Inspection on 11/05/05 for Allendale

This inspection was carried out on 11th May 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

Allendale 12/09/07

Allendale 03/05/06

Allendale 15/02/06

Allendale 07/12/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Allendale 53 Polefield Road Blackley Manchester M9 7EN Lead Inspector John Oliver Unannounced 11 May 2005 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 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. Allendale F55 F05 s43949 Allendale V226342 D110505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Allendale Address 53 Polefield Road Blackley Manchester M9 7EN 0161 795 8051 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Allendale Rest Home Limited Karen Elizabeth Warwick Care home only (PC) 24 Category(ies) of Old age, not falling within any other category registration, with number (OP) (24) of places Allendale F55 F05 s43949 Allendale V226342 D110505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 All service users will fall within the category of old age. 2 3 The maximum number of service users accommodated for personal care only shall be 24. The service should, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Date of last inspection 07 December 2004 Brief Description of the Service: Allendale is a privately owned home that provides accommodation for up to 24 residents requiring personal care only. The home is located in the Blackley area of Manchester close to Booth Hall Childrens Hospital and North Manchester General Hospital. Local facilities and public transport links are within easy walking distance. There is limited parking to the front of the property. The building is a large extended and converted detached house set in its own grounds. Access to the front of the property is at ground level. There is a ramp access at the rear of the property. Accommodation is provided on three floors, served by 2 passenger lifts and the home is accessible to residents who use a wheelchair. Grab rails are provided throughout the home. Bedroom accommodation is on the ground, first and second floors. There are 16 single and 4 double rooms. All rooms provide a wash hand basin. En-suite facilities are provided in 11 of the single rooms and all 4 of the double rooms. There are 2 lounges, one of which provides a small dining area and 1 dining room. Both lounges have patio doors leading out to a well-maintained and enclosed patio area, which enables residents to sit outside in warm weather. Allendale F55 F05 s43949 Allendale V226342 D110505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was conducted by one inspector over a 6-hour period on 11th May 2005. During the course of the inspection a number of records were examined and time was spent talking with four residents and three members of staff to obtain their views of the service delivered and offered in Allendale. A tour of the building was also carried out. On the day of the inspection the registered manager was on duty and was able to answer any questions arising from the inspection process. Not all National Minimum Standards were inspected on this occasion and it is strongly recommended that this report be read in conjunction with previous reports of inspections carried out. No complaints had been received since the last inspection and no enforcement action has been taken. A number of improvements required from the last inspection and have been reiterated in this report. What the service does well: The home felt comfortable and welcoming and the atmosphere was relaxed and friendly. Staff interacted with residents in a pleasant manner. A number of residents spoke of the support offered by the staff in the home. Comments such as “they are kind”, “they don’t rush” and “I choose what I want…” are amongst the statements made. Staff spoken to during the inspection was very positive about the management of the home and the support that they received to carry out their job role. The registered manager had a visible presence in the home and was available for both staff and residents to talk to. Although specific issues relating to training were not inspected on this occasion, from conversation with most staff, it is evident that training is seen as a priority by the management and staff appeared to appreciate this support and was keen to develop their individual knowledge and skills further. Allendale F55 F05 s43949 Allendale V226342 D110505 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Allendale F55 F05 s43949 Allendale V226342 D110505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Allendale F55 F05 s43949 Allendale V226342 D110505 Stage 4.doc Version 1.30 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 standard(s) 1,2,3,4 and 6 Although an assessment of residents care needs took place prior to their admission the records failed to give sufficient information about how the residents needs would be met. EVIDENCE: The files of three residents recently admitted to the home were examined. Two contained Care Management Assessments but none contained a pre admission assessment carried out on behalf of Allendale. The manager who is also the owner of Allendale, had not confirmed in writing to the resident that taking into account of the assessment that the home was suitable for the purpose of meeting their needs. Written information in the files of these residents did indicate that the manager had visited them in their own home/hospital environment prior to admission into Allendale. Observing interaction between residents and staff and discussion with residents and staff indicated that the home was able to meet the needs of the Allendale F55 F05 s43949 Allendale V226342 D110505 Stage 4.doc Version 1.30 Page 9 residents currently accommodated although documented evidence of this was missing from files. Healthcare professionals from other agencies were seen to visit individuals in the home during the inspection. A pre admission assessment document must be developed ensuring that those details described in 3.3 of the National Minimum Standards are clearly included. Allendale F55 F05 s43949 Allendale V226342 D110505 Stage 4.doc Version 1.30 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 standard(s) 7,8 and 9 Limited information with regards to residents identified care needs was available to show how the health care needs were being met. The home’s policy, procedure and systems relating to medication was insufficient in detail to ensure that the medication administration system protected residents. EVIDENCE: At the inspection carried out on 19th July 2004 the manager and staff had worked hard at developing a new care planning format. Although