Inspection on 03/05/06 for Allendale

This inspection was carried out on 3rd May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 15/02/06

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 3rd May 2006 10:30 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.V292151.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.V292151.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.V292151.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 15th February 2006 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.V292151.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 carried out over a five hour period on 3 May 2006. During the course of the inspection a number of records were examined and time was spent talking with the registered manager, deputy manager, a number of staff on duty and three residents living in the home. A tour of the home was also carried out. As this was a key inspection all the National Minimum Standards were inspected. A number of improvements required from the last inspection had not been carried out and have been stated again in this report. During the inspection a number of issues relating to health and safety needed dealing with quickly and an official letter was given to the registered manager. What the service does well: What has improved since the last inspection? Allendale DS0000043949.V292151.R01.S.doc Version 5.1 Page 6 The home now has a rolling programme for the renewal and maintenance of repairs, maintenance and refurbishment of the home. This was seen during the inspection and it was good to see that such a lot of work had been carried out in the home where it had been identified as being needed in areas such as redecoration, new furniture and general maintenance issues. Pre-admission assessments are now carried out by the manager or a senior member of staff before any new resident moves into the home and a letter is written to the prospective resident following this assessment to inform them if the home can meet their needs or not. This is good practice. What they could do better: The manager needs to make sure that information about what it is like to live at the home is up to date and readily available to give to prospective residents and their families. This will help them to make a positive choice about the home and to ask any questions that they may have. Care plans and risk assessments need further information including and must be reviewed at least every month. This will ensure that the health, safety and care needs of the residents are met in the best way possible at all times. The manager and staff needs to make sure that know the type of things residents like to do regarding social activities. Information needs to be gathered from each resident about the things they would like to do and arrangements can then be made for staff to support these things to take place. The manager needs to make sure that before any new member of staff starts work in the home all pre-employment checks have been thoroughly completed and all paperwork is in place. This is to make sure that only suitable people are employed in the home. The management team need to know what training each staff member has done and needs to do in order that they are able carry out their jobs in the best way possible and in a safe and responsible way. Each member of staff must have a training record kept of their file that is regularly reviewed. This will enable further training to be planned in accordance with the needs of the individual staff member. The manager and staff need to know that they are delivering a good service to residents. A method of finding out the views of residents and their relatives/friends must be developed and this information recorded and used to plan improvements that may be needed. Allendale DS0000043949.V292151.R01.S.doc Version 5.1 Page 7 The manager and management team must make sure that the fire alarm is tested on a weekly basis and that any repairs identified are carried out. This is important so that residents are protected. Accidents need to be recorded in a better way with more information about what happened and any action that is taken. Accidents should be monitored to make sure staff are aware if a resident is having numerous accidents that are similar and may place the resident at risk e.g. a lot of falls. A number of things have been identified in this report that needs to be done for the health and safety of both residents and staff. It is important that any requirements identified are carried out and completed within the timescale(s) given to make sure residents and staff both live and work in a safe and comfortable environment. 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.V292151.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.V292151.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): 1,2,3,4 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all residents are provided with relevant information about the home prior to admission. Improvements are needed to ensure relevant information is made available regarding meeting individual needs. EVIDENCE: The files of the three residents were examined during the inspection. Two of the residents had lived in the home for a short period of time and the third for over twelve months. None of the files contained a Service User Guide or individual contract or terms and conditions with the home and, only the most recently admitted residents’ file contained a completed pre-assessment and a letter from the manager confirming that the home could meet their assessed needs. The manager stated that she was currently reviewing the preadmission/admission process for the home and was very clear that no Allendale