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Inspection on 12/04/06 for Allendale House Residential Care Home

Also see our care home review for Allendale House Residential Care Home for more information

This inspection was carried out on 12th April 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The manager ensures that appropriate assessments are undertaken of any prospective resident. This includes assessments by social workers for referrals by the Local Authority and assessments by the manager or a senior care worker. Prospective residents and their families are encouraged to visit Allendale House before making it their choice of home. Discussions with some of the residents, families and the local GP practice nurse indicate that health care needs are monitored closely. All relevant information is recorded in the care records. The medication systems used in the Home are good. Visitors are made welcome and the residents praise the quality of the food provided. There have been no complaints made to the Commission for Social Care Inspection or the manager regarding the service provided at Allendale House. In situations where the Home manages the finances of service users, records are well kept and all transactions witnessed. The manager keeps the Commission for Social Care Inspection informed of any significant events or changes in the Home.

What has improved since the last inspection?

At the last visit on 14/12/05, the manager was reminded to undertake individual resident risk assessments to ensure their safety. Evidence during this inspection indicated that this work has commenced, although further assessments will be required with regard to fire evacuation. A hand washing facility has been provided in the laundry room and four radiators have now been covered. The files for all new staff were checked and the correct recruitment procedures are now being followed. Protection of Vulnerable Adults and Criminal Records Bureau checks are being carried out appropriately and two references obtained for all staff.

What the care home could do better:

A Statement of Purpose and Service Users` Guide has been developed for the Home, however the manager must ensure that the information complies with the Care Home`s Regulations and that each resident is given a copy of the Guide, which includes the complaints procedure. The manager and staff team should, together with the residents, explore further the whole issue of choice and flexibility for the service users to ensure that the daily routines suit the individual resident and are not being imposed by the staff. Staff training has improved, however there are still gaps in mandatory provision and the manager needs to ensure that auxiliary staff also receive Protection of Vulnerable Adults and manual handling training. Health and Safety issues must now be addressed in the Home, regardless of the future environmental changes being planned. Some areas have been highlighted throughout Commission for Social Care Inspection visits, however the manager should undertake regular Health and Safety audits of the environment to ensure the safety of residents, staff and visitors. To make sure that the residents and their families are regularly consulted about the care received in the Home and encourage the development of an `open culture`, the manager needs to expand the quality assurance system and make a collation of this work available to the relevant persons including the Commission for Social Care Inspection.

CARE HOMES FOR OLDER PEOPLE Allendale House Residential Care Home 11 Milehouse Lane Wolstanton Newcastle Staffordshire ST5 9JR Lead Inspector Sue Jordan Key Unannounced Inspection 12th April 2006 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 Residential Care Home DS0000004907.V289794.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 House Residential Care Home DS0000004907.V289794.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Allendale House Residential Care Home Address 11 Milehouse Lane Wolstanton Newcastle Staffordshire ST5 9JR 01782 627388 01782 740466 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) Mrs Marcia Patricia Anderson Mrs Marcia Patricia Anderson Care Home 17 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (17), of places Physical disability over 65 years of age (5) Allendale House Residential Care Home DS0000004907.V289794.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 5 PD(E) in bedrooms 7,8 & 9 only Date of last inspection 2nd August 2005 Brief Description of the Service: Allendale House is a private residential care home, located close to the villages of May Bank, Wolstanton and within close proximity to Newcastle-under-Lyme. Access to the villages and main town is via a main bus route The Home is registered to provide care to seventeen older people, although there were thirteen people resident at the time of this inspection. The property is a large detached Victorian house that provides spacious and attractive accommodation. There is a secluded garden area. The Home’s Statement of Purpose, Service Users’ Guide and the CSCI inspection reports are available in the hallway area. The manager informed the Commission for Social Care Inspection on 10/04/06 that Allendale House charges its residents £317 to £368 per week. The Home is managed and owned by Mrs Marcia Anderson. Allendale House Residential Care Home DS0000004907.V289794.