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Inspection on 18/04/05 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 18th April 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 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

Being small in size and registration, Allendale House is able to provide a homely environment whereby the residents have established friendships with others and their visitors are made welcome by all. The Home has good communal space, which is nicely separated into smaller areas, allowing for choice and privacy. The equipment used in the Home is maintained and serviced appropriately. The residents say that they feel safe and well cared for.

What has improved since the last inspection?

Medical appointments and visits are now being recorded in the residents` care plans. The residents say that the food in the Home has improved since the employment of a new cook and that their wishes are being heard and new meals introduced as a result. They particularly like the home made cakes and deserts. Work has started on the care plan records and minor improvements have been made.

What the care home could do better:

Adequate assessment and subsequent care planning must be further improved to ensure that the Home is able to meet the needs of the residents, both new and established. A number of areas of need have been identified during inspections, which when checked against the care plans are not recorded. Activities are being organised for the residents, but talking to them it was evident that there are some of their preferences for daily life are not being considered. Some of the residents and a visitor spoke of not going out of the Home as often as they would like. The staff spoken to were not as aware of the correct local Adult Protection procedures to follow in the event of an abusive situation. Adequate training and procedures must be available to them to ensure that they have this knowledge. The recruitment procedures in the Home do not fully protect the residents and the appropriate checks and records kept, must be made before staff are employed. A tour of the environment was undertaken and whilst the Home has the charm and potential to offer cosy and comfortable surroundings for the residents, there are some areas, which require further work to meet the standards. The manager reported that she has plans to drastically change and improve the building. Improvements are required to improve the hygiene and infection control measures in the Home, which include the general cleanliness and laundry procedures. Staffing problems have had an effect on the management of the Home, as the manager is having to work as part of the staff team and sometimes in the kitchen. This does not allow her the time to maintain the records or adequately supervise the staff. Responsibilities under health and safety are a high priority and must be closely monitored.

CARE HOMES FOR OLDER PEOPLE Allendale House Residential Care Home 11 Milehouse Lane Wolstanton Newcastle, Staffordshire ST5 9JR Lead Inspector Sue Jordan Unannounced 18 April 2005 09.45 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 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 E51-E09 S4907 Allendale House V222179 180405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Allendale House Residential Care Home Address 11 Milestone Lane Wolstanton Newcastle Staffordshire ST5 9JR 01782 627388 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) Mrs Marcia Patricia Anderson Mrs Marcia Patricia Anderson Care Home 17 Category(ies) of 2 DE(E) registration, with number 17 OP of places 5 PD(E) Allendale House Residential Care Home E51-E09 S4907 Allendale House V222179 180405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 5 PD(E) in bedrooms 7,8 & 9 only Date of last inspection 22 February 2005 Brief Description of the Service: Allendale House is a private residential care home, located close to the villages of May Bank and Wolstanton. The home is also within close proximity to Newcastle-under-Lyme, a thriving market town with a wide range of shops and community resources. Access to the villages and main town is relatively straightforward as it is on a main bus route.The property is a large detached Victorian house that provides spacious and attractive accommodation. The exterior and interior are in a good state of structural repair. The home has four small lounge areas, which are well furnished and decorated. The residents are able to integrate in small groups, which avoids an institutional feel. There is also a large communal dining room that contains adequate seating and is furnished and presented along domestic lines. The bedrooms are located on the ground and first floor and three of the ground floor bedrooms have direct access to the large rear garden via sliding patio doors. The garden is well maintained and is equipped with adequate garden furniture. It is popular during the summer months but was not being used at the time of the inspection.The Home is managed and owned by Mrs Marcia Anderson. Allendale House Residential Care Home E51-E09 S4907 Allendale House V222179 180405 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five and three-quarter hours to check the progress being made by the Home to meet the thirteen requirements made at the last inspection on 22/02/05. The methods used were discussions with two care staff, six of the residents, two visitors and the manager. Care plans were examined, as well as staff personnel