using this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people living in the home have access to an appropriate complaints procedure and feel able to raise any concerns. Procedures on safeguarding vulnerable adults are in place and for supporting residents to manage their personal monies. EVIDENCE: “Service users at Alison House Care Home are overall happy with service we provide. Service users are aware of the complaints procedure if a situation was to occur. All service users have expressed that Alison House care staff are very supportive with residents views and listens to them attentively”. (Extract from the AQAA prepared by the home) “I go with the manager once a month to the building society to get my money and then I look after it myself.” (Quote from a resident) Alison House DS0000010601.V374997.R01.S.doc Version 5.2 Page 19 We looked at the complaints procedure and this was easy to follow. The AQAA stated that there had been no complaints since the previous inspection. The surveys completed by the residents said they would know who to speak to if they were not happy. There have been no safeguarding vulnerable adult issues since the last inspection. We looked at the staff training records and these show that all the staff apart from one received safeguarding vulnerable adult training since the last inspection. We talked to the manager about how they support the residents when they become distressed. She was able to describe how they know each person well and are able, to speak to them and help them relax. We spoke to the manager about how the residents manage their personal finances. She said that they now all go to collect their own money with staff support. One person who was previously keeping her money in the office now looks after her own money. These arrangements are recorded in their care plans. One resident has very little personal money. The manager explained that this is because she has refused in the past to claim disability living allowance. This needs to be addressed with her social worker as the lack of monies restricts her choice of what she can buy for herself. Alison House DS0000010601.V374997.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24,28 and 30 were inspected. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People living in the home benefit from a comfortable and homely environment, although this would benefit from a programme of modernisation. EVIDENCE: “The home is located in a quiet residential street which has a local park at the end of the road. We are also close to Edmonton Shopping Mall and market, cafes, lesiure centre, library and numerous restaurants and fastfood takeaways. Alison House provides a welcoming and a homely environement. Alison House DS0000010601.V374997.R01.S.doc Version 5.2 Page 21 Residents are encouraged to bring their own belongings and personal photos, encouraging a comfortable and a homely environment. Residents are provided with personal keys to lock their rooms”. (Extract from the AQAA prepared by the home) The service consists of a terraced house. The home is clean, safe and comfortable. There are local shops available very close to the home and access to public transport. The home has three large single bedrooms. We looked at two bedrooms and they were adequately furnished with a double bed. Bathrooms and shower rooms are easily accessible from all the bedrooms. One resident said how much she enjoyed having a television in her room. The home has adequate communal space consisting of an open plan kitchen, dining area and lounge on the first floor. The home also has an enclosed garden. A designated smoking area is provided in the conservatory. The house was clean and tidy. The house is very dark and much of the furniture and fittings are old and the home would benefit from a programme of refurbishment. Alison House DS0000010601.V374997.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,33,34,35 and 36 were inspected. People using this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The residents are supported by a small team of staff who have all worked in the service for a number of years. Training and supervision has been provided to enable them to work to a high standard. EVIDENCE: “Alison House provides all staff with a programme of training. Alison House provides a clear job description for all staff working at the home. It clearly identifies staff main duties and responsibilities. All staff have a CRB cleared certificate. Alison House supports all staff to pursue their skills and knowledge into access courses towards college and university”. (Extract from AQAA prepared by the home) Alison House DS0000010601.V374997.R01.S.doc Version 5.2 Page 23 “The staff treat me OK and are very helpful”. (Extract from a survey completed by a resident) “My manager provides me with feedback on a regular basis enabling me to further my duties helping me to improve on the service I am providing”. (Extract from a survey completed by staff) We checked the rota for the home and this showed that there is a team of five regular staff working at the home. Mr and Mrs Espino who are the registered providers carry out most of the care. Three other members of their family assist on a part-time basis. Two other relatives come to the home occasionally when Mrs Espino needs to pop out. There is one person on duty during the day and at night one-person sleeps in the home. There have been no staff changes for a number of years. The staff training records were inspected for the manager and the four care staff. One of the staff had completed an NVQ in care level 2 and one is a qualified nurse. Another one of the care staff needs to complete the NVQ and the manager said that none were registered to start the training at present. We looked at the recruitment records for staff members. It was found that all the staff had all the necessary recruitment checks including references and ID, a POVA check and a CRB disclosure. The manager said that no further training was booked at the time of the inspection. She was aware of training provided by Haringey Social Services and was also told about the need to link with Skills for Care. We looked at the supervision records. All the care staff had received regular two-monthly individual supervision. The format used for supervision is appropriate. Alison House DS0000010601.V374997.R01.S.doc Version 5.2 Page 24 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,39 and 42 were inspected. People using this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. All residents