Inspection on 20/12/05 for Aliwal Manor

This inspection was carried out on 20th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Aliwal Manor 01/04/08

Aliwal Manor 03/04/07

Aliwal Manor 02/08/06

Aliwal Manor 20/09/05

Aliwal Manor 23/09/04

Aliwal Manor 20/04/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Aliwal Manor Turners Lane Whittlesey Cambridgeshire PE7 1EH Lead Inspector Don Traylen Announced Inspection 20th December 2005 10:00 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 Aliwal Manor DS0000015291.V261186.R01.S.doc Version 5.0 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. Aliwal Manor DS0000015291.V261186.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Aliwal Manor Address Turners Lane Whittlesey Cambridgeshire PE7 1EH 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) 01733 203347 01733 203566 Excelcare Holdings Care Home 30 Category(ies) of Dementia - over 65 years of age (9), Old age, registration, with number not falling within any other category (30) of places Aliwal Manor DS0000015291.V261186.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th September 2005 and Additional Inspection on 26 October 2005 Brief Description of the Service: Aliwal Manor is a care home providing residential accommodation for up to 30 (thirty) service users, including nine places for people with a formal diagnosis of dementia. The home is situated in the town of Whittlesey, Cambridgeshire with good access to local facilities. The home is divided up into four separate units: Wordsworth, Shelley, Byron, and Tennyson and includes a specific unit designated for service users with dementia. Each unit is staffed by one member of staff, other than the dementia care unit, which has a staff ratio of two staff for nine service users. Each unit has a separate lounge, a dining room and kitchen where snacks and drinks are prepared. The main meals are prepared in a central kitchen and there is also a main laundry room. There are an adequate number of toilets and the home has five large bathrooms, which have assisted bathing equipment. There is also a separate shower room. The home employs an activities coordinator who works at the home for four hours a day. There is also a separate day centre, which is accessed by people in the local community and can be used by service users living in the home. Aliwal Manor DS0000015291.V261186.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection follows an inspection made on 20 September 2005 and an additional inspection visit of 26 October 2005 that was made in response to a complaint made to the CSCI. The CSCI have published a report of the inspection of the 20 September 2005. The following is a summary of the additional inspection visit of the 26 October 2005: • • • • The Medicine Administration Record (MAR) sheets were inspected and revealed an error in the recording of amounts of medication held by the home. There was a missing initial/signature from medication that should have been prescribed on the 23/10/2005. There were no photographs to identify 5 service users. There were no recordings of reason or comments to account for medication when one service user was absent from the home on “social leave”. There were no recordings made to qualify an entry marked “F”. The arrangements and records maintained by night care staff to check service users were inspected and the admission procedure for new service users was inspected. These two practices were considered to be satisfactory. The inspector discussed the above concerns about administering medication with the acting manager, the Regional Operation Manager and Team Leader. It was agreed that the home would address each requirement made in relation to administering medication and do this within two or three days of this inspection date. The following are the requirements arising from the inspection. Action must be taken to meet requirements as they are made under the Care Standards Act 2000. Recommendations are seen as good practice and should be given serious consideration. Aliwal Manor DS0000015291.V261186.R01.S.doc Version 5.0 Page 6 REQUIREMENTS 1. The home must ensure there is a current photograph of any service user who is being administered any prescribed or non-prescribed medication and the service user’s photograph must be displayed with the Medicine Administration Record sheets maintained in the home so that staff can identify the named service user. 2. Medicine Administration Record (MAR) sheets must contain an entry for all times when medication has been prescribed and identified to be taken. Any reasons for non-administration of medicine and when a service user is not present in the home, must be recorded on the reverse section of the sheet that allows for a comment to be recorded for the reasons for the nonadministration. Records showing “social leave”, or “other”, must cross reference to written reasons for these entries. 3. Medicine Administration Record (MAR) sheets must be clearly and accurately maintained for all medication prescribed for any service user. Particular attention must be paid to the recording of any changes in a service user’s medication. 