Inspection on 15/02/06 for Allendale

This inspection was carried out on 15th February 2006.

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 11/05/05

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 Key Unannounced Inspection 15th February 2006 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 Allendale DS0000043949.V285959.R01.S.doc Version 5.1 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. Allendale DS0000043949.V285959.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Allendale Address 53 Polefield Road Blackley Manchester M9 7EN 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) 0161 795 8051 Allendale Rest Home Limited Karen Elizabeth Warwick Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Allendale DS0000043949.V285959.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. All service users will fall within the category of old age. 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 National Care Standards Commission 11th May 2005 Date of last inspection 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 DS0000043949.V285959.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was conducted over a four hour period on 15 February 2006. During the course of the inspection a number of records were examined and time was spent talking with the deputy manager and three residents living in the home. A tour of part of the home was also carried out. 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 had not been carried out and have been reiterated in this report. What the service does well: What has improved since the last inspection? The manager and senior team of the home have made a good effort since the last inspection to reorganise the office so that it is easier to work in and that as a result information can be more easily found. The manager has made good progress in developing a new care plan format that is easier to use. At the time of this inspection she was in the process of transferring information to the new care plan formats for all residents living in the home. A regular check of the premises is now carried out and things such as hot water temperatures are checked and recorded on a weekly basis to make sure Allendale DS0000043949.V285959.R01.S.doc Version 5.1 Page 6 that residents and staff are not placed at any risk. Other things such as repairs and maintenance of the house are listed and carried out in order of priority. The manager has made arrangements with a new pharmacy to provide a medication service that meets the need of the home and the required standards relating to administering medication. It will also mean that staff who give out medication will receive the right training. What they could do better: A number of new staff are being employed who had not been thoroughly checked before they started working in the home. Appropriate references and Criminal Record Bureau checks had not been received before the person started work. This could place both the residents and other staff working in the home at risk from someone who is unsuitable to be employed in a caring role. An official letter was left at the home at the end of the inspection about this matter. Not all requirements that had been made at the last inspection had been carried out within the timescales given. Care plans need more details about how staff should assist and support the resident in meeting their identified needs. The information available to staff about giving out medication needs looking at and more information must be provided to make sure medication is given out properly. There are few activities that take place in the home. This must be looked at to make sure people living in the home are able to enjoy doing the things they like to do. Some areas of the home could be better planned, such as where the wheelchairs are stored when not in use. A lot of wheelchairs are placed in the hallway or corridor leading to the lounge area of the home. This not only looks unsightly but can also be a hazard to any resident or member of staff passing. Fire alarm tests had not been carried out on a weekly basis. This could place both residents and staff at risk should the fire alarm not being working. An official letter was left at the home at the end of this inspection about this matter. Allendale DS0000043949.V285959.R01.S.doc Version 5.1 Page 7 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 DS0000043949.V285959.R01.S.doc Version 5.1 Page 8 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 Allendale DS0000043949.V285959.R01.S.doc Version 5.1 Page 9 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 and 4 Although an assessment of residents care needs took place prior to their admission the records failed to give sufficient information about how the resident’s needs would be met. EVIDENCE: The file of one of the most recently admitted residents to the home was examined. A Care Management assessment was in place as was 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. This was a requirement at the last inspection conducted in May 2005 and has been reiterated in this report. Allendale DS0000043949.V285959.R01.S.doc Version 5.1 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, 9 and 10 Although some improvements had taken place to the care planning process there was still limited information available to care staff. The homes medication policy is insufficient in detail to ensure that the medication administration system protected residents. EVIDENCE: A number of care plans were examined during this inspection. It was evident that the manager had spent time in developing a new care planning format that is intended to offer a much more holistic picture of a residents’ needs. However, those seen had not always been completed in a consistent way and did not clarify exactly how staff should meet an individuals needs in the most appropriate way. This could lead to care needs identified in the assessment process prior to admission into the home being excluded from the care planning process. This could place residents at risk. At the time of the inspection the medication administration processes for the home was under review. After experiencing numerous difficulties with their current provider, the home had arranged for a new pharmacy to deal with medication for the home. Discussion with the deputy manager confirmed that Allendale DS0000043949.V285959.R01.S.doc Version 5.1 Page 11 the new pharmacist would be arranging appropriate training