benefit from a permanent manager but they need to ensure they access the appropriate management and care training to keep their practice up to date. The residents are protected by appropriate health and safety measures being available in the home. EVIDENCE: “All appliances are routinely checked and recorded. Fire, gas and electrics are Alison House DS0000010601.V374997.R01.S.doc Version 5.2 Page 25 tested by qualified technician. All service users rights and best interests are safe guarded by the record keeping policy”. (Extract from the AQAA prepared by the home) The service has a registered manager. The manager is a qualified nurse who has many years experience of caring for people with mental health needs. The manager has not completed an NVQ level 4 in management and care, although she does have a City and Guilds qualification. The manager said that she had spoken to an NVQ assessor to see if her existing qualification is equivalent to an NVQ. A letter stating that the managers qualification was equivalent to an NVQ was shown to us. This letter was not on headed notepaper and the manager was not able to say, which organisation the assessor worked for. The manager said she had not contacted Skills for Care. This demonstrated that the manager had not appropriately sought to identify her training needs and make arrangements for her own training and development. The company has questionnaires to seek the views of residents, relatives and other care professionals as part of a quality improvement exercise. The manager had obtained the views of the residents and one relative. She said that no care professionals had responded. The responses were all positive. In terms of fire safety the AQAA said the fire alarm and fire extinguishers had been serviced. The fire alarm records show the alarm is checked weekly and fire drills have taken place every three months. The training records show that the staff have received fire safety training since the last inspection. The AQAA showed that all the health and safety maintenance checks had taken place. The staff training records show that since the last inspection the staff had completed food hygiene, first aid and infection control training. Alison House DS0000010601.V374997.R01.S.doc Version 5.2 Page 26 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 2 2 3 3 3 4 3 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 2 25 x 26 x 27 x 28 3 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 x LIFESTYLES Standard No Score 11 2 12 2 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 x 2 x 3 x x 3 x Version 5.2 Page 27 Alison House DS0000010601.V374997.R01.S.doc Are there any outstanding requirements from the last inspection? YES 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 YA6 Regulation 15(1) Requirement Timescale for action 21/04/09 2. YA9 13(4) 3. YA12 16(2)(m) The registered person must ensure that staff receive training on person centred planning so they can support each resident to have a person centred care plan. This requirement is amended and restated from the previous inspection. Timescale of 31/1/09 was unmet. 21/04/09 The registered person must ensure each resident has a comprehensive risk assessment that covers all areas of current and potential risk and clearly states how these risks will be reduced. This is to ensure the residents are kept as safe and well as possible. This requirement is amended and restated from the previous inspection. Timescale of 31/12/08 was unmet. The registered person must 21/04/09 ensure that they support the residents to take part in a wider range of community based learning, skill development, sport and leisure in the local community. This requirement is amended and restated from the DS0000010601.V374997.R01.S.doc Version 5.2 Alison House Page 28 previous inspection. Timescale of 31/12/08 was unmet. 4. YA17 16(2)(i) The registered person must ensure that healthy and nutritious food choices are offered at all times and that healthy food is always available in the home. This is to ensure the residents eat a healthy diet. This requirement is amended and restated from the previous inspection. Timescale of 31/12/08 was unmet. The registered person must ensure that the welfare of the residents is maintained by ensuring they are supported to wear clean clothes and have their hair well cut at all times. The registered person must ensure that the home is kept in a good state of repair by arranging a programme of refurbishment for the home. The registered person must ensure that 50 of the staff team have completed or are undertaking NVQ training by one other member of staff starting their NVQ training. This is to ensure staff receive the training needed to perform their role to a high standard. This requirement is amended and restated from the previous inspection. Timescale of 31/12/08 was unmet. The registered person must ensure the staff are registered on future training courses to ensure staff have access to training to ensure they perform their work to a high standard. The registered person must ensure the manager starts an NVQ level 4 in care and management having established DS0000010601.V374997.R01.S.doc 21/04/09 5. YA18 12(1) 21/04/09 6. YA24 23(2) 21/04/09 7. YA32 18(1)(c) 21/04/09 8. YA35 18(1)(c) 21/04/09 9. YA37 10(3) 21/04/09 Alison House Version 5.2 Page 29 if her current qualification contributes towards this qualification. This is to ensure she has the appropriate skills to carry out the management role. This requirement is amended and restated from the previous inspection. Timescale of 31/12/08 was unmet. 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 YA1 Good Practice Recommendations The statement of purpose and service user guide should be made available in an accessible format. It should also reflect how the home meets the needs of each resident in terms of their equality and diversity. The registered person should support each resident to develop further, their independent living skills. The registered person should support residents who want to find a way of practicing their religion or culture by looking at opportunities for volunteer visitors and social clubs. The registered person should ensure the residents are supported to access the DSS benefits to which they are entitled, if necessary seeking support from the care professionals. 2. 3. YA11 YA12 4. YA23 Alison House DS0000010601.V374997.R01.S.doc Version 5.2 Page 30 Care Quality Commission London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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