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over seven hours and was undertaken by two inspectors. The methodologies used were scrutiny of pre-inspection information completed by the manager and two Commission for Social Care Inspection comments cards, discussions with a number of the residents, the manager and some staff as well as a group of visiting relatives and the local GP practice nurse. Case tracking of two residents was undertaken, which included discussions and checking of their records. The records for all four new staff employed since the last inspection were checked, including recruitment and training documents. A random selection of the Health and Safety records were seen and the medication systems examined. A tour of the environment was taken. What the service does well: The manager ensures that appropriate assessments are undertaken of any prospective resident. This includes assessments by social workers for referrals by the Local Authority and assessments by the manager or a senior care worker. Prospective residents and their families are encouraged to visit Allendale House before making it their choice of home. Discussions with some of the residents, families and the local GP practice nurse indicate that health care needs are monitored closely. All relevant information is recorded in the care records. The medication systems used in the Home are good. Visitors are made welcome and the residents praise the quality of the food provided. There have been no complaints made to the Commission for Social Care Inspection or the manager regarding the service provided at Allendale House. In situations where the Home manages the finances of service users, records are well kept and all transactions witnessed. The manager keeps the Commission for Social Care Inspection informed of any significant events or changes in the Home. Allendale House Residential Care Home DS0000004907.V289794.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: A Statement of Purpose and Service Users’ Guide has been developed for the Home, however the manager must ensure that the information complies with the Care Home’s Regulations and that each resident is given a copy of the Guide, which includes the complaints procedure. The manager and staff team should, together with the residents, explore further the whole issue of choice and flexibility for the service users to ensure that the daily routines suit the individual resident and are not being imposed by the staff. Staff training has improved, however there are still gaps in mandatory provision and the manager needs to ensure that auxiliary staff also receive Protection of Vulnerable Adults and manual handling training. Health and Safety issues must now be addressed in the Home, regardless of the future environmental changes being planned. Some areas have been highlighted throughout Commission for Social Care Inspection visits, however the manager should undertake regular Health and Safety audits of the environment to ensure the safety of residents, staff and visitors. To make sure that the residents and their families are regularly consulted about the care received in the Home and encourage the development of an ‘open culture’, the manager needs to expand the quality assurance system and make a collation of this work available to the relevant persons including the Commission for Social Care Inspection. Allendale House Residential Care Home DS0000004907.V289794.R01.S.doc Version 5.1 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Allendale House Residential Care Home DS0000004907.V289794.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 House Residential Care Home DS0000004907.V289794.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, 5, 6 Assessments are undertaken and received for each prospective resident, ensuring that the manager can determine whether the Home is able to meet their needs. Information is available to new residents and their families and they are offered the opportunity to visit the Home before making a decision as to whether they wish to live there. This is an indicator of a “good” service for those people choosing a residential care home. EVIDENCE: The Statement of Purpose and Service User Guide are available in the lobby area of Allendale House. These were last amended and updated in May 2005. Minor amendments are still required to both documents; The Statement of Purpose must include admission details, which stipulate whether Allendale House accepts emergency admissions. The manager was advised to make a decision regarding emergency admissions and update The Statement of Purpose accordingly. The Service Users’ Guide needs to include the views of the residents. Allendale House Residential Care Home DS0000004907.V289794.R01.S.doc Version 5.1 Page 10 The manager confirmed that the ‘actual’ room to be occupied has now been added to individual contracts and that this information is also included in the Local Authority assessment/contract. Pre-admission assessments were received for both of the two new residents. The Home had also undertaken their own assessments from which care plans have been developed. Discussions with one of the new residents confirmed that she and her family had been given the opportunity to visit the Home prior to making a decision as to whether to live there. The Home was primarily chosen for its close location to family but the resident confirmed that it had been a positive move and that she was very happy with the Home and the staff. Allendale House does not provide intermediate care. Allendale House Residential Care Home DS0000004907.V289794.