Inspection on 19/10/05 for Allendale House

This inspection was carried out on 19th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Allendale House 05/02/07

Allendale House 24/05/05

Allendale House 14/01/05

Allendale House 01/07/04

Similar services:

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Snydale Care Home

Hawkhills

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Beeches The - North Yorkshire County Council

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Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Allendale House 21 George Street Hedon Hull East Riding Of Yorks HU12 8JH Lead Inspector Mr M. A. Tomlinson Unannounced Inspection 19th October 2005 09:30 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 House DS0000019642.V257096.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Allendale House DS0000019642.V257096.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Allendale House Address 21 George Street Hedon Hull East Riding Of Yorks HU12 8JH 01482 898379 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) Mr Eustace Nanayakkara Ms Shirley Ann Williams Care Home 19 Category(ies) of Dementia - over 65 years of age (19), Old age, registration, with number not falling within any other category (19) of places Allendale House DS0000019642.V257096.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th May 2005 Brief Description of the Service: Allendale House is located close to the centre of the market town of Hedon and within reasonable walking distance of shops, leisure and health services. It is a relatively short walk to access local public transport. The home is registered for 19 service users in the categories of older people and older people with dementia. The home does not provide specialist or nursing care. Should such care be required on a short-term basis then it would be provided by the community healthcare services. The accommodation comprises of 11 single rooms and 4 shared bedrooms. Two of the shared rooms presently have single occupancy. One of the single rooms has an en suite toilet. The home has two floors with access by a chair lift to the upper floor. There is a lounge, which extends to a conservatory and a dining area. There is a separate sitting area, which is also used for service users who smoke. There is a garden area to the rear, which is accessible to service users via ramps. Allendale House DS0000019642.V257096.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second of two statutory unannounced inspections undertaken by the Commission of Social Care Inspection during this inspectoral year. The inspection took a total of six hours including preparation time. The inspection primarily focused on the requirements and recommendations made during the previous inspection and on those National Minimum Standards not assessed on that occasion. The registered manager was available throughout the inspection and was provided with ‘feedback’ at the completion of the inspection. The majority of the service users were spoken to either in private or in a group setting. The opportunity was taken to speak with those staff on duty and a service user’s visiting relative. An inspection of the premises was undertaken including the majority of the service users’ private rooms. A number of statutory and non-statutory records were examined. What the service does well: What has improved since the last inspection? All of the requirements and recommendations made during the previous inspection, except for the registered manager’s qualifications, had been addressed. Since the last inspection a comprehensive quality assurance monitoring process had been introduced through which the manager had highlighted and addressed any shortfalls in the quality of the service provided. The supervision of staff had been formalised in a positive and constructive manner. The computer system had been connected to the Internet thereby providing the manager with access to the latest guidance and trends in social care. Allendale House DS0000019642.V257096.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Allendale House DS0000019642.V257096.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Allendale House DS0000019642.V257096.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 The service users can be assured that the quality of their pre-admission assessment will enable the home to assess whether their needs can be met. EVIDENCE: Four service users’ care records were inspected. They provided recorded evidence that all prospective service users are fully assessed before they are admitted into the home. The pre-admission assessments were comprehensive and provided detailed information on which a decision could be made as to the appropriateness of a planned placement. The assessments not only looked a person’s needs but also identified their abilities. In general the registered manager had undertaken the assessments. In a number of cases the home’s assessments were in addition to assessments made by a service user’s placing agency. There was recorded evidence that the assessments directly involved the service user concerned and, where appropriate, members of their family. It was evident that the pre-admission assessments were used as the basis for developing a service user’s initial care plan. The home’s administrator provided confirmation that all prospective service users had been informed in writing that the home was able to meet their specific needs. Intermediate care was not provided by the home. Allendale House DS0000019642.V257096.R01.S.doc Version 5.0 Page 9 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): 9 and 10 The service users are provided with good standards of individual support from the staff and are treated with appropriate respect. EVIDENCE: The home continued to use a monitored dosage system for the administration of the service users’ medication. Only nominated senior members of staff were responsible for the security and the administration of the medication. The local pharmacist had provided them with training. The medication was appropriately secured in a locked cabinet. The responsible member of staff on duty carried the key to the drugs cupboard. The medication administration records were complete and up to date. Cream, ointments and general medication were only administered to the prescribed person. A senior member of staff described the administration process. It was evident that