files and some Health and Safety records. A tour of the Home was also undertaken. What the service does well: What has improved since the last inspection? Medical appointments and visits are now being recorded in the residents’ care plans. The residents say that the food in the Home has improved since the employment of a new cook and that their wishes are being heard and new meals introduced as a result. They particularly like the home made cakes and deserts. Work has started on the care plan records and minor improvements have been made. Allendale House Residential Care Home E51-E09 S4907 Allendale House V222179 180405 Stage 4.doc Version 1.20 Page 6 What they could do better: 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 House Residential Care Home E51-E09 S4907 Allendale House V222179 180405 Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection Allendale House Residential Care Home E51-E09 S4907 Allendale House V222179 180405 Stage 4.doc Version 1.20 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 standard(s) 3, 4 The residents’ records do not indicate that an assessment of need is undertaken prior to admission or that the prospective service user and/or their representatives have been involved in care planning. This does not give prospective service users the assurance needed that the Home can meet their needs. EVIDENCE: The records for a recent admission were checked and an assessment of long term needs and care plan had been completed, however the document was not dated. Therefore it was not clear if an assessment was carried out prior to admission to the Home and a Community Care Assessment was not available. None of the other three files contained initial assessment information, although work has started to complete short-term care plans. Mobility risk assessments have not been expanded even when it is ascertained that there is a risk of falling. None of the care plans/assessments seen were signed by the service user or their representatives. Allendale House Residential Care Home E51-E09 S4907 Allendale House V222179 180405 Stage 4.doc Version 1.20 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 standard(s) 7, 8, 10 Although there have been some slight improvements in care planning, more work is required to demonstrate within the records that all of the residents’ care and health needs are being met. The shortfalls in documentation would not support the Home in the event of an incident being investigated and could potentially place residents at risk. EVIDENCE: Four care plans were checked at this inspection and there was some improvement from the last inspection in the amount of information available. Work has commenced to complete the short-term care plans, however the Home uses the Spandex system and many of the sections are not yet completed, including risk assessments. The manager must ensure that the care plans are based on all areas of care needed and these are listed in ‘Care Homes for Older People’, National Minimum Standard 3.3. One of the residents has some aggressive tendencies however there is no information as to how staff should manage this behaviour safely for themselves or the service user. The personal care sections are not being kept up to date. Allendale House Residential Care Home E51-E09 S4907 Allendale House V222179 180405 Stage 4.doc Version 1.20 Page 10 When it is established that a resident has a history of falls, a more detailed risk assessment is required to determine how this person is to be kept safe. Medical and health appointments are now being recorded in the appropriate sections and staff concerns are recorded in the daily notes. One of the service users is attended regularly by the district nurse. The residents in the Home commended the care delivered and one said that she felt safer than she had in her own home. A visiting daughter said that the family were confident about their Mother’s care. Information regarding each resident is given to the staff at the start of every shift, during a ‘handover’ session. Family members said that they were made to feel welcome in the Home and that the staff and manager were very friendly. The lounge area is separated into smaller areas, which allows the visitors and the resident to speak privately. Screening is available in all of the shared rooms. Allendale House Residential Care Home E51-E09 S4907 Allendale House V222179 180405 Stage 4.doc Version 1.20 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 standard(s) 12, 13, 14, 15 Although there is evidence that some activities are being organised for the residents, individual requests and choices are not being recorded and as a result are in danger of being ignored. EVIDENCE: During the inspection a qualified keep fit instructor came into the Home and held a gentle exercise session to music. Many of the residents participated and said that they enjoyed it. This activity is organised weekly. Music entertainment is planned for Bank Holiday Monday. Some of the female residents like to have their fingernails manicured and a member of the care staff was doing this. A visiting family member said that she thought the Home organised quite a lot for the residents, although this was not supported in discussions with them. One resident said that she would like to be able to go into the garden and that she has only been supported to do so once in five years. She said, “ Five years in here all the time is enough to drive anyone mad”. Another said that she would like to go for a walk