for all staff with the responsibility for administering medication in the home. Those records examined appeared to have been appropriately recorded and signed. However, as at the last inspection, a number of records indicated that medication that was to be taken as “Use as directed by your doctor” was still appearing on Medication Administration Records (MAR). The manager must ensure that the pharmacy arranges for such directions to be removed from MAR’s and appropriate and clearly defined directions must be printed. Lack of such appropriate information could place residents at risk from medication being administered incorrectly. A requirement from the last inspection was that the policy on medication be reviewed and updated and to also include various information such as the ‘self-administration of medication’. These requirements have been reiterated in this report. During the inspection it was seen that staff appeared to treat residents with respect and courtesy. Allendale DS0000043949.V285959.R01.S.doc Version 5.1 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, 13 and 14 Improvements are needed to ensure that residents social and recreational needs are met. EVIDENCE: Although it was seen that the new care plan format included details of those activities an individual was interested in, it was difficult to ascertain if those activities were taking place. Three residents spoken with said that some activities take place such as “exercise class” (relaxation therapies) and bingo but “not much else”. Discussion with the deputy manager confirmed that no restrictions were placed on visitors coming to the home and a number of residents confirmed that their relatives regularly visit. Observation during the inspection indicated that residents appeared to be offered choice in matters such as food, where they wanted to sit and, if they wanted to go to the privacy of their rooms. Allendale DS0000043949.V285959.R01.S.doc Version 5.1 Page 13 A number of bedrooms seen during the inspection also indicated that the residents had been given the opportunity to bring in some personal possessions with them in order to personalise their private space and reflect their character. Allendale DS0000043949.V285959.R01.S.doc Version 5.1 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 and 18 Information was available to ensure that residents know their concerns will be listened to. Further information was needed to ensure residents are protected from abuse. EVIDENCE: Discussion with the deputy manager confirmed that no complaints had been received by the service since the last inspection conducted in May 2005. There was a clear complaints policy and procedure in place. There was a policy available relating to adult protection and ‘Whistle Blowing’. However, there was no indication within that policy that the home was using the local authority’s guidance ‘No Secrets’ as part of their strategy for managing any allegations of abuse. Managers and staff working in the home would benefit from abuse awareness training. This will ensure that staff has the correct information should they need to deal with any allegation(s) of abuse and therefore ensure the protection of the resident(s). Allendale DS0000043949.V285959.R01.S.doc Version 5.1 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): 19,24 and 25 Overall the general environment of the home was clean and tidy although the décor to some bedrooms needed improvements. Some action was required to ensure the health and safety of residents. EVIDENCE: During the inspection Mr Warwick, a partner in the business visited the home. His role within the home includes maintenance of the premises. He was able to produce a copy of the work schedule and the plan for carrying out repairs and the updating of some furniture in the home. Only a small number of bedrooms were viewed during this inspection and it was noted that most were clean, comfortable and personalised to reflect the character of the resident. However, double room 9 (old building) is in need of re-decoration and some new furniture. A number of doors throughout the building did not appear to be closing into their rebates effectively and required checking and re adjusting. This is to ensure the safety of residents and staff as the doors are fire doors. Allendale DS0000043949.V285959.R01.S.doc Version 5.1 Page 16 A high number of residents living in the home require the use of a wheelchair to aid their mobility throughout the day. A high number of wheelchairs were being stored along a wall leading into the lounge area. Discussion with the manager confirmed that this was for ease of access for the staff. However, the storage of wheelchairs in this way presents a hazard to both residents and staff and alternative arrangements must be made e.g. store in residents’ own room. A number of radiators still required radiator guards fitting. Although the manager on duty said that risk assessments had been completed for these radiators they could not be found on the day of the inspection. Allendale DS0000043949.V285959.R01.S.doc Version 5.1 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): 28, 29 and 30 Staff are skilled and trained to carry out their jobs. However, the home does not adhere to the recruitment policies and procedures that are in place. This could place residents at risk. EVIDENCE: The deputy manager confirmed that eleven (11) care staff had successfully completed the National Vocational Qualification (NVQ) at level 2 and a further five (5) were in the process of completing it. Although a number of staff files contained certificates obtained after training had been completed, no files contained a training and development plan which made it difficult to assess what training each member of staff had completed. The files of the last three members of staff to be employed by the home since the last inspection were examined. Of concern was the lack of references and Criminal Record Bureau checks. This not only indicates the home are not processing staff applications in line with their own agreed procedures but are also placing residents and other staff at risk from people who may be inappropriate to be employed in the home. An Immediate Requirements Notice was issued. Allendale DS0000043949.V285959.R01.S.doc Version 5.1 Page 18 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, 35 and 38 The registered manager has the necessary skills and experience to manage the home and ensures that she