Inspection on 09/06/05 for Allendale

This inspection was carried out on 9th June 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Allendale 29/03/07

Allendale 18/11/05

Allendale 02/02/05

Allendale 12/05/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOME ADULTS 18-65 Allendale Road 1 Allendale Road Mutley Plymouth PL4 6JA Lead Inspector Antonia Reynolds Announced 9 June 2005 th 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 Road D52-D04 S3421 Allendale Road V221433 090605 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Allendale Road Address 1 Allendale Road, Mutley, Plymouth, Devon, PL4 6JA 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) 01752 670247 01752 670247 enquiries@thepriory.org.uk Katherine H L Finnigan,The Very Rev Archpriest Benedict Ramsden, Mr Simeon Ramsden, Mrs Lilah Ramsden Kate Daglish Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Allendale Road D52-D04 S3421 Allendale Road V221433 090605 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 1. Three service users in the category of Mental Disorder (MD). 2. Age 18 - 65. 3. Kate Daglish must complete the Registered Managers Award by 30th June 2006. Date of last inspection 2nd February 2005 Brief Description of the Service: 1, Allendale Road is a care home providing personal care (if required) and accommodation for three people, aged 18 - 65, with various mental disorders. It is owned by The Community of St Antony and St Elias which is a private sector organisation owning several other care homes in Devon. The home was opened in 1993 and is a two storey, end of terrace property, located in a cul de sac in the residential area of Mutley in Plymouth. All the homes bedrooms are single and are on the 1st floor. None of these have wash hand basins or en suite facilities. There is a lounge room and kitchen/diner on the ground floor. The home has small back and front yards and all areas are accessible to the service users. Allendale Road D52-D04 S3421 Allendale Road V221433 090605 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place between 9.35am and 3.10pm. The Registered Manager, Kate Daglish, was present throughout. A tour of the premises took place and records relating to care, the staff and the home were inspected. The three service users, as well as staff on duty, were spoken with and observed during the day. What the service does well: What has improved since the last inspection? What they could do better: The Commission for Social Care Inspection has only received copies of two monthly provider visit reports in the last year, and these must be carried out each month. The home does not have a sheltered area in the yard where service users can smoke and this would be useful to protect service users from different weather conditions. Service users would benefit from a team of core staff to provide continuity and consistency of care. Staff would benefit from more comprehensive medication training. All records containing confidential information about service users should be kept individually. Allendale Road D52-D04 S3421 Allendale Road V221433 090605 Stage 4.doc Version 1.20 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Allendale Road D52-D04 S3421 Allendale Road V221433 090605 Stage 4.doc Version 1.20 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Allendale Road D52-D04 S3421 Allendale Road V221433 090605 Stage 4.doc Version 1.20 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3, 4 and 5 Residents are provided with adequate information about the services and facilities they can expect to receive. Prospective residents are given opportunities to visit the home to decide whether they would like to live there and to meet the other residents and staff. EVIDENCE: Residents were clear about the services and facilities available in the home and the Registered Manager confirmed that each resident had been given a copy of the Service User Guide. Although no new residents have been admitted to the home recently, the Registered Manager confirmed that assessments are carried out prior to admission, as much information as possible is obtained from the prospective resident, relatives and representatives, as well as other professionals involved in the person’s care, and this is documented. Introductory visits are arranged for prospective and existing residents to meet each other and become familiar with the home prior to admission. Individual records are kept for each of the residents and these contained assessments, care plans and risk assessments, all of which had been recently reviewed. Ongoing evaluation is recorded daily. Contracts with purchasing authorities are kept in the organisation’s head office, but statements of terms and conditions of residency have been produced, although these do not specify the room to be occupied. Allendale Road D52-D04 S3421 Allendale Road V221433 090605 Stage 4.doc Version 1.20 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, 9 and 10 The residents are enabled to participate in, and make decisions about, all aspects of their lives. EVIDENCE: Each resident has a care plan and risk assessments that are regularly reviewed. The staff were fully aware of the needs of each resident. Any restrictions on choice or freedom were documented and had been agreed with the resident and other people involved in the person’s care. Residents were able to describe and explain why these agreements were in place. The attitude and approach of the staff team promotes independence, enabling residents to make decisions about lifestyles and daily routines, demonstrating excellent practice. Records relating to service users’ money were up to date and accurate. There was a different system in place for each service user, showing that individual assessments of abilities and needs have been carried out. Staff at the home complete Residents Reports which are sent to the organisation’s Head Office. These reports contained confidential information pertaining to all the service users on the same page, therefore it would not be possible for residents to access these records, as they would see information Allendale Road D52-D04 S3421 Allendale Road V221433 090605 Stage 4.doc Version 1.20 Page 10 relating to others. Consideration should be given to altering this system to ensure that all information about individual residents is kept