occasionally and that “every day is the same”. Another visitor said that her only criticism of the Home was a lack of trips out in the community. The care plans contain a tick list for activities attended, however there is no evidence that individual preferences have been ascertained and there is no structured activities plan. Allendale House Residential Care Home E51-E09 S4907 Allendale House V222179 180405 Stage 4.doc Version 1.20 Page 12 The residents are encouraged to receive visitors and those spoken to said that they made to feel welcome in the Home. One of the residents receives regular visitors and also goes out for lunch and shopping with her daughter. Another resident told of going to her daughters at Christmas. Most of the residents spoken to said that they enjoyed the meals prepared by the new cook and that he also made lovely home-made deserts and cakes. It was the cook’s day off on the day of this inspection and the manager cooked the lunch, which was a full roast dinner and desert. The residents expressed their enjoyment of it and alternatives were offered to some. One of the residents is assisted to eat and another asked to stay in the lounge and have just a desert, this was supported. A daily record is made of the meals prepared in the Home, although an actual menu was not seen. One of the residents said that some of the meals prepared are a bit strange and although there is a list of some of the residents’ likes and dislikes this could be expanded and used in menu planning. However other residents said that if they had mentioned that they liked a particular meal it had been presented at some point after the discussion. The new cook has a current basic food and hygiene certificate, although the manager’s is now out of date. All staff involved in meal preparation must have the relevant training and qualifications. A Health and Safety audit of the kitchen was undertaken in June 2004 and the Home was recently visited by the Environmental Health Department. The manager reported that all of the recommendations had been complied with. Allendale House Residential Care Home E51-E09 S4907 Allendale House V222179 180405 Stage 4.doc Version 1.20 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 standard(s) 17, 18 The Home’s policies and procedures, including recruitment and a lack of staff training do not adequately demonstrate that residents are fully protected from abuse. EVIDENCE: Polling cards for the forthcoming general election have been sent to the Home. A member of staff spoken to was not able to demonstrate knowledge of the procedures to follow in the event of an abusive situation and there was no evidence that staff have received training in the local Adult Protection procedures. It was not ascertained as to whether the Home now has a copy of the Department of Health’s ‘No Secrets’ document, as previously required. Recruitment procedures need to be strengthened to ensure the safety of the residents. Although the manager said that Protection of Vulnerable Adults, (POVA), checks had been carried out for new staff prior to employment, evidence of this was not available. One of the staff files requested at this inspection was unavailable and three more were checked. One did not contain evidence of a Criminal Records Bureau disclosure or a POVA 1st check and one contained one reference only. A resident said that she felt safe and secure since living at the Home and this was confirmed by her daughter. Allendale House Residential Care Home E51-E09 S4907 Allendale House V222179 180405 Stage 4.doc Version 1.20 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 standard(s) 19, 20, 21, 22, 24, 25, 26 The manager has ideas for building improvements in the Home, which when realised will ensure that the environmental requirements are addressed. This will improve the Home’s environment further and ensure the safety and comfort of the residents. In the interim period more effort is required to provide a clean, hygienic environment and to ensure that all health and safety concerns are identified and supported by risk assessments. EVIDENCE: A tour of the Home’s environment was undertaken. The Home has adequate communal areas, allowing residents privacy and a choice of where to sit. The dining room is pleasantly situated and all of the residents can comfortably share a meal. There are a number of radiators, which still require covering. The manager said that the radiators in potentially dangerous areas had been covered and that this had been done via a risk assessment approach. Copies of the risk Allendale House Residential Care Home E51-E09 S4907 Allendale House V222179 180405 Stage 4.doc Version 1.20 Page 15 assessments were not seen. The present bedroom door locks do not comply with fire safety standards and are not as such in use. The manager is applying for planning permission to improve the Home’s environment, to provide single rooms with en-suite bathrooms and stated that the radiators, door locks and re-decoration would be addressed during these improvements. A maintenance plan is required as evidence that the environmental standards are to be met, with proposed timescales. There are a number of shared rooms in the Home, but all contain screening and residents spoken to are happy to share. This was also confirmed by a visitor. The Home had managed to recruit domestic staff, but unfortunately this person has since left and a number of areas were not as clean as they should be, including the underneath of an assisted