4. The Medicine Administration Record (MAR) sheets must be maintained with accurate records of the amounts of medication brought forward, or started and entered at the commencement of the four-weekly MAR sheets maintained by the home. --------------------------------------------------------- The above are the requirements made in the Additional Inspection report of the 26 October 2005. Aliwal Manor DS0000015291.V261186.R01.S.doc Version 5.0 Page 7 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 Aliwal Manor DS0000015291.V261186.R01.S.doc Version 5.0 Page 8 contacting your local CSCI office. Aliwal Manor DS0000015291.V261186.R01.S.doc Version 5.0 Page 9 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 Aliwal Manor DS0000015291.V261186.R01.S.doc Version 5.0 Page 10 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): 3,6, Service users are only admitted to the home after a comprehensive assessment but the home could improve their admission process to enhance the assessments details. EVIDENCE: Service users are assessed by PCT Care Management assessments. The view of the acting manager was that some of these assessments provided for respite arrangements are not current and do not accurately describe a person circumstances. Assessments details are kept on service users files. The manager or team-leader will usually conduct a home visit to establish the needs of prospective service users. Respite arrangements are different and sometimes do not allow the home to make a prior home visit to the service user. The manager and inspector discussed how the home should establish a formal and recorded ‘admissions interview’ with new respite service users and their relatives or representatives, to establish a common meeting ground to discuss needs, expectations of care and as a polite way of welcoming new service users. Intermediate care is not provided by the home. Aliwal Manor DS0000015291.V261186.R01.S.doc Version 5.0 Page 11 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): 7,9, Service users are not adequately protected by the practices carried out by the home when administering medication. Care Plans are not always accurate reflections of care that has, or is being provided. EVIDENCE: One Care Plan for a respite arrangement did not have a title or indication that it was a Care Plan; did not include an identifying photograph; did not contain accurate records in the daily diary of the person leaving, no dates of professional (GP) who had visited and there were no dates for the significant events that had been recorded. One service user who is cared for in her bed has suitable specialist health provided bed and pressure relieving mattress. She has regular input from health professionals and GP who are monitoring her health and advising staff about appropriate care. Two Medication Administration Record (MAR) sheets that had been damaged by a spillage had been replaced by written sheets. They should have been replaced by an urgent request for new sheets as a mistake could have been made by the home when transcribing hand written information. The acting Aliwal Manor DS0000015291.V261186.R01.S.doc Version 5.0 Page 12 manager stated he had requested copies of the MAR sheets from the pharmacist. One MAR sheet had not been adequately completed with a reason and had not been completed in a timely manner when one service user had not received their medication on the morning of the inspection. Staff failed to act appropriately when this prescribed medication for one service user was known to not have been administered. This same failure of procedure to follow-up and seek qualified medical advice was found to have occurred in the previous additional inspection on 26 October 2005. An earlier complaint made to the home about medication not having been administered had been upheld. The facts of these finding and the implications were discussed with the manager, the team leader and the operations manager. The home has a medications policy and procedures that address this situation. Failure to prevent a recurrence of this failure to implement appropriate medication procedures may result in legal action being taken. Amounts of seven different prescribed medication for 3 service users, including 2 controlled drugs, were checked and found to be accurately accounted for and accurately recorded. Controlled drugs were stored separately in a locked box, in a safe within a locked cupboard. Non-controlled drugs/medication are kept separately in each unit in locked trolleys that are kept in lockable cupboards. Aliwal Manor DS0000015291.V261186.R01.S.doc Version 5.0 Page 13 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): 13,14,15, Service users maintain contacts with family and relatives. EVIDENCE: A group of service users informed the inspector they are able to make choices about meals and their daily routines. A number of service users stated they have relatives who visit them regularly. An appetising and well-presented meal of meat and fresh vegetables was observed being served. Service users stated they really enjoyed their food and that it was usually to their expectations. The cook was observed to ask service users if they enjoyed their meal and listened to their comments. This consultation was clearly appreciated and enjoyed for the social interaction in addition to the discussion about food. Aliwal Manor DS0000015291.V261186.R01.S.doc Version 5.0 Page 14 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, Complaints made to the home are listened to and responded to by the home. EVIDENCE: One complaint made known to the CSCI was being dealt with by the home at the time of inspection and was unresolved at the time of inspection. Aliwal Manor DS0000015291.V261186.R01.S.doc Version 5.0 Page 15 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): 19,21,22,23,24,25,26, Service users enjoy a clean, well-maintained and comfortable home. EVIDENCE: The home’s internal environment is spacious and well provided with adequate toilets and bathrooms and was very clean on the day of inspection. There were no noticeable odours. All hazardous fluids and materials had been kept in locked areas. One service user who is cared for in her bed has suitable specialist health provided bed and pressure relieving mattress. Bathrooms are spacious and have suitable equipment for