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, 10 The care records are well maintained and reviewed monthly. Medication systems are adequate and health care needs monitored and appropriately addressed. This reflects “good” care practices. EVIDENCE: The care records of three residents were checked, two of which are new to the Home. They demonstrate continuing improvement to care planning and where possible the residents are encouraged to sign their agreement. Risk assessments are now being completed as and when required and all of the records are reviewed monthly. The records also contain ample evidence that professional health care is accessed as required. One of the new residents explained that she had been able to retain her own GP. The practice nurse was visiting the Home and she confirmed that the staff respond promptly to health needs, including pressure care concerns. She also said that the staff follow any instructions and guidance given. A visiting relative also said that the staff communicate any health concerns and treatment with them promptly and appropriately. Allendale House Residential Care Home DS0000004907.V289794.R01.S.doc Version 5.1 Page 12 Discussions with a number of residents confirmed that they their privacy is respected. Screens are available in shared bedrooms and two residents currently sharing a room said that they were very happy with the arrangement. One of the residents said that she received lots of attention from staff and that they were very nice. Bedroom door locks will be provided when the Home is renovated and refurbished. The medication systems were checked and administration, storage and recording were found to be suitable. The local Pharmacist has undertaken a medication audit and the staff member administering the medication confirmed that she had received training. Medication training is included in staff induction. Allendale House Residential Care Home DS0000004907.V289794.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, 15 Visitors are made welcome and the residents praise the quality of the food provided. The manager is required to explore further ways of creating flexible lifestyles for the residents in order that ‘institutionalised’ staff practices are avoided. Daily routines and lifestyles are “adequate” for the residents. EVIDENCE: There is a comfortable, family-like atmosphere in the Home, confirmed in discussions with a number of residents. There were a number of visitors in the Home and discussions with residents confirmed this as usual. A birthday tea was being arranged for one of the residents. Various entertainers come to the Home and low-key activities such as manicuring are undertaken by staff. There is space in the Home for residents to be alone or receive their visitors more privately. An activities record is maintained for each resident. One of the residents said that she would be visiting her family on Easter Sunday. Discussions with a resident indicated that she was going to bed earlier than she would like and that she had to rise early to be ready for breakfast. When asked if this was her choice she stated, “the girls like me in bed at that time”. This was discussed with the manager who promised that she would explore this further with staff, and she did stress that she would not advocate this Allendale House Residential Care Home DS0000004907.V289794.R01.S.doc Version 5.1 Page 14 inflexible a service. Examination of the relevant resident’s records found that the preferred daily routines section of the initial assessment had not been completed, although real choices should be offered daily and not ‘written in stone’. Further discussions were held with the cook and manager as to whether more choices could be introduced at mealtimes, for example the use of serving dishes and gravy jugs on the table rather than ‘plated up’ meals. The manager and staff team should, together with the residents, explore further the whole issue of choice and flexibility for the residents. This will be monitored at future Commission for Social Care Inspection visits. The Commission for Social Care Inspection undertook a Random Inspection to the Home on 09/05/06 at 20.00hrs. On arrival at Allendale House, all but two of the residents were in the lounge. One resident was in the bath and another in their bedroom. The inspectors were satisfied that residents are not being ‘put to bed’ before or at 20:00hrs. Subsequent discussions with some of the service users, staff and the manager resulted in a meeting being held between the manager and the Commission for Social Care Inspection on 15/05/06. The areas of choice and flexibility were discussed and the manager intends to initiate a general meeting with the residents and their families. The Commission for Social Care Inspection intends to seek further the views of relatives, residents and significant others with regard to these areas. The residents speak very highly of the food provided at the Home and the cook has designed a highly visible four weekly menu. Most of the residents originate from the Stoke-on-Trent area and traditional ‘potteries’ dishes are included. An alternative to the menu is offered if a resident does not feel like having the meal presented. Discussions with the cook indicated that he would research cultural requirements and choices if applicable. There are no specific dietary requirements at present, although the cook was advised to examine further the area of nutrition for older people and is being sent a copy of the Commission for Social Care Inspection ‘Improving Meals for Older People in Care Homes’. The residents enjoy a lively banter with the cook, who is happy to provide drinks on request. The kitchen procedures are adequate. Allendale House Residential Care Home DS0000004907.V289794.