bath chair. The manager said that this had been reported to her that morning by a member of night staff. There is a stair lift fitted onto the main stairs and records of maintenance were seen. There is a notice to say that residents can only use the lift supported by staff, although this should be supported by risk assessments. The hoist and assisted bath aids have been maintained. One of the bedrooms had a strong smell of urine and cleaning arrangements must be implemented to combat this. The staff/visitors’ toilet does not have a seat and it was noted that a number of the toilet seats are looking very worn and require replacement. The washing machine has a sluice facility, although there is no hand washing facility for staff. A member of staff explained the systems used for the laundering of soiled linen and at present the Home does not use alginate bags, which is recommended as good practice for infection control. Allendale House Residential Care Home E51-E09 S4907 Allendale House V222179 180405 Stage 4.doc Version 1.20 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 The recruitment difficulties in the Home have a direct impact on the care delivered and the ability of the manager and staff to find the time to complete vital documentation. EVIDENCE: There have been recruitment problems in the Home and some of the recently employed staff have since left. The manager is currently trying to recruit additional staff, to work both days and nights and was receiving requests for application forms on the day of the inspection. The rota indicated that originally three members of care staff, the manager and a domestic were working on the morning of this inspection. However staffing problems meant that only the manager and two care staff were on duty and as it was the cook’s day off the manager had to provide the meals. The staffing difficulties are reflected in the record keeping as the manager is continually having to work ‘hands-on’ and frequently has to work extra shifts in the Home to cover staff absences. The Home does use agency staff, but does endeavour to use personnel familiar with the Home and its residents. The manager discussed the possibility of using staff from overseas. The manager was required as a result of the last inspection, to implement night-time monitoring systems for the residents, which are agreed with them and/or their significant others and included in the care plans. The care plans do not indicate that such systems have been introduced. Allendale House Residential Care Home E51-E09 S4907 Allendale House V222179 180405 Stage 4.doc Version 1.20 Page 17 One of the staff files requested at this inspection was unavailable but three more were checked. The files did not contain all of the required elements and the manager was shown Schedule 2 of The Care Homes Regulations, which lists them. One did not contain evidence of a Criminal Records Bureau disclosure or a POVA 1st check and one contained one reference only. None contained a proof of identity or a photograph. Discussions with staff and examination of the staff files did not indicate that mandatory training is accessed for staff at the required frequencies. The manager is trained as a manual handling trainer, however underarm assistance was being given on the day of the inspection, which is not good practice. A member of staff commencing work at the Home on 11/04/05 has started to work through an induction booklet, although this work has not been signed off by the tutor. The other member of staff on duty is working towards NVQ 2. Allendale House Residential Care Home E51-E09 S4907 Allendale House V222179 180405 Stage 4.doc Version 1.20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 36, 37, 38 Management and Administration systems in the Home are poor and do not adequately protect the residents and staff. EVIDENCE: As evidenced throughout this inspection and report, management issues are being compromised by staffing difficulties in the Home. The manager has to concentrate her personal efforts on providing care to the residents as part of the staff team and at times also has to provide meals. Although major efforts have been made since the last inspection, further work is required to improve record keeping, including care planning information and risk assessments. Many residents indicated in their discussions that they found the manager to be approachable and committed. Allendale House Residential Care Home E51-E09 S4907 Allendale House V222179 180405 Stage 4.doc Version 1.20 Page 19 Staff are not receiving structured supervision and a requirement has been made regarding this issue at the last two inspections. The manager reported that most of the staff have not worked in the Home for more than six months and that they have undergone induction training/supervision, however the induction booklet seen for the newest recruit had not been signed by a senior member of staff. There are also staff that have worked in the Home for a longer period of time and a discussion with one such staff member demonstrated that structured supervision is not received, although it was reported that the manager is approachable and supportive. Care staff must receive a minimum of six formal supervisions per year and it is good practice to record such sessions, for the supervisor and supervisee to sign them and a copy kept by both. The issues which should be covered in supervision are listed in ‘Care Homes for Older People’, National Minimum Standard 36.3. Auxiliary staff