is accessible to residents, their families and staff. Financial procedures for the home need reviewing and a number of issues relating to health and safety places both residents and staff at risk. EVIDENCE: The deputy manager confirmed that both she and the registered manager of the home, Karen Warwick is working towards obtaining the Registered Managers Award. Discussion with staff and residents indicated that the management team operated an ‘open door’ policy and were readily accessible to discuss any general issues and any issues of concern about the home. Allendale DS0000043949.V285959.R01.S.doc Version 5.1 Page 19 The home deals with the personal allowance for the majority of residents living in the home and the records and balances of a number of people were checked during this inspection. Although these were found to be correct it was of concern, as at previous inspections, that large sums of money were being held for a number of people living in the home. 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 record of fire alarm tests and fire drills were checked. It was seen that the last recorded fire alarm test was done on 20.01.06. Fire alarm tests must be carried out weekly to ensure the safety of both residents and staff in the home. An Immediate Requirements Notice was issued. The last fire drill recorded was on June 30 2005. Although this was less than 12 months ago the drill did not include all staff working in the home. This could place both residents and staff at risk. No evidence could be found of the fixed Electrical certificate (5 yearly) and the landlord’s Gas safety certificate. This could place both residents and staff at risk. Up to date risk assessments were not available for working practices carried out in the home and no evidence was available to indicate that a fire risk assessment for the premises had been completed. This could place both residents and staff at risk. Allendale DS0000043949.V285959.R01.S.doc Version 5.1 Page 20 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 3 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X 3 2 X STAFFING Standard No Score 27 X 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X 2 X X 2 Allendale DS0000043949.V285959.R01.S.doc Version 5.1 Page 21 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 OP4 Regulation 14 Requirement Timescale for action 11/04/06 2. OP7 15 3. OP8 17 4. OP9 13 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 30 June 2005 not met) Care plans must be expanded to 28/04/06 provide clear guidance to staff on the actions to be taken to meet the resident’s health and social care needs. Care plans must be kept under review. Risk assessments must be linked to the plan of care (Previous timescale 30 June 2004 not met) Plans of care must include details 28/04/06 of any pressure sores and of the treatment and equipment provided to support the resident (Previous timescale 30 June 2004 not met) (a) A policy relating to the 28/04/06 administration of medicines when residents are temporarily away from the home must be developed to include other instructions to the DS0000043949.V285959.R01.S.doc Version 5.1 Allendale Page 22 family member/person administering the medication (Previous timescale 31 July 2005 not met) (b) The self-medication policy must be further developed to include a comprehensive assessment of the residents capabilities prior to self-medication. (Previous timescale 31July 2005 not met) Medication prescribed to be given to residents and described, as Use as directed by your doctor must not appear on medication administration records. Discussion with the pharmacist must take place to ensure that clear directions for administering medication is clearly stated (Previous timescale 30 June 2005 not met) Residents living in the home must be consulted about their social interests, and arrangements must be made to enable them to engage in local, social and community activities should they so wish. The policy relating to adult protection must be reviewed and updated to direct staff to use the local authority’s guidance ‘No Secrets’. The registered person shall make arrangements, by training or by other measures, to prevent residents being harmed or suffering abuse or being placed at risk of harm or abuse. Room 9 (old building) must be redecorated and furniture replaced where needed as a matter of priority. DS0000043949.V285959.R01.S.doc 5. OP9 12 28/04/06 6. OP12 16 26/05/06 7. OP18 12 26/05/06 8. OP18 13 30/06/06 9. OP19 23 30/06/06 Allendale Version 5.1 Page 23 10. OP19 23 11. 12. OP19 OP25 13 13 13. OP29 19 14. OP30 18 15. OP35 23 16. OP38 13 17. 18. OP38 OP38 13 23 19. OP38 13 An audit of all doors must be carried out and adjustments made where necessary to ensure that they close into their rebates effectively. An appropriate place must be used to store wheelchairs when not in use. Risk assessments must be completed for those radiators not covered by guards as a matter of priority (Previous timescale 31 July 2005 not met) The registered person shall not allow any person to work in the home until all relevant preemployment checks have been completed and returned as satisfactory. The registered person must ensure that there is a staff training and development programme with individual records being kept for each member of staff. Suitable provision must be made for the storage and safekeeping of money (Previous timescale 30 June 2005 not met) The provider must provide evidence of Electrical Mains Testing (Previous timescale 30 June 2005 not met) The provider must provide evidence of Gas safety checks being completed. The manager must provide a written statement of the policy, organisation and arrangements for maintaining safe working practices (including risk assessments) (Previous timescale 31 August 2005 not met) A fire drill must be carried out with all staff employed in the home. DS0000043949.V285959.R01.S.doc 28/04/06 24/03/06 24/03/06 15/02/06 28/04/06 28/04/06 28/04/06 28/04/06 30/06/06 30/06/05 Allendale Version 5.1 Page 24 20. OP38 13 The fire alarm system must be tested on a weekly basis. 15/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Allendale DS0000043949.V285959.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection CSCI, Local office 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 DS0000043949.V285959.R01.S.doc Version 5.1 Page 26 - 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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