part of the process entailed medication being ‘decanted’ from the blister packs into unmarked plastic containers thereby introducing the possibility of error. One ‘designated controlled drug’ was in use. This was secured in a separate container and required two staff for its administration and recording. The staff confirmed that any non-prescribed medicine or ‘homely remedies’ are only given with the approval of a general practitioner. It was observed that the staff Allendale House DS0000019642.V257096.R01.S.doc Version 5.0 Page 10 administered the medication in a careful and unhurried manner. They signed the medication record sheets at the time of administering the medication. From discussions with the service users, and observation of the staff, it was apparent that the service users are afforded appropriate respect and that their dignity was maintained. For example, the staff were observed to knock on bedroom doors before entering and addressed the service users by their preferred name. The staff assisted the service users with considerable patience and did not ‘rush’ the service users but allowed them to take their time. It was evident that the staff had established a good relationship with the service users and although a key worker system was in place the staff were aware of all of the service users’ primary needs. On the day of the inspection the service users were well groomed and dressed in clean and appropriate clothing. Having locks on the bedroom doors and screening in the shared rooms enhanced the service users’ privacy. Allendale House DS0000019642.V257096.R01.S.doc Version 5.0 Page 11 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 The service users are provided with good levels of stimulation by the staff thereby negating the possibility of boredom and apathy. EVIDENCE: It was apparent from discussions with the service users that they are encouraged to lead reasonably active lives. The more able ones were able to go out with friends or staff. One service user attended a medical appointment, for example, without assistance from the staff, and another attended a day centre. The service users were provided with a range of social activities both within and external of the home. The staff endeavoured to spend time each afternoon with the service users and engaged them in group activities. There was a record of this ‘quality time’ spent with the service users. It was apparent that the service users were well stimulated and enjoyed having a conversation on a range of topics. Several of the service users enjoyed ‘doing their own thing’ such as attending the local ‘Working Men’s’ club. Allendale House DS0000019642.V257096.R01.S.doc Version 5.0 Page 12 Allendale House presented as a friendly and homely environment. This was confirmed by a service user’s visiting relative who also stated that the staff were very helpful and kept her informed of her mother’s condition. She stated that she was fully satisfied with the service provided by the home and that the staff had given her ‘peace of mind’. It was apparent that visitors could come and go as they pleased and that they were made to feel welcome by the staff. The service users presented as being relaxed in their environment, were very ‘chatty’ and had retained a sense of humour. Allendale House DS0000019642.V257096.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 The service users are protected by sound Adult Protection policies and procedures and by having unrestricted access to the manager or their key workers. EVIDENCE: In response to the requirement made during the previous inspection, the manager had developed the policy on the safe guarding of service users’ money to include information on the safekeeping of money and valuables and the arrangements for consultations on financial affairs. This policy was displayed in the entrance corridor. Records of a recent complaint clearly showed that the complaint was fully investigated and action taken based upon the outcome of the investigation. It was apparent that the manager promoted an ‘open’ style of management and encouraged service users and their relatives to discuss problems and issues before they became formal complaints. It was evident from discussions with the manager that she took complaints very seriously and saw them as part of the quality assurance process in way of improving the service provided. Following the recommendation made during the previous inspection, the manager had obtained a copy of the POVA Guidance issued by the Department of Health. Allendale House DS0000019642.V257096.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 The home provides a comfortable environment, which meets the needs of the service users and is a homely place in which to live. EVIDENCE: No changes had been made to the premises since the last inspection. They continued to be decorated and furnished to a satisfactory standard. As far as could be ascertained from the records, the home complies with the requirements of the Fire and Environmental Health Departments. The majority of the service users had personalised their bedrooms and consequently the rooms looked homely and comfortable. None of the bedrooms had en suite facilities. Two bedrooms had patio doors opening up into the garden area. One bedroom, whose occupant had behavioural problems, was relatively bare. The reason for this was identified in the service user’s care plan. There are ample shared toilets and bathrooms available. A new bath hoist had recently been installed in the primary bathroom. On the day of the inspection the premises were clean and free from unpleasant odours. According to the service users this standard of cleanliness was the norm. Following the Allendale House DS0000019642.V257096.R01.S.doc Version 5.0 Page 15 previous inspection the hot water supply had been fitted with a control in order to maintain the hot water within safe limits. Whilst the laundry room was rather small, it was, however, of an acceptable standard. It was confirmed by the registered manager that the registered provider is intending to build an extension to increase the number of bedrooms and provide improved laundry facilities. At present the manager does not have a dedicated office and consequently the majority of administrative tasks take place in the lounge/dining room. The manager acknowledged that is rather intrusive for the service users and could lead to problems of confidentiality. It is planned for this problem to be addressed with the building of the extension. Allendale House DS0000019642.V257096.