DS0000043949.V292151.R01.S.doc Version 5.1 Page 10 prospective resident would be admitted into the home until such an assessment had been completed by herself or the deputy manager. Later discussion with the deputy manager confirmed that the registered manager “usually” carried out a pre-assessment visit to the prospective resident in the hospital or his or her own home. A copy of the current Service User Guide was provided during the inspection. This needs reviewing and updating, as information was incorrect and out of date therefore not providing the prospective residents and their relatives with relevant and current information about the home. This could restrict the prospective residents’ ability to make informed choices about where to live. Once completed a copy must be sent to the Commission for Social Care Inspection (CSCI). Allendale DS0000043949.V292151.R01.S.doc Version 5.1 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): 7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although some improvements had taken place in the care planning process there was still limited information available to care staff. The home’s medication policy is insufficient in detail to ensure that the medication administration system protected residents. EVIDENCE: At the time of the inspection the manager was still in the process of updating all care plans onto the new care plan format. Of the three resident files being examined only two had a care plan. The third file belonged to a resident admitted into the home on 28 April 2006. No care plan had yet been developed for this resident although Care Management information was available. Lack of such information could mean that the residents’ needs are not met and could place the resident at risk. Care plans did not reflect that the individual resident and/or their representative had been involved in developing the care plan and only one review had taken place since the plan had been put in place in January 2006. Allendale DS0000043949.V292151.R01.S.doc Version 5.1 Page 12 This could mean that residents’ needs are not met in the most appropriate way. Risk assessments were in place. However, the information contained within the risk assessments did not clearly identify what the risk was and how this risk should be managed. This could place the resident at further risk. Reading through information contained within the daily records and care plans and, discussion with staff, confirmed that other health care professionals such as district nurses and doctors were fully involved in promoting and maintaining the health of individual residents. It was confirmed by the manager that no resident was suffering with pressure sores although appropriate equipment was available in the home to be used (after assessment) for those residents who may be prone to developing pressure areas to ensure their comfort and wellbeing. Discussion with a number of residents and observation during the inspection confirmed that privacy and dignity is maintained and respected. Staff were heard speaking to residents in a respectful manner and closed toilet doors for residents after assisting them. One resident said, “Staff look after you really well, no fuss, like living here”. Another resident said: “I can have visitors in my own room”. The home has recently changed the supplying pharmacy for the home. This is in response to problems that were being experienced with the previous pharmacy. A monitored dosage system called ‘Venalink’ is now being used. Since the last inspection a new medication trolley has been supplied and the home now uses two trolleys in which to store medication. A random selection of Medication Administration Records (MAR) was examined. These were clear to understand. However, on one record a tablet had been prescribed to be administered on a Monday morning only but a signature was apparent for every day of the week. Such errors could place resident’s health at risk. A requirement from the last inspection was that the medication policy and procedure be reviewed and updated and to also include various information such as the ‘self-administration of medication’. The manager confirmed that this still had not been done. This requirement has been reiterated. Allendale DS0000043949.V292151.R01.S.doc Version 5.1 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): 12,13,14 and 15 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. Improvements are still needed to ensure that residents social and recreational needs are identified and met. Residents’ dietary needs require further monitoring to ensure appropriate dietary intake is maintained. EVIDENCE: Although some new games had been purchased such as ‘skittles’ there was very little evidence of activities taking place in the home that had been planned with residents full involvement. No record was kept of the activities that do take place or the residents who participate in them. A member of staff spoken to said social activities had “much improved”, “we play skittles” and listen to “wartime music and dance”. Residents were seen and heard to enjoy a very lively game of skittles. During the inspection a meal was observed being served to the residents. This consisted a roast dinner of chicken and a full compliment of fresh vegetables. Discreet observation during the meal time indicated that the residents thoroughly enjoyed this meal and residents spoken to later said “Good dinner”, Allendale DS0000043949.V292151.R01.S.doc Version 5.1 Page 14 “Plenty of food – very nicely cooked”, “Staff help you if you need it”, “Very nice, try to do many things to be different”. One gentleman preferred a large cooked breakfast and a ‘snack’ at lunchtime. About 1 hour before the