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 Although a complaints procedure is available in Allendale House, not all residents are aware of this. In order that the residents are fully protected, auxiliary staff must be included in Adult Abuse guidance and awareness. The protection of residents is “adequate”. EVIDENCE: There have been no complaints made to the Commission for Social Care Inspection or the manager regarding the service provided at Allendale House. An appropriate complaints procedure is located centrally in the main entrance and a comments book is also in operation. One resident confirmed receipt and knowledge of the complaints procedure, although another was not so sure. A staff member thought that not all residents have been given a Service Users’ Guide and therefore a complaints procedure. The manager said that she would raise the issue of complaints with the residents and families in order that they are encouraged to freely express any anxieties. A visiting relative said that she felt comfortable raising any concerns with staff. Protection of Vulnerable Adults First and Criminal Records Bureau checks are carried out correctly for all potential staff and residents’ finances are, if applicable, maintained and managed safely. One staff member confirmed that she had received an Adult Abuse work booklet, which she had worked through, although it was identified that auxiliary staff do not receive the same guidance and they must be included. The manager was advised to request the Local Allendale House Residential Care Home DS0000004907.V289794.R01.S.doc Version 5.1 Page 16 Authority Adult Protection team to deliver training to the staff on the local procedures to be followed. A relatives’ comments card was completed and received by the Commission for Social Care Inspection prior to this visit. A specific comment was made, “My mother has lived in Allendale House for four years and has become more relaxed and content as she feels safe among other residents and staff”. Allendale House Residential Care Home DS0000004907.V289794.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, 26 The manager must undertake a Health and Safety audit throughout the Home to ensure that stringent safety measures are in place, which protect the residents, staff and visitors. The current Health and Safety of the environment is “poor”. EVIDENCE: Some areas of the environment of Allendale are in need of refurbishment. During the last eighteen months the Commission for Social Care Inspection has identified some areas of concern, which it was promised would be addressed as part of renovation plans. There have been a number of delays and the manager is currently reassessing the proposed plans. She was informed at this inspection that a full Health and Safety audit must be completed of all areas of the environment to ensure that the appropriate safety measures are in place in the interim period. Issues that must be addressed include water temperatures; the water on the first floor was too hot to the touch, there are uncovered radiators, windows, which require restrictors and some infection control issues Allendale House Residential Care Home DS0000004907.V289794.R01.S.doc Version 5.1 Page 18 were identified. The drying room needs a smoke alarm. These were all reported to the manager at the inspection feedback. A full audit will necessitate further risk assessments, of which there were presently only five. Although fire alarm testing and equipment maintenance is up to date, there has been no drills or training since July 2005. The manager was also informed of the need to undertake individual assessments on the residents for fire evacuation purposes. The lounge areas of the Home are comfortable and homely and there is a pleasant garden area. Allendale House Residential Care Home DS0000004907.V289794.R01.S.doc Version 5.1 Page 19 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, 30 Staff turnover has been high although the residents praise the staff working at the Home and recruitment procedures have improved. Further work is needed to ensure that all staff receive the training and guidance required, which includes an awareness of the residents’ personal rights and choices. This is indicative of “adequate” staffing. EVIDENCE: There has been a high turnover of staff at the Home in the last twelve months. The manager informed the Commission for Social Care Inspection on 07/02/06 of some staffing difficulties whereby a number had left the Home and some were off sick. Copies of the staff rotas were sent to the Commission for Social Care Inspection prior to this visit, which indicated that minimum staffing levels are being maintained and this was confirmed during this inspection. This however needs to be in line with the required fire evacuation assessments. Four new senior care workers have recently been employed. During this visit, two care workers, one domestic and the cook were on duty. The manager came into the Home to assist the inspection. The information completed by the manager and received by the Commission for Social Care Inspection regarding NVQ levels is not correct. The nursing qualifications of the new staff cannot be calculated into the ratios because the Home is not a nursing home and nursing practices must not be carried out by the Home’s staff. The findings of this inspection indicate that the staff and Allendale House Residential Care Home DS0000004907.V289794.R01.S.doc Version 5.1 Page 20 residents would benefit from the ‘values-based’ training provided within NVQ awards. The residents spoken to praised the staff and some of the comments made were: “The staff are very kind and supportive” and “The girls are great”. One relative said that she is “very happy with the care given” and that the approach of staff is good. Some discussions with residents and staff indicated that some staff are not aware of individual choices resulting in possible institutionalised practices. A requirement has been made that the manager investigates this matter. The files for all new staff were checked and the correct recruitment procedures are now being followed. Protection of Vulnerable