care plans were on each residents file, they were incomplete, inconsistent in their contents, and did not give sufficient details has to how individual needs must be met. Information in the day to day records indicated that two residents were suffering with pressure sores. Although the district nursing service was providing appropriate treatment, the individual care plans did not reflect that the residents had pressure sores, nor did they indicate the treatment being Allendale F55 F05 s43949 Allendale V226342 D110505 Stage 4.doc Version 1.30 Page 11 provided. However, aids and adaptations were seen to be in the home to meet the specific needs of these individuals. Discussion with staff during the inspection indicated that although there was a lack of written information relating to individuals care needs, the staff did appear to have good background knowledge of the individuals needs and support required. This meant that care could only be delivered in accordance with what individual staff may remember of individual needs rather than that what should be included and identified within the plan of care. Medication was checked during the inspection. All Medication Administration Records (MAR) contained a photograph of the resident making identification easier. A number of records had gaps where signatures should have been to show the administration of medication had taken place. Medication no longer prescribed for the individual was still being printed onto the MAR by the pharmacy. A number of MAR indicated medication that was to be taken as “Use as directed by your doctor”. The manager must contact the pharmacy and arrange for such directions to be removed from records and appropriate and clearly defined directions must be printed. A requirement from the inspection carried out on 7th December 2004 that the policy relating to the administration of medicines be reviewed and updated had not been met and has been reiterated. Allendale F55 F05 s43949 Allendale V226342 D110505 Stage 4.doc Version 1.30 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 standard(s) 15 Meals served at the home were varied, nutritious, healthy and well balanced with residents preferences catered for. EVIDENCE: On the day of the inspection the main meal was served at lunchtime. Staff were observed to be assisting residents in a courteous and polite way. A number of residents chose to take their meal in the lounge or their own rooms. Residents were consulted with regard to their personal preference and portions of food were seen to be of an appropriate size. Residents asked for larger or smaller portion. Staff were observed to maintain a discreet presence whilst people were eating and those residents requiring additional support were given this in a sensitive manner. The menu had been developed on a seasonal basis and in accordance with the likes and dislike of the residents. Menus appeared to reflect a varied and nutritious diet. A choice of alternative meals was available. At the time of the inspection no resident had a specific religious or cultural dietary requirement. Food stocks were plentiful and appeared to be well known ‘brand names’. Allendale F55 F05 s43949 Allendale V226342 D110505 Stage 4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 This was not assessed. EVIDENCE: Allendale F55 F05 s43949 Allendale V226342 D110505 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,24,25 and 26 Overall the general environment of the home was clean, tidy and comfortable although the décor of some bedrooms needed improvement and privacy locks fitting to the doors. EVIDENCE: Evidence available indicated that some routine renewal and maintenance of the home had taken place since the last inspection. Numerous bedrooms were viewed during this inspection and a number were in need of redecoration and new furnishings. Those bedrooms seen were clean, comfortable and personalised to reflect the character of the resident. Bedroom doors did not have appropriate locks fitted. This made it difficult for residents to ensure that their bedroom remains private when they are not in their room. Residents spoken to during the inspection did not appear to be very concerned about the lack of locks on bedroom doors. However, bedrooms must be fitted with a lock suited to the individual capabilities of the resident and must remain accessible to staff in emergencies. Allendale F55 F05 s43949 Allendale V226342 D110505 Stage 4.doc Version 1.30 Page 15 Each resident must be provided with a key unless a risk assessment indicates otherwise. The manager said this matter would be addressed. Communal space was seen to be comfortable and no changes had taken place since the last inspection. Toilet and bathroom facilities are in close proximity to resident rooms. There are 16 single and 4 double rooms of which 11 single have en-suite facilities. A number of radiators were not ‘low surface temperature’ types and guards had not been fitted. Risk assessments must be carried out for these. The hot water temperature throughout the home is thermostatically controlled and each bathroom had a thermometer for testing hot water. There was no evidence of tests of temperatures being carried out. The laundry is sited in the basement of the home and, since the last inspection, has been refitted with new ‘computerised’ washing machines. The tiling above the window in the kitchen was uneven and a number of tiles were loose. These required refixing to prevent the possibility of tiles ‘crashing down’ into the sink area. A walk around the external grounds of the property indicated that it was generally well kept. However, pathways and other communal areas were in need of sweeping to clear them of debris that had obviously blown across from other properties. This would ensure that residents would not be put at additional risk of slipping or tripping. Allendale F55 F05 s43949 Allendale V226342 D110505 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, The numbers of staff on duty and rostered throughout the week were sufficient to meet the needs of the residents accommodated. EVIDENCE: At the time of the inspection the home accommodated 22 residents all of whom required personal care only. The numbers of staff on duty at the time of the inspection were above the staffing levels recommended by the previous registering authority and was of sufficient numbers to meet the needs of the residents accommodated in the home. Discussion with a number of the staff team during the inspection indicated that NVQ training had been positively encouraged by the manager of the home and NVQ Level 2 had been attained by a number of care staff. Staff said that developing their