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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 The service users are provided with good standards of support by dedicated and competent staff. EVIDENCE: From an inspection of the staff roster, it was apparent that there had been no regression in terms of staffing levels since the previous inspection. In general the day staffing consisted of a minimum of two care staff on duty along with the registered manager, administrator, cook and domestic. Following the comments included in the previous inspection report the staffing arrangements had been reviewed and all of the staff, except one, were now over the age of eighteen. From discussions with the staff it was evident that they were able to meet the needs of the service users. One service user stated, “ The staff are wonderful – they couldn’t be better”. It was observed that the staff assisted the service users with commendable patience and understanding. Evidence was provided that new staff had been provided with induction training up to the required standard. Eight staff had a National Vocational Qualification at level 2 or above and two more staff intending to obtain the qualification. The staff presented as being well motivated and trained to a good standard. They presented as have a good understanding of their role and how they contributed as individuals to the overall aims of the home. There was a record of the ‘quality one-to-one time’ spent by staff with allocated service users. From discussions with the staff, it was apparent that staff were Allendale House DS0000019642.V257096.R01.S.doc Version 5.0 Page 17 so dedicated that they carried out personal tasks for the service users, such as shopping, in their own time. According to the staff this was done willingly and was not an expectation. The staff records, along with discussions with the manager, confirmed that the home had a robust staff recruitment, selection and vetting process. On occasions where the ‘POVA First’ procedure had been implemented appropriate supervision arrangements had been put in place for the member of staff involved. The staff confirmed that they had received contracts of employment. Allendale House DS0000019642.V257096.R01.S.doc Version 5.0 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): 31,32,33,35,36,37 and 38 The manager has a clear vision for the home, which she has communicated to the staff and the service users. EVIDENCE: The registered manager presented as having an open and democratic style of management and had encouraged and enabled the staff to undertake appropriately delegated responsibilities. It was apparent that the manager had established a very good relationship with the staff, the service users and their relatives. The manager stated that she considered her daily contact with the service users as being very important to provide them with the opportunity to raise concerns or worries. One service user stated, “The manager, Shirley, is fantastic. She always has a word each day and will listen and help with problems” and another said, “She’s fair but firm with the staff. She always has a smile”. The registered manager was undertaking a National Vocational Qualification at level 4 in care and had achieved a qualification of Advanced Allendale House DS0000019642.V257096.R01.S.doc Version 5.0 Page 19 Management in Care. It was evident that the manager worked closely and in conjunction with the home’s administrator in particular with regard to records, policies and procedures. A review of all policies and procedures was undertaken every six months. The staff had signed as having read them. Access was available to the Internet. The home was registered under the Data Protection Act. Recorded evidence was available to confirm that the staff were provided with regular supervision by the manager. This supervision was undertaken on a ‘themed’ basis in order to cover a different subject during each supervision session. Since the previous inspection a Quality Assurance (QA) Monitoring system had been developed. Use had been made of questionnaires in order to assess the quality of the service provided. Evidence was available to confirm that where comments had been made the manager had taken appropriate action. The QA system was comprehensive and ensured that all of the primary functions of the home would be reviewed during the annual cycle. A number of statutory records were inspected including five care records, the accident and the fire records. All were maintained to a good standard. The care records had good standards of recording that was clear, unambiguous and meaningful. Recorded evidence was provided by the registered manager to confirm that the Registered Provider had made regular visits/inspections. As previously mentioned in this report, a policy and procedure had been developed to protect the service users’ financial interests. It was the stated policy of the registered manager to have minimal involvement with the service users’ finances if at all possible. All of the maintenance and safety certificates were current. Since the previous inspection the majority of the fire doors had been fitted with an automatic closing device. According to the manager this action had been taken with the approval of the fire officer. It was apparent that the registered manager had taken appropriate action to ensure that the environment was safe for the service users and the staff. Allendale House DS0000019642.V257096.R01.S.doc Version 5.0 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 4 3 X 3 3 3 3 Allendale House DS0000019642.V257096.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 OP9 Good Practice Recommendations Staff should be provided with training in the administration and safe handling of medication to an accredited, or equivalent, standard. Medication should not be decanted into plastic pots except at the point of administration for reasons of hygiene. The registered manager should have NVQ level 4 in management and care or equivalent by the end of 2005. 2 OP31 Allendale House DS0000019642.V257096.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 House DS0000019642.V257096.R01.S.doc Version 5.0 Page 23 - 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. 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