Adults and Criminal Records Bureau checks are being carried out appropriately and two references obtained for all staff. Some evidence of staff supervision was available, although many of the staff team are new. Induction booklets are completed by new staff and ‘signed off’ by the manager. One of the staff said that she had been able to attend numerous training courses and was hoping to undertake the NVQ award. The staff training records indicated that improvements have been made in this area, however there are some inconsistencies. It is recognised that there have been major staff changes however the manager was reminded that auxiliary staff should undertake manual handling of safe loads and Protection of Vulnerable Adults training. This will continue to be monitored. Allendale House Residential Care Home DS0000004907.V289794.R01.S.doc Version 5.1 Page 21 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, 36, 38 The management procedures need to include more robust quality assurance and monitoring of Health and Safety issues to ensure the satisfaction and safety of the residents. The management and administration in the Home is “poor”. EVIDENCE: Allendale House is owned and managed by Mrs Marcia Anderson. She is a qualified nurse and is undertaking NVQ 4 in management. She was present in the Home during the afternoon of the inspection. The manager acts as appointee for one of the service users. The records of transactions were checked and systems found to be satisfactory. The resident and two members of staff witness all transactions. Allendale House Residential Care Home DS0000004907.V289794.R01.S.doc Version 5.1 Page 22 The manager reported that she is presently sending Quality Assurance questionnaires to families and professionals and a questionnaire had been completed by a service user on respite care. The results of the audit must be included with The Service User Guide. The manager should expand the quality assurance systems to include a collation of the audits and this information must be available to the residents, interested parties and the Commission for Social Care Inspection. It is recommended that the collation include an action plan, which provides evidence that suggestions for improvement are taken seriously. It is also recommended that the manager expand the quality assurance system and introduce additional methods to questionnaires alone. These could include residents’ and/or family meetings. A comments book is situated in the hallway. A random selection of the Health and Safety maintenance records were checked and evidence that regular safeguarding checks take place. However, during a tour of the environment, some Health and Safety issues were identified, which have been identified in that particular area of the report. The manager records accidents within a bound book and was informed that she must complete the data protection formats and file them individually. The manager submits reports to the Health and Safety Executive under the RIDDOR, (Reporting of Injuries, Diseases and Dangerous Occurrences), regulations. However she needs to obtain the appropriate recording forms from the HSE, (Health and Safety Executive). Allendale House Residential Care Home DS0000004907.V289794.R01.S.doc Version 5.1 Page 23 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 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 2 Allendale House Residential Care Home DS0000004907.V289794.R01.S.doc Version 5.1 Page 24 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 Minor amendments are required to The Statement of Purpose and The Service Users’ Guide. Previous Requirement. Minor amendments are required to the service user contracts. Previous Requirement. The manager and staff team should, together with the residents, explore further the whole issue of choice and flexibility for the residents. The registered person shall supply a written copy of the complaints procedure to every service user. All staff, including auxiliary must be given guidance and instruction in the prevention of Adult Abuse and the procedures to follow. The manager must undertake a Health and Safety audit throughout the Home to ensure that stringent safety measures are in place, which protect the DS0000004907.V289794.R01.S.doc Timescale for action 01/06/06 2 OP2 5 (1b, c) 01/06/06 3 OP14 12 (2, 3) 01/05/06 4 OP16 22 (5) 01/06/06 5 OP18 13 (6) 01/06/06 6 OP19 23(2b)13 (4a,b,c) 01/06/06 Allendale House Residential Care Home Version 5.1 Page 25 residents, staff and visitors. A copy must be sent to the Commission for Social Care Inspection. Staff training must be provided appropriate to the role and at the required frequencies. The registered person shall establish and maintain a system for reviewing at appropriate intervals and improving the quality of care provided at the care home. The registered manager must ensure so far as is reasonably practicable the health, safety and welfare of service users and staff. 7 8 OP30 OP33 18 (1c-i) 24 01/06/06 01/06/06 9 OP38 23(4e),13 (4)12(1a) 01/06/06 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 OP33 Good Practice Recommendations It is recommended that the collation include an action plan, which provides evidence that suggestions for improvement are taken seriously. It is also recommended that the manager expand the quality assurance system and introduce additional methods to questionnaires alone. These could include residents’ and/or family meetings. Allendale House Residential Care Home DS0000004907.V289794.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Residential Care Home DS0000004907.V289794.R01.S.doc Version 5.1 Page 27 - 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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