mealtime, staff were heard informing residents what the main meal consisted of and if they would like anything else. This was done in a polite and sensitive way. Although no individual nutritional assessments had been carried out, discussion with the cook and residents confirmed that regular ‘chats’ were held regarding meals and menus and the cook had a good understanding of individuals likes and dislikes. A requirement regarding completing nutritional assessments has been made. No visitors came into the home during the inspection but residents confirmed that their family and friends regularly came to the home and were made “very welcome”. The signatures in the visitor’s book confirmed this. Residents were seen to freely access all parts of the home during the inspection and were supported by staff where needed. For those individuals with poor/limited mobility, individual wheelchairs had been provided to ensure that the person could still be involved in accessing the community, going shopping or for ‘walks’. Allendale DS0000043949.V292151.R01.S.doc Version 5.1 Page 15 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): 16,17 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information was available to ensure that residents know their concerns will be listened to. Further information is needed to ensure residents are protected from abuse such as appropriate details relating to policies and procedures used. EVIDENCE: Discussion with the manager confirmed that no complaints had been received by the service since the last inspection conducted in February 2006. There was a clear complaints policy and procedure in place. The Commission for Social Care Inspection had received one complaint since the last inspection. This complaint is from the relative of one resident and has raised some concerns about how residents are supported and monitored on a day-to-day basis. This complaint was discussed with the registered manager and a response will be sent to the complainant. There is 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. This could place residents at risk from inappropriate action being taken should such an allegation be made. Allendale DS0000043949.V292151.R01.S.doc Version 5.1 Page 16 Managers and staff working in the home would benefit from abuse awareness training. This will ensure that staff have the correct information should they need to deal with any allegation(s) of abuse and therefore ensure the protection of the resident(s). Local elections are due to take place tomorrow (4 May) and it was confirmed that those residents capable of going to vote were offered the opportunity to do so and discussion with those residents’ confirmed this. Allendale DS0000043949.V292151.R01.S.doc Version 5.1 Page 17 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): 19,24,25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall the general environment of the home was clean and tidy and improvements to the premises are taking place. Some further action was required to ensure the health and safety of residents. EVIDENCE: A tour of the building was undertaken during the inspection. It was seen that a requirement at the inspection conducted in February 2006 that the wheelchairs must be stored appropriately had now been met. This reduced the risks to residents and staff from being obstructed when moving around the hallway/corridor of the home. Lounges were comfortable and a number of new lounge chairs had been purchased adding to the comfort for the residents. Allendale DS0000043949.V292151.R01.S.doc Version 5.1 Page 18 A number of bedrooms were viewed in the process of this inspection and it was evident that a programme of re-decoration and re-furnishing was taking place. New bedroom furniture is due to be delivered for six bedrooms on 9 May 2006 and discussion with the manager confirmed that this is being done in priority of need and will continue as part of a rolling programme of maintenance and renewal. A copy of this programme was seen during the inspection. A number of residents gave their permission for their rooms to be viewed and these were found to be appropriately furnished and included some of the residents’ own furniture which reflected their character. Rooms were clean, comfortable and accessible. However, some repairs to existing furnishings are required. Room A The light shade must be cleaned to ensure lighting in the room is not being restricted. The commode was in poor condition and must be replaced to ensure that appropriate cleaning can be carried out to reduce any risk to the health of the resident. Although furniture was basically good in this room, the two bedside cabinets needed the drawers repairing in order that the residents can use them. The bath panel in the en-suite to this room must be replaced and the toilet seat re-secured to ensure the health and safety of the residents’ whose room this is. Room B Requires redecoration as part of the rolling programme of maintenance. Room C Needs a new doorplate fixing where the carpet is beginning to fray to prevent any hazard to the resident whose room it is. The room of a recently admitted resident was seen and discussion with the manager confirmed that arrangements had been made for some of his own furniture to be brought in to further personalise his room. Of concern was that there was some evidence that ‘someone’ had been smoking in the bedroom of one of the residents. Cigarette ends were in the toilet bowl in the en-suite and the resident whose room it is does not smoke. This could place both residents and staff at risk and must be addressed. Allendale DS0000043949.V292151.R01.S.doc Version 5.1 Page 19 Also, in the same en-suite the bath was being used to ‘soak’ soiled commode ‘pots’. This is not only poor practice but can place the residents health at risk and must be addressed. Since the last inspection conducted in February 2006 doors throughout the home had been re-adjusted where required in order to close into their rebates effectively. However, a number of doors need re-adjusting again to ensure that in the event of the fire alarm activating they will close into their rebates effectively. It was also seen that a number of rooms had been provided with new commodes. The temperature of hot water emission is checked on a weekly basis and a record kept ensuring that any hot water accessible and used by residents remains at a consistent and safe temperature (maximum 44° Celsius). Carpets are regularly cleaned and no unpleasant odours were detectable throughout the building during the course of the inspection. Allendale DS0000043949.V292151.R01.S.doc Version 5.1 Page 20 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 and 30 Quality in this outcome is adequate. This judgement has been made using available evidence including a visit to the home. Staff are skilled and trained to carry out their jobs but further training is required. Recruitment policies and procedures are in place but are not always adhered to. This could place residents at risk. EVIDENCE: Staffing rotas were examined during the inspection and these indicated that enough staff was employed throughout the home on a daily basis to meet the needs of the residents currently living there. The manager confirmed this. The registered manager’s hours were not included in the day-to-day care hours for the home and this should allow her time to overview management issues. It is commendable that eleven care staff have attained the National Vocational Qualification at Level 2 and that a further five are currently working towards achieving this award. The registered manager and deputy manager are also working towards achieving the Registered Managers Award Level 4. Although there was some indication on staff files that training was taking place, this was inconsistent and difficult to assess. Individual training and development plans were not available. Training in matters such as moving and handling, basis food hygiene, first aid and other appropriate work relating training must be reviewed and updated for all staff where required. This is to Allendale DS0000043949.V292151.R01.S.doc Version 5.1 Page 21 ensure the health and safety of the residents living in the home and the staff when carrying out their work related duties. At the time of the inspection the registered manager was in the process of reviewing all staff files. No new staff had been employed in the home since the inspection conducted in February 2006. A requirement made at that inspection regarding staff records had been partially met. Allendale DS0000043949.V292151.R01.S.doc Version 5.1 Page 22 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): 31,33,35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 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: Discussion with the manager during the inspection confirmed that she is continuing to work towards achieving the Registered Managers Award at Level 4 and that when on duty, remains rota free in order to deal with the day-today management of the home. There is no method in place for quality auditing how the home and staff deliver the service to those people living there. Staff and residents’ meetings are held Allendale DS0000043949.V292151.R01.S.doc Version 5.1 Page 23 inconsistently and no questionnaires are used to gather information from other interested parties such as relatives, friends and other health care professionals. Lack of such methods of monitoring the service will make it difficult for the management and staff to assess if they are meeting resident needs and fulfilling the Statement of Purpose of the home. The home continues to deal with the personal allowances for the majority of residents living in the home and the balances of a number of people were checked during this inspection. Although these were found to be correct it was of concern, as at the last inspection, that large sums of money were being held for a number of those people. The storage of this money must be reviewed and alternative arrangements made. A full discussion with the manager was had about this and it was suggested that contact be made with individual residents’ care manager to further discuss an appropriate way of dealing with personal monies. 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 16.02.06. Testing of the fire alarm system must be carried out on a weekly basis to ensure the safety of both residents and staff in the home. An Immediate Requirement Notice was issued. The last recorded fire drill was carried out on June 30 2005. This drill did not include all staff that is employed to work in the home. This could place both residents and staff at risk. All staff employed in the home must participate in at least one fire drill in any 12 month period. This was a requirement made at the inspection carried out in February 2006. However, it is acknowledged that the timescale for completing this requirement has not yet expired. 