Inspection on 05/02/07 for Allerton Court

This inspection was carried out on 5th February 2007.

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

Allerton Court 06/02/09

Allerton Court 07/02/06

Allerton Court 12/09/05

Allerton Court 21/10/04

Allerton Court 27/05/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Allerton Court 234 Hydes Road West Bromwich West Midlands B71 2ED Lead Inspector Mr Richard Eaves Key Unannounced Inspection 5th February 2007 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 Allerton Court DS0000004793.V326057.R01.S.doc Version 5.2 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. Allerton Court DS0000004793.V326057.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Allerton Court Address 234 Hydes Road West Bromwich West Midlands B71 2ED 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) 0121 588 5494 NONE Sandwell Community Caring Trust *** Post Vacant *** Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48) of places Allerton Court DS0000004793.V326057.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user is currently under 65 years of age and will remain until such time that the current service users placement is terminated. 7th February 2006 Date of last inspection Brief Description of the Service: Allerton Court is a residential home registered to provide 24-hour care for a maximum of 48 people over the age of 65. Purpose built, and situated at the end of a private drive, the Home benefits from extensive grounds and ample parking facilities. Accommodation is provided over two floors, which is subdivided into four separate Units, each with its own lounge, dining room and kitchenette. In addition to the main staircase a passenger lift provides access to the first floor. The majority of the bedrooms (36) have en-suite facilities, with ample additional bathroom and toilet provision having the necessary adaptations. Situated in the Hall Green area of West Bromwich the Home enjoys easy access to local services and public transport. The Home also provides a day centre service for 12 people which has it’s own large lounge, toilets, shower, kitchenette and conservatory. Residents of the Home are welcome to attend and join in the activities of the Centre. Fees for the home are £323 each week. Allerton Court DS0000004793.V326057.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection visit was undertaken by an Inspector from the Commission for Social Care Inspection using the following information: reports from the organisation relating to the conduct of the home, the preinspection questionnaire, comment card responses from service users and relatives and records held at the home. The inspection involved a full tour of the bedrooms, communal rooms and service areas and provided an opportunity to speak with most of the service users. Comment cards were received from 9 service users and 8 relatives/visitors to the home, the results of which are included in the body of the report but were overall very positive towards the home. What the service does well: What has improved since the last inspection? Since the last inspection a senior carer has taken on the role of co-ordinating activities on a daily basis and opportunities other than those offered by the day centre are more frequent and to the wishes of the service users. Allerton Court DS0000004793.V326057.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Allerton Court DS0000004793.V326057.R01.S.doc Version 5.2 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 Allerton Court DS0000004793.V326057.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 – 5. Quality in this outcome area is good. The homes statement of purpose and service user guide are good sources of information providing details of the service enabling service users and families to make informed decisions about admission to the home. Pre-admission assessments are undertaken by the most experienced staff and confirmation is given to the service users that their needs can be met by the home and further confirmed by contract at the time of admission. Service users are invited to visit and trial the home before committing themselves to staying at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The statement of purpose and service users guide are subject to regular review and are an excellent source of information for current and prospective service users. A copy of the service user guide was seen in each of the bedrooms visited. Allerton Court DS0000004793.V326057.R01.S.doc Version 5.2 Page 9 A sample of case files were randomly selected from each of the four units for case tracking and show that the assessment document, known as the ‘Data Sheet’, is detailed, including all activities of daily living and a range of risk assessments. The sample checked could be improved by more detail about the assessed needs and a review date included. The file documents information of the service user or representatives involvement in the assessment process. Each file includes a copy of the contract/ terms and conditions and a letter confirming that the assessed needs can be met by the home. New service users are offered the opportunity to visit prior to accepting a place at the home and some will have knowledge of the home from attendance at the day centre. A number of respondents to the survey said they had visited the service prior to accepting a place at the home, one other said that family had chosen while in hospital and was very pleased to be at the home. The home does not provide an intermediate care service. Allerton Court DS0000004793.V326057.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7 - 10 Quality in this outcome area is good. Care plans are derived from a comprehensive range of assessments and provide the basis for the delivery of care and detail the actions required of staff to meet the identified needs. Health care needs of service users are fully met. Medications are well managed all facilitating the promotion of service users health. Service users are treated with respect and their privacy upheld. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A sample of case files were selected at random in each area of the home to be inspected and case tracked. The care plans were drawn from the assessed needs process and were relevant and maintained to a good standard. The care plans reflect actual care requirements but would benefit from more detailed direction of the actions required of staff. Plans are subject to monthly review, a summary of care needs are kept for each service user along with the daily records in a file known as the staff information file and provides details of individuals daily routines. Allerton Court DS0000004793.V326057.R01.S.doc Version 5.2 Page 11 All service users are registered with a GP and the district nursing service visits on request. Allied medical services such as dentist, ophthalmic and chiropody are provided on a regular and as required basis. A monitored dosage system is used for the administration of medicines provided by a local chemist who also audits the service on a quarterly basis. An inspection of the administration of medication procedure identified that is was administered to a satisfactory level. Medications are stored in locked cupboards on each unit, records are maintained of medicines received and returned to the pharmacists. Staff involved in the administration of medicines have receive accredited training. The induction programme includes a section on treating service users with respect and their privacy is upheld, locks are fitted to bedroom doors, staff were observed to knock before entering bedrooms and interact in a friendly and open way using the service users choice of name. A public telephone is located in the day centre area but service users take calls on each units telephone. There are no double rooms although two rooms on each unit are linked should there be a requirement for a couple to share. Allerton Court DS0000004793.V326057.