separately. Allendale Road D52-D04 S3421 Allendale Road V221433 090605 Stage 4.doc Version 1.20 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15, 16 and 17 Residents can learn life skills, attend work placements, participate in any community and leisure activities, choose their own daily routines and enjoy a healthy diet of their choice. EVIDENCE: The residents, and information contained in their care plans, confirmed that they were enabled to live as full a life as they wished to and had opportunities for personal development. Residents were encouraged to participate in all the domestic activities in the home and to take part in leisure activities of their choice. The home did not provide transport as a general rule for service users as they are encouraged to use public transport wherever possible. However, the Community has a few different types of transport available when required for service users to participate in a variety of different outdoor activities. On occasion, staff may use their own cars and the Registered Manager confirmed that appropriate insurance cover is in place. It was evident, through observation during the inspection, that service users felt very ‘at home’ and were empowered to make decisions. Service users confirmed that they could make their own meals, drinks and snacks and chose the menu. Allendale Road D52-D04 S3421 Allendale Road V221433 090605 Stage 4.doc Version 1.20 Page 12 Contact with relatives and friends was encouraged and there were no limitations in place regarding visitors to the home. Allendale Road D52-D04 S3421 Allendale Road V221433 090605 Stage 4.doc Version 1.20 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 and 20 Residents receive support in the way, and at the time, that they want and need. Health care needs are addressed as soon as they are identified. EVIDENCE: Residents’ care plans provided information about personal, emotional and health care needs. Residents and the Registered Manager confirmed that external professional advice and guidance was sought when necessary from local health care professionals or social services. Through observation it was clear that timings were flexible and the choice of the resident. A monitored dosage system was being used, regular medication reviews take place and risk assessments had been carried out regarding whether or not service users were able to keep their own medication, the result being that no-one selfadministered medication. Medication was locked away safely and records pertaining to its administration were up to date and accurate. Records showed that there have been a few incidents regarding medication errors and the Registered Manager confirmed that staff receive additional ‘in house’ training should an incident occur. However, the organisation should consider accessing a more detailed and comprehensive medication training course for staff. Allendale Road D52-D04 S3421 Allendale Road V221433 090605 Stage 4.doc Version 1.20 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 Residents are protected from abuse, neglect and self-harm. Residents can be confident that the Registered Provider always deals with complaints seriously and any concerns from residents are listened to and acted upon immediately. EVIDENCE: Neither the home nor the Commission for Social Care Inspection have received any complaints regarding the service since the last inspection. The home has a complaints procedure and the residents explained how they would make a complaint and who they would talk to. Regular house meetings were held where any issues could be raised and dealt with immediately, although it was also clear from discussion that residents could raise any issue at any time. The management and staff team were aware of adult protection issues, procedures were available, and training has been undertaken, or is planned, for all staff members. Each resident receives the personal allowance element of income support and the mobility component of Disability Living Allowance (where received) from the organisation’s head office, to spend as they wished. Allendale Road D52-D04 S3421 Allendale Road V221433 090605 Stage 4.doc Version 1.20 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29 and 30 The home is comfortable, safe and clean. Bathroom and toilet facilities are adequate for the present residents. Residents are ‘at home’ in the environment and clearly feel they belong. EVIDENCE: Each resident has a single bedroom on the 1st floor, none of which have en suite facilities or wash hand basins. Residents confirmed they did not need wash hand basins in their bedroom. Bedrooms were individually furnished and contained many personal possessions. Bedroom doors were fitted with appropriate locks and all of the residents had a key to their own bedroom door, therefore had a choice as to whether to lock it or not. The home had a bathroom on the 1st floor consisting of a bath with over bath shower, toilet and wash hand basin. The door was fitted with an appropriate lock to afford privacy but which could be accessed by staff in an emergency. There were shared rooms on the ground floor consisting of a kitchen/diner and a lounge room, which contained personal possessions belonging to the residents. Allendale Road D52-D04 S3421 Allendale Road V221433 090605 Stage 4.doc Version 1.20 Page 16 Infection control practices were satisfactory, items of personal protective equipment, such as disposable gloves, were available and the home had a local contract for the disposal of clinical waste. The home has a ‘no smoking’ policy within the building but residents may smoke in the back yard. However, there is no protection from either inclement weather or the sun and some form of shelter would benefit the residents. Allendale Road D52-D04 S3421 Allendale Road V221433 090605 Stage 4.doc Version 1.20 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35 and 36 Recruitment procedures are robust and residents’ needs are met by good staffing levels. Continuity and consistency of care are affected by the organisation’s policy of moving staff, causing stress and anxiety for some residents. EVIDENCE: Staff files inspected showed that the organisation has a robust recruitment procedure and all the required information was available. The documentation confirmed that Criminal Record Bureau checks had been carried out