Inspection on 20/09/05 for Aliwal Manor

This inspection was carried out on 20th September 2005.

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

Aliwal Manor 01/04/08

Aliwal Manor 03/04/07

Aliwal Manor 02/08/06

Aliwal Manor 20/12/05

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 Shirley Christopher Unannounced Inspection 20th September 2005 11:10 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.V250647.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.V250647.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.V250647.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23 September 2004 Brief Description of the Service: Aliwal Manor is a care home providing residential accommodation for up to thirty service users, including nine registered 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 for nine service users. The units have separate lounges, dining rooms and kitchens, 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 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.V250647.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on the 21 September 2005 at 11:10 am. The home was fully staffed at the time and both the acting manager and the Regional Operations Manager were telephoned by the team leader and arrived at the home shortly afterwards. During the course of the inspection, a number of records were inspected including, 3 care plans, four staff files, the complaints procedure, staff training and supervision records, a newly revised induction record, the service user guide, statement of purpose and the quality assurance document. Four care staff were spoken to and ten service users. A tour of the inside of the home was conducted. What the service does well: What has improved since the last inspection? The home has appointed a new manager who is currently on his probationary period and has yet to submit an application to the Commission for Social Care inspection in respect of his position. Both care staff and service users felt that Aliwal Manor DS0000015291.V250647.R01.S.doc Version 5.0 Page 6 he was approachable and a welcome asset to the home. A recent relatives meeting had been held to introduce the new manager. It was not possible to identify what improvements had been made given the short period of time he has been in post, but he had a number of ideas and service priorities to implement. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Aliwal Manor DS0000015291.V250647.R01.S.doc Version 5.0 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 Aliwal Manor DS0000015291.V250647.R01.S.doc Version 5.0 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): 1,3,4,5 The home provides sufficient information to enable service users to decide if the home is able to meet their needs prior to admission. These needs are kept under review to ensure the ongoing suitability of the home. EVIDENCE: The home produced an up to date service user guide and statement of purpose, which meets the requirements of the Care Homes Regulations 2001. Both documents are displayed in the main reception area. The manager confirmed that the service user guide can be reproduced in different formats and languages where required. The manager confirmed that service users and or their representatives are encouraged to look round the home before admission and there is a review approximately six weeks after admission. A number of service users spoken to stated that they specifically chosen the home and were satisfied with all aspects of life at the home. The manager stated on admission a key worker is allocated to the service user and they are in the process of introducing a checklist for new admissions to ensure a smooth transitional period. Aliwal Manor DS0000015291.V250647.R01.S.doc Version 5.0 Page 9 Evidence of pre admission assessments was seen on several service user files, and a pre admission care diary is sent out to family members to be completed. This provides information about the service user’s social history and family tree. A letter is sent out from the home confirming that it is able to meet service users needs following assessment and a contract is issued, although none were requested on this occasion. The home demonstrated how they are able to meet the needs of the service users through appropriate interactions observed on the day of inspection and evidenced through speaking to service users and staff. Aliwal Manor DS0000015291.V250647.R01.S.doc Version 5.0 Page 10 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): 7,8,10,11 Care plans adequately address how the needs of service users are to be met. EVIDENCE: Service user files provided evidence that a pre admission assessment is completed and that a care plan is implemented shortly afterwards addressing both physical care and social care needs. Spiritual needs are addressed and the home has contact with churches of various denominations and services are provided. Evidence was seen of both a monthly review of the care plan and an annual review. Care staff spoken to confirmed that they are involved in the review of the care plans. Service user files also provided evidence of appropriately kept records addressing how the health care needs of service users are met. A range of primary care services and Doctors surgeries regularly supports the home. The manager confirmed that some training is scheduled re the prevention of