should also be supervised as part of the normal management process on a continuous basis. Some of the Health and Safety records were checked and a few of the maintenance/safety checks and or training are overdue, including the gas safety checks, the fire risk assessment for the Home and the annual fire safety training. The records for the portable appliance testing, stair lift and manual handling maintenance demonstrated that they are regularly tested. The fire safety records were examined and fire alarm and emergency lighting testing is done at appropriate intervals. The manager reported that staff had undergone fire evacuation training on two occasions during the previous week; however there were no records made and it is recommended that this be done to show who was involved in the evacuation, the time it took and any issues, which may arise. Allendale House Residential Care Home E51-E09 S4907 Allendale House V222179 180405 Stage 4.doc Version 1.20 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. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 3 COMPLAINTS AND PROTECTION 2 3 2 3 x x x 2 STAFFING Standard No Score 27 2 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x 3 2 2 x x x x 1 1 2 Allendale House Residential Care Home E51-E09 S4907 Allendale House V222179 180405 Stage 4.doc Version 1.20 Page 21 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 3 Regulation 14 (1a,b,c,d) 14 (2a,b) 14 (2a,b) Requirement The needs of prospective residents must be assessed prior to admission to the Home and the assessments kept under review. The Home must demonstrate its ability to meet the individual assessed needs of the service users. The care plans must contain the information required, which details the care necessary for the staff to meet the assessed needs of the service users. Care plans must be reviewed regularly and therefore up to date. Previous Requirement Activities should be planned following individual consultation with the residents of their preferences, likes and dislikes. More evidence is required that the residents are enabled to engage in local, social and community-based activities. More evidence must be provided that the registered person conducts the home so as to maximise service users’ capacity to exercise personal autonomy and choice. Previous Timescale for action 01/06/05 & on-going 2. 4 01/06/05 & on-going 01/06/05 & on-going 3. 7 15 (1&2) 4. 12 16 (2n) 01/06/05 & on-going 01/06/05 & on-going 01/06/05 & on-going 5. 13 16 (2m) 6. 14 12 (2, 3) Allendale House Residential Care Home E51-E09 S4907 Allendale House V222179 180405 Stage 4.doc Version 1.20 Page 22 Requirement 7. 19 13 (6) Manager to obtain a copy of DoH “No Secrets” & ensure that staff have knowledge of the local Adult Protection Procedures. Previous Requirement Evidence is required that plans are in place to maintain and improve the environment, the priority being areas of health and safety concern. Bathroom and toilet areas and the equipment within, must be clean and suitable for use. Infection control procedures should be strengthened to ensure the health and safety of staff and residents, including maintaining the cleanliness of the Home, improving the laundry procedures and combating offensive odours. The manager must demonstrate that systems of night-time monitoring are introduced, which are agreed with the service user and/or significant other and included in the care plan information. Previous Requirement Staff recruitment procedures must be robust and the records listed in Schedule 2 of The Care Homes Regulations kept obtained and kept in the Home. The correct procedures must be followed with regard to CRB disclosures and evidence available. Staff training must be provided appropriate to the role and at the required frequencies. Systems must be in place which allow for effective management and administration Manager and deputy to organise a timetable of formal staff 01/06/05 8. 19 23 (2b) 13 (4a,b,c) 16 (2j) 23 (2b,c) 16 (2j,2k) 23 (k) 13 (3) 01/06/05 9. 10. 21 26 01/06/05 01/06/05 11. 27 12 (2,3) 14 (2) 15 (2) 01/06/05 12. 29 19 (1a,b,c 4 & 5), 17 (2 & 3) 13 (5), 19 (1,4 & 5) 18 (1c-i) 10 (3) 17, 18, 19 18 (2) 01/06/05 13. 29 01/06/05 & on-going 01/06/05 & on-going 01/06/05 & on-going 01/06/05 Page 23 14. 15. 16. 30 31 36 Allendale House Residential Care Home E51-E09 S4907 Allendale House V222179 180405 Stage 4.doc Version 1.20 17. 37 17 18. 38 23 (4e), 13 (4), 12 (1a) supervision to reflect six sessions minimum per year.Previous Requirement Individual records and home 01/06/05 records must be up to date and in good order and maintained in accordance with data protection.Previous Requirement The registered manager must 01/06/05 & ensure so far as is reasonably on-going practicable the health, safety and welfare of service users and staff. 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. Refer to Standard 7 26 Good Practice Recommendations It is recommended that residents of their representatives are asekd to sign the care plans as evidence of their knowledge and involvement. It is recommended that the advice of an infection control nurse be sought as to the most appropriate systems to implement in the Home. Allendale House Residential Care Home E51-E09 S4907 Allendale House V222179 180405 Stage 4.doc Version 1.20 Page 24 Commission for Social Care Inspection Stafford - 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 E51-E09 S4907 Allendale House V222179 180405 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!