but were kept in the organisation’s head office. All staff were provided with contracts of employment and job descriptions. Regular staff meetings and individual supervision sessions took place and were documented. Staff and records confirmed that regular house meetings took place, which residents also attended. Staff received regular individual supervision sessions and annual appraisals. The organisation has a training co-ordinator who maintains an overview of what the organisation requires, as well as ensuring that individual staff members receive the training they need. Staff confirmed that they participated in various courses, both provided ‘in house’ or by external training providers, including National Vocational Qualifications. Allendale Road D52-D04 S3421 Allendale Road V221433 090605 Stage 4.doc Version 1.20 Page 18 Residents and staffing rotas confirmed that there were always a minimum of two staff on duty at all times, who slept in at night. Sleeping accommodation for staff was in the office and the spare room on the ground floor. The Registered Manager confirmed that she is usually (although not always) on duty in addition to the two staff members, from 9am to 5pm Mondays to Fridays, although these timings are flexible depending on the needs of the service users. The organisation operates an ‘on call’ system whereby members of the management team are available out of office hours. The organisation has a policy of moving staff members between homes so that everyone is familiar with the needs of the residents and this is considered to contribute to the community feeling the organisation wishes to engender. Whilst recognising that this policy has some benefits for residents and the organisation, there may be residents who find this system rather stressful and it does not allow for continuity and consistency of care. Therefore consideration should be given to providing the home with a stable core team of staff to reduce the anxiety levels of particular residents. Allendale Road D52-D04 S3421 Allendale Road V221433 090605 Stage 4.doc Version 1.20 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, and 42 The management approach is open, inclusive and positive, providing clear leadership and guidance. Community participation and enablement of service users is the focus of the organisation. Service users’ rights, health, safety and welfare are protected and promoted. EVIDENCE: The Registered Manager has been in post for approximately a year and is undertaking a level 4 National Vocational Qualification and the Registered Manager’s Award. The Registered Manager’s job description is still awaiting review. The residents and staff who were spoken with confirmed that they are consulted and included in decisions regarding the running of the home. All documentation relating to residents was up to date and accurate. Records relating to health and safety issues, such as risk assessments, the accident book, fire log book, employers liability insurance certificate, gas safety checks and portable electrical appliance testing were available and up to date. Fire safety training for staff had been carried out and the Registered Manager Allendale Road D52-D04 S3421 Allendale Road V221433 090605 Stage 4.doc Version 1.20 Page 20 confirmed that all staff were up to date. All staff complete training in emergency first aid. The use of hot water has been risk assessed and none of the hot water is regulated as this is not deemed necessary for the residents. Records were kept of the temperature of the refrigerators/freezers but there was no hot food probe available to check that hot food, in particular roast joints, reaches the required temperature. Advice was given to risk assess and provide one if necessary. The organisation has devised a quality assurance system, which will be implemented in due course. The Registered Provider is required to carry out unannounced monthly visits but the Commission for Social Care Inspection has only received copies of two reports in the last year. SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Allendale Road Score x 3 3 3 2 Standard No 22 23 ENVIRONMENT Score 3 3 Standard No 24 Score 3 Version 1.20 Page 21 D52-D04 S3421 Allendale Road V221433 090605 Stage 4.doc INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 2 Score 25 26 27 28 29 30 STAFFING 3 3 3 2 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 2 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 2 x x 3 x Allendale Road D52-D04 S3421 Allendale Road V221433 090605 Stage 4.doc Version 1.20 Page 22 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 YA39 Regulation 26 Requirement The Registered Provider must make arrangements for the home to be visited at least once a month by the Responsible Individual, one of the partners, or an employee of the organisation who is not directly concerned with the conduct of the care home. A written report must be produced and copies supplied to relevant people, including the Commission for Social Care Inspection. (Original timescale of 2nd March 2005 extended). Timescale for action 9.9.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 5 10 20 Good Practice Recommendations Residents contracts/statement of terms and conditions should specify the room/s to be occupied. All confidential information pertaining to residents should be kept separately. The Registered Provider should consider accessing more detailed and comprehensive medication training for staff. D52-D04 S3421 Allendale Road V221433 090605 Stage 4.doc Version 1.20 Page 23 Allendale Road 4. 5. 6. 7. 28 31 31 42 The Registered Provider should provide an external sheltered area for residents who smoke. The Registered Provider should consider providing a stable core staff team to enhance continuity and consistency of care. The Registered Provider should review and update the Registered Managers job description to reflect the level of responsibility and legal accountability of the post. The Registered Manager should consider purchasing a hot food probe. Allendale Road D52-D04 S3421 Allendale Road V221433 090605 Stage 4.doc Version 1.20 Page 24 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Road D52-D04 S3421 Allendale Road V221433 090605 Stage 4.doc Version 1.20 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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