falls and this is an area where the district nurses have also provided training. Service users spoken to stated that the level of care they received was good. They were able to exercise choice in terms of all aspects of daily living and routines in the home were flexible. No evidence was provided of service user involvement in the implementation and Aliwal Manor DS0000015291.V250647.R01.S.doc Version 5.0 Page 11 review of their care plans. There is a sheet on file asking for their consent to keep and review information, but these had not been signed on the files seen. Medication records were not inspected on this occasion. Several files inspected provided evidence that service users and their families are consulted about their last wishes in the event of their death and, or change in health status. Aliwal Manor DS0000015291.V250647.R01.S.doc Version 5.0 Page 12 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): 12,15 Social life in the home is inclusive and includes the involvement of the local community EVIDENCE: The home employs an activities officer who works for four hours a day and divides her time between the four units. She keeps written notes with regards to service users hobbies, interests and participation in activities. Three service user files were inspected and there was a record of social activities they had participated in, a family history and a brief social profile, some were more comprehensive than others. The feedback from service users about the provision of activities was mixed. Most service users acknowledged that there were activities provided, but they chose not to participate. They valued the opportunity to interact with other service users in their units and felt mealtimes were especially important. One service user was particularly keen on sports and felt he had no one to share this with. He commented that poor reception meant they were unable to get channel 5 on the television. The home has a day centre, which provides a service to the local community. It is also open to residents of the home. At the time of inspection, they were playing cards and dominoes. There was also a visit from the trolley dollies who supply the service users with fresh fruit, confectionary and sundries. They Aliwal Manor DS0000015291.V250647.R01.S.doc Version 5.0 Page 13 contribute to the resident’s funds. The home has a designated hairdressing room. The regional manager confirmed that an important aspect of the home was to involve the whole community, examples given was regular relatives meetings. Residents meetings also determine what activities they would like to do. Church services are held and the Methodist church holds tea afternoons. The local schoolchildren visit at Christmas and the Lions visit, (a club run/ attended by local business men.) There is a regular volunteer to the home who gives the gentleman a wet shave. The Regional manager confirmed that the home hope to reintroduce a newsletter, which will advertise forthcoming events and ‘in house’ news. Care staff were observed offering positive choices to service users and assisting them in a way that promoted their independence. Just after 11:00 am service users were still getting up at their leisure and one lady confirmed that she did not go to bed until about 11:30 pm and was supported by staff accordingly. Meals are prepared in the main kitchen and served up in hot heating trolleys. Several main choices are offered, but other alternatives can be provided. The service users spoken to stated that the quality of food was good. A meal was being provided during the course of the inspection and choices of vegetables, gravy and seconds were offered. Aliwal Manor DS0000015291.V250647.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): 16,18 The home has adequate policies and procedures in place for dealing with complaints and for the protection of vulnerable adults. EVIDENCE: The home has an adequate complaints policy and procedure. A number of complaints have been received and were recorded appropriately. The complaints procedure is clearly displayed in the main reception area and is included as part of the service user guide. The complaints procedure should be amended slightly to reflect the complainants right to refer the complaint to the CSCI at any stage if they wish. The manager confirmed that staff had received training on the protection of vulnerable adults, through Cambridgeshire Social Services and that this is also covered by in house trainers and as part of new staffs’ induction. The home had adequate policies and procedures at the last inspection and these were not revisited. Aliwal Manor DS0000015291.V250647.