easy access into baths. The external paintwork to the wooden fascia boarding is worn and flaking off and is in need of maintenance. Aliwal Manor DS0000015291.V261186.R01.S.doc Version 5.0 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): 30, Service users will benefit if arrangements are made for further staff training. EVIDENCE: A training matrix has been made although it reveals a lack of refresher training in First Aid and a shortage of training in many areas particularly dementia related care. Training records have been restarted and training had been planned and provide in the latter months since the inspection of 20 September 2005. Progress has been made in establishing which staff have received what training. A comprehensive induction programme has been drawn up. The acting manager has made progress in producing records of training and in identifying development and training needs. However, further improvement is required in training achievements and in maintaining these records of training. Evidence of achievements in the induction programme are also required. Training in medication administration must ensure that staff can transfer this training to their work. Aliwal Manor DS0000015291.V261186.R01.S.doc Version 5.0 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): 37,38 The home has a comprehensive set of policies and procedures that promote the welfare and protection of service users. EVIDENCE: The acting manager has been in post since August 2005 and stated he intends to apply to become the registered manager when his probationary period is completed. Training records already referred to in this report should be improved to identify who has provided training and what quality or level of training is being provided. Generally the training matrix should be informed by some analysis of the quality and appropriateness of the training and not just the title. More emphasis on providing details of the training should be produced during an inspection. Aliwal Manor DS0000015291.V261186.R01.S.doc Version 5.0 Page 18 No feedback from service users was received by the CSCI from the service users comment cards sent to the home. Only 3 relatives comment cards were returned. A respite stay questionnaire to assess the level of satisfaction has been devised by the acting manager. However, there were no responses available to read. There was not sufficient evidence of effective quality assurance arrangements for service users or relatives to make their views or comments known to the CSCI. Aliwal Manor DS0000015291.V261186.R01.S.doc Version 5.0 Page 19 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 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 x 3 X 3 3 3 3 3 3 STAFFING Standard No Score 27 X 28 X 29 X 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X 2 3 Aliwal Manor DS0000015291.V261186.R01.S.doc Version 5.0 Page 20 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 OP9 Regulation 13(2) Requirement Medicine Administration Record (MAR) sheets must contain an entry for all times when medication has been prescribed and identified to be taken. Any reasons for nonadministration of medicine and when a service user is not present in the home, must be recorded on the reverse section of the sheet that allows for a comment to be recorded for the reasons for the nonadministration. Records showing “social leave”, or “other”, must cross reference to written reasons for these entries. This requirement was made at the last inspection on 26 October 2005 and the section dealing with nonadministration has not been adequately implemented. Failure to comply may result in legal action being taken. A programme for the planned maintenance of the exterior paintwork must be produced and kept in the home. Dementia care training must be DS0000015291.V261186.R01.S.doc Timescale for action 01/01/06 2 OP19 23(2)(b) 01/03/06 3 OP30 18 01/04/06 Page 21 Aliwal Manor Version 5.0 3 cont. 4 OP30 5 6 OP30 OP30 (1)(c[i]) 18 (1)(c[i]) 13(6) 18 (1)(c[i]) arranged for all staff. Care Planning training must be arranged for all staff. Induction training core skills must include training in preventing abuse. Induction learning topics must show evidence of achievement. 01/02/06 01/02/06 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP3 Good Practice Recommendations The home should establish a formal and recorded ‘admissions interview’ with new respite service users and their relatives or representatives, to establish a common meeting ground to discuss needs, expectations of care and care planning and as a polite way of welcoming new service users. Care Plans should be titled, contain a recent photograph of the service user, be maintained so that significant events affecting the person are recorded and reflected if any changes to the care arrangements are made and include accurate details of any health service professional visits. The home should ensure that service users are made aware of forthcoming inspections and when requested by the CSCI service users’ should be consulted and their comments should be sought. Training records should identify who has provided training what quality or level of training is being provided. Generally the training matrix should be informed by some analysis of the quality and appropriateness of the training and not just the title. More emphasis on providing details of the training should be available for future inspections. 2 OP7 3 OP33 4 OP37 Aliwal Manor DS0000015291.V261186.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE 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 Aliwal Manor DS0000015291.V261186.R01.S.doc Version 5.0 Page 23 - 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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