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. Discussion with the manager confirmed that arrangements had been made for an electrical contractor to visit the home week commencing 8 May 2005 to carry out an assessment of the premises and make arrangements to conduct a 5 yearly examination of the electrical wiring. Although accidents were being recorded, information was inconsistent and reports were not being transferred onto individual files. Staff need to record information to include what they did following an accident e.g. the person went to hospital or first aid given. There also needs to be some monitoring system in place to ensure proactive action is taken should a resident appear to have numerous and frequent accidents or accidents that are very similar e.g. falls. This should be done to ensure residents’ health and wellbeing is not compromised. Allendale DS0000043949.V292151.R01.S.doc Version 5.1 Page 24 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 2 2 3 3 X N/A 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 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 2 X X X X 2 3 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 X 1 X 2 X X 2 Allendale DS0000043949.V292151.R01.S.doc Version 5.1 Page 25 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 OP1 Regulation 4&5 Requirement The registered person must review and update the Statement of Purpose and the Service User Guide to reflect the current services and terms and conditions of the home. A copy must be supplied to the Commission. 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. Risks assessments must be linked to the plan of care and clearly identify how each risk will be monitored and managed. Nutritional screening must be undertaken on admission and subsequently on a periodic basis and a record maintained. (a) A policy relating to the administration of medicines when residents are temporarily away from the home must be developed to include DS0000043949.V292151.R01.S.doc Timescale for action 25/08/06 2 OP7 15 25/07/06 3 OP8 14 25/06/06 4 OP9 13 25/06/06 Allendale Version 5.1 Page 26 other instructions to the family member/person administering the medication. (b) The self-medication policy must be further developed to include a comprehensive assessment of the residents’ capabilities prior to self-medication. (Previous timescale 31st August 2004 and 28 April 2006 not met) 5 OP9 13 6 OP12 16 7 OP18 12 & 13 Staff with the responsibility of 30/05/06 administering medication must sign the medication record at the time of administration. Residents living in the home 26/05/06 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 wish to do so (Previous timescale 26/05/06 not expired). The registered person shall make 30/06/06 arrangements, by training or by other measures, to prevent residents being harmed or suffering abuse or being placed at risk of harm or abuse (Previous timescale 30/06/06 not expired). 8 OP18 12 & 13 The policy relating to adult protection must be reviewed and updated to direct staff to use the local authority’s guidance ‘No DS0000043949.V292151.R01.S.doc 26/05/06 Allendale Version 5.1 Page 27 9 OP19 13 Secrets’ (Previous timescale 26/05/06 not expired). The provider must take remedial measures to address the following: (a) The commode in room A 30/06/06 must be replaced. (b) The two bedside cabinets in room A must be repaired. The bath panel in the en-suite of room A must be replaced. (c) . 10 11 12 13 OP19 OP19 OP19 OP19 23 23 13 & 23 13 & 23 The toilet seat in the en-suite of room A is ‘loose’ and must be secured. Room B must be redecorated as part of the rolling programme of maintenance. A new doorplate must be fitted to the carpet edge in room C. An audit of all doors must be carried out and adjustments made where necessary to ensure that they close into their rebates effectively. (a) To ensure the comfort, hygiene and health and safety of resident’s, smoking must not be permitted in places other than those allocated and risk assessed for such purposes. To ensure the health, safety and hygiene of resident’s, commode pots must not be soaked in baths or any other facilities used by Version 5.1 Page 28 12/05/06 12/05/06 12/05/06 30/06/06 14 OP24 13 & 23 12/05/06 (b) Allendale DS0000043949.V292151.R01.S.doc residents to maintain their personal hygiene. 15 OP29 19 The registered person shall not allow any person to work in the home until all relevant preemployment checks have been completed with individual records being kept for each member of staff. The registered person must ensure that there is a staff training and development programme with individual records being kept for each member of staff (Previous timescale 28/04/06 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. Suitable provision must be made for the storage and safekeeping of money (Previous timescales 30/06/05 and 28/04/06 not met). A fire drill must be carried out with all staff employed in the home (Previous timescale 30/06/06 not expired) (a) The provider must provide evidence of Electrical Mains Testing. The provider must provide evidence of Gas Safety checks being completed (Previous timescale 28/04/06 not met). The manager must provide a written statement of the policy, organisation and arrangements for maintaining safe working practices. DS0000043949.V292151.R01.S.doc 30/06/06 16 OP30 18 30/06/06 17 OP33 24 27/10/06 18 OP35 23 30/06/06 19 OP38 13 30/06/06 20 OP38 13 30/05/06 (b) 21 OP38 23 25/08/06 Allendale Version 5.1 Page 29 22 OP38 13 (a) Accidents must be appropriately recorded with details of any action taken identified. Accident records must be appropriately filed away. 30/05/06 23 OP38 23 The fire alarm system must be tested on weekly basis (Previous timescale 15/02/06 not met). 04/05/06 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 OP19 Good Practice Recommendations It is strongly recommended that the light shade in room B is thoroughly cleaned to ensure lighting in the room is not restricted. Allendale DS0000043949.V292151.R01.S.doc Version 5.1 Page 30 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.V292151.R01.S.doc Version 5.1 Page 31 - 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!