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): 19,20,21,24,26 The home is fit for purpose and maintained in a good condition. EVIDENCE: Most areas of the home were inspected and were maintained to a good standard of cleanliness and maintenance, with no obvious hazards identified. The home is divided up in to smaller units, which creates an inclusive atmosphere. The interaction between service users was very good, some of who had known each other before moving into the home. A number of service user bedrooms were seen and although none had en-suite, all had a sink in their room and were individualised. Lockable space is provided and service users are asked if they want keys to their bedroom doors, but in reality few do. The home has sufficient bathrooms, a shower and toilets, which are fit for purpose. Aliwal Manor DS0000015291.V250647.R01.S.doc Version 5.0 Page 16 Aliwal Manor DS0000015291.V250647.R01.S.doc Version 5.0 Page 17 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 Staff are employed in sufficient numbers and the home has rigorous preemployment checks in place. EVIDENCE: Staffing rotas were inspected and showed staff employed in sufficient numbers with a member of staff on each unit, two on the dementia care unit and the manager who is supernumerary to the rota. An administrator and other catering and domestic staff support him. The home had several vacancies but do not use agency staff. Cover is provided through staff overtime. Three care staff were spoken to as part of this inspection and had been in post for a number of years and felt that they were appropriately supported and equipped to do the job. They confirmed that they had completed relevant training although not all was up to date, but was being renewed. Actual percentages of staff with an NVQ qualification was not confirmed but the Regional manager stated that it was over 50 . Four staff files were inspected and provided evidence of thorough recruitment processes and all the necessary prerequisites were in place. For staff employed after July 2004, Criminal records checks are kept on file. A file for a recently employed member of staff was checked and did not have a staff photograph or evidence of identification, although a CRB was in place. In addition to this there was no evidence of her induction or training covered as part of her probationary period. The regional manager confirmed that they offer a range of inductions and this has recently been revamped, but is often kept by the member of staff, until key Aliwal Manor DS0000015291.V250647.R01.S.doc Version 5.0 Page 18 competencies have been assessed. Evidence of mandatory training was not provided for the staff files inspected. The manager confirmed that he is in the process of updating all the mandatory training and ensuring certificates are kept as evidence of training. Aliwal Manor DS0000015291.V250647.R01.S.doc Version 5.0 Page 19 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): 31,32,33,36,37 Record keeping was generally of a good standard and there are systems in place for the protection of staff, visitors and service users. EVIDENCE: The manager is newly in post and has not yet submitted his application to the CSCI for approval of his registration. Care staff and service users spoken to confirmed that they had met the manager and he had held various meetings, including a relatives meeting to introduce himself. He has also worked a number of care shifts to familiarise himself with care practices in the home. The home has a well-established quality assurance system which takes into account service user views through regularly distributed questionnaires twice a year. Results are published and made available and kept in the main reception. It was suggested that the results indicating areas of satisfaction and areas Aliwal Manor DS0000015291.V250647.R01.S.doc Version 5.0 Page 20 where improvements could be made are more widely accessible to service users and could perhaps be included as part of the newsletter. Staff supervision is provided and staff appraisals are being revamped, as the home are preparing for the Investors in People Award. Unit meetings are held and these are counted as group supervision. The frequency of supervision has lapsed recently but is being addressed by the manager and a supervision schedule has been completed. Recent evidence was provided of staff, resident and relatives meetings. Aliwal Manor DS0000015291.V250647.R01.S.doc Version 5.0 Page 21 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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 4 3 X x 3 x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x x 3 3 x Aliwal Manor DS0000015291.V250647.R01.S.doc Version 5.0 Page 22 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. 1 2 Standard OP29 OP30 Regulation 19-(1) (b) (i) 18,(1) (a) (c) (i) Requirement All staff files must contain the relevant documentation as required by this regulation. Staff files must provide evidence that new staff have received induction training within the first six weeks of employment and have completed all the mandatory training, which must be kept up to date. Timescale for action 30/10/05 30/10/05 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 OP12 Good Practice Recommendations Opportunities should be provided to enable service users to pursue individual interests and hobbies. It was stated by one service user how much they enjoyed sports, but were unable to because his interest was not shared by others. The complaints procedure should be revised to state that complainants may take their complaint to the CSCI at any DS0000015291.V250647.R01.S.doc Version 5.0 Page 23 2 OP16 Aliwal Manor 3 OP33 stage of the complaint and not only once, it has been fully investigated by Excel Care. The manager plans to reintroduce a newsletter. The newsletter could give some feedback to service users about how the home are performing. Aliwal Manor DS0000015291.V250647.R01.S.doc Version 5.0 Page 24 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.V250647.R01.S.doc Version 5.0 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!