knowledge and skills meant that residents would benefit from services being delivered in a more appropriate manner. Allendale F55 F05 s43949 Allendale V226342 D110505 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35 and 38 The home’s policies, procedures and financial systems ensured that resident’s health and financial interest was protected and safeguarded. EVIDENCE: Discussion with the manager and residents confirmed that resident meetings were not routinely held. No development plan was in place and there was no indication that feedback had been sought from residents or their family/friends regarding the service delivered. Balances of money checked on the day of the inspection were quite high. The storage of this money must be reviewed and alternative arrangements made. Holding large sums of money on the premises creates a risk to both residents and staff. A number of wheelchairs were being used without footrests in place. No risk assessments had been carried out. Allendale F55 F05 s43949 Allendale V226342 D110505 Stage 4.doc Version 1.30 Page 18 Discussion with the registered manager indicated that a qualified electrician had checked all electrics and electrical wiring. However, no certificate to clarify this work had been carried out was available. Risk assessments had not been carried out for all safe working practice topics and, no written statement was available of the policy, organisation and arrangements for maintaining safe working practices including: moving and handling; use of techniques for moving people and objects that avoid injury to residents or staff; fire safety: understanding and implementation of appropriate fire procedures. Allendale F55 F05 s43949 Allendale V226342 D110505 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 2 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 3 3 x 3 2 2 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x 3 x 2 x x 2 Allendale F55 F05 s43949 Allendale V226342 D110505 Stage 4.doc Version 1.30 Page 20 yes Are there any outstanding requirements from the last inspection? 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 3 Regulation 14 Requirement The needs of a potential resident must be assessed prior to admission. The details of this assessment must be kept on file. Residents must be informed in writing following the pre admission assessment that the care home is able/not able to meet their needs (Previous timescale 31st January 2005 not met) Care plans must be expanded to provide clear guidance to staff on the actions to be taken to meet the residents health and social care needs. Care plans must be kept under review. Risk assessments must be linked to the plan of care. Plans of care must include details of any pressure sores and of the treatment and equipment provided to support the resident. (a) A policy relating to the administration of medicines when residents are temporarily away from the home must be developed to include other instructions to the family member/person adminstering the medication. F55 F05 s43949 Allendale V226342 D110505 Stage 4.doc Timescale for action 30th June 2005 30th June 2005 2. 4 14 3. 7 15 30th June 2005 4. 8 17 30th June 2005 31st July 2005 5. 9 13 Allendale Version 1.30 Page 21 6. 9 13 7. 9 13 8. 9 12 9. 9 13 10. 19 23 11. 12. 13. 19 19 24 23 23 12 (b) The self-medication policy must be further developed to include a comprehensive assessment of the residents capabilities prior to selfmedication. (Previous timescale 31st August 2004 not met) Staff with the responsibility of administering medication must sign the medication administration record at the time of administration. Details of medication no longer prescribed to an individual resident must not appear on the medication administration record. Medication prescribed to be given to residents and described as Use as directed by your doctor must not appear on medication administation records. Discussion with the pharmacist must take place to ensure that clear directions for administering medication is clearly stated. Individual prescriptions must be seen by the home to ensure a full audit trail of medicaiton is maintained. As part of the rolling programme of repair and maintenance, those bedrooms identified to the manager during the inspection as requiring redecoration and refurnishing must be done in order of priority. The loose wall tiles above the new kitchen window must be refixed. Pathways and other external communal areas must be cleared of any debris. Bedroom doors must be fitted with a suitable locking device that is suited to residents capabilities and rooms must be F55 F05 s43949 Allendale V226342 D110505 Stage 4.doc 30th June 2005 30th June 2005 30th June 2005 30th June 2005 30th November 2005 30th June 2005 30th June 2005 30th September 2005 Page 22 Allendale Version 1.30 14. 25 13 15. 25 13 16. 33 24 17. 18. 35 38 23 13 19. 38 13 20. 38 23 accessible to staff in emergencies. (Previous timescale 25th March 2005 not met) Risk assessments must be completed for those radiators not covered by guards as a matter of priority (Previous timescale 25th March 2005 not met) The home must have evidence of regular hot water temperature testing (Previous timescale 31st January 2005 not met) Effective quality assurance and quality monitoring systems must be put into place to measure success in meeting the aims, objectives and Statement of Purpose of the home (Previous timescale 25th March 2005 not met) Suitable provision must be made for the storage and safekeeping of money. Wheelchairs must not be used without foot rests being in place unless a risk assessment indicates otherwise. The provider must provide evidence of Electrical Mains Testing and Portable Appliance Testing (Previous timescale 31st January 2005 not met) The manager must provide a written statement of the policy, organisation and arrangements for maintaining safe working practices (Previous timescale 25th March 2005 not met) 31st July 2005 30th June 2005 30th September 2005 30th June 2005 30th June 2005 30th June 2005 31st August 2005 21. Allendale F55 F05 s43949 Allendale V226342 D110505 Stage 4.doc Version 1.30 Page 23 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 Good Practice Recommendations No recommnedations have been made as a result of this inspection. Allendale F55 F05 s43949 Allendale V226342 D110505 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection 9th Floor, Oakland House Talbot Road Manchester M16 0PQ 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 Allendale F55 F05 s43949 Allendale V226342 D110505 Stage 4.doc Version 1.30 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. 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