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12 – 15. Quality in this outcome area is good. The home provides a varied social and recreational activities that provide interest and pleasure for the residents. Visitors are welcome and help to keep service users informed about the wider community Many aspects of care evidences that service users exercise choice and control over their lives. The meals at Allerton Court care home are good and the home is able to cater for special dietary needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users have opportunities to engage in planned activities (e.g. Bingo, visiting singers/musicians and one-to-one activities, including shopping trips/ trips out in the Home’s mini-bus, a small group are attending the ballet this week. Others like to attend the events at the day centre and one lady informed the inspector that she was going down stairs following her lunch. Nine respondents to the survey found the activities were to their liking and capacity. Since the previous inspection a senior care has been identified to coordinate activities within the residential part of the premises. Allerton Court DS0000004793.V326057.R01.S.doc Version 5.2 Page 13 The religious observance needs of service users are met by regular visits from the local church and regular services at the home which the vicar has provided dates throughout the year. A number of service users have attended services at church. The home has open visiting and a number of families were met and all spoke well of the home. Service users spoken with all said they felt free to make their own choices, spending time in their own room or visiting the day unit and other units about the home, usually returning for mealtimes. They also said they chose their clothing daily, this was further evidenced in the individual summary of care that directs staff to ask what the service user wants to wear. The home is not appointee for any service user but does accept personal allowances from their relatives for safe keeping and records of all transactions are maintained. There was no information seen of external advocacy schemes and a recommendation to obtain this and make available to service users and their relatives. Residents do engage in regular 2 monthly meetings and a wide range of topics chosen by them are discussed. The service user guide makes clear that persons own furniture can be brought in and access to own records is also clearly stated. The home has a 4-week rolling menu that is well thought out and offering variety and a balanced diet to service users, choice of lunch meal including a cooked option is always available and a record kept of individual service users intake and meals taken in the setting of their choice. Regular satisfaction surveys are undertaken of the meals served. The main meal of the day is served at lunch and well received. The tea and supper menus require to be formalised and the tea menu to be more clear about choice. The supper needs to be included in the menu to demonstrate that the maximum period between meals does not exceed 12 hours A special menu had been prepared for over the Christmas holiday period. Of the 9 comments returned 6 said they always liked the meals while 3 said usually. All spoken with said they had enjoyed their lunch taken during the inspection. Allerton Court DS0000004793.V326057.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 - 18 Quality in this outcome area is good. The home has a satisfactory complaints policy and service users and their supporters can be confident that their views will be listened to and acted upon. Staff undertake adult protection training preparing them to uphold the welfare of the service users and to protect their rights. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure is readily accessible to service users and their supporters with reference in the contract, the procedure is available in the service user guide issued to each bedroom. No complaints have been received since the last inspection. Of eight relative respondents 2 said they were not aware of the complaints procedure, none had ever had to make a complaint. The 9 service users all said they new how to complain. The electoral roll has recently been completed and a number of service users have received confirmation that they will be able to make a postal vote in future elections the manager states that many like to attend the polling station and have been supported in this in the past. Allerton Court DS0000004793.V326057.R01.S.doc Version 5.2 Page 15 The home has robust procedures for responding to any suggestion of abuse and in-house training is given in adult protection procedures both at induction and with ongoing updates. The policy and procedures for protection and prevention of abuse were reviewed during September 2006. A copy of the Department of Health practical guide was also available. Policies were available for managing violence, restraint and whistle blowing. Allerton Court DS0000004793.V326057.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 - 26 Quality in this outcome area is excellent. The home provides an excellent standard of décor, furnishings and managed services providing a safe, disabled accessible environment and an attractive, and homely place to live. The home is clean, free from odours and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Home has a full range of maintenance contracts in place, with all areas clearly benefiting from regular refurbishment/redecoration. The garden, which has level paved areas enabling easy walks or wheelchair use, provides a safe environment at the rear of the premises with a very pleasant outlook. Bedrooms, all of which are generously sized, some include en-suite toilet, are comfortably furnished, and equipped to meet the standards. Residents are clearly encouraged to personalise bedrooms with their own possessions including furnishings. Allerton Court DS0000004793.V326057.R01.S.doc Version 5.2 Page 17 Hot water outlets for service users are subject to monthly testing, it was noted that the records were at the limit of the recommended range and require adjustment to achieve the standard of 43°c, it is also recommended that mixing valves are anti-scald tested and serviced annually. The laundry is well organised with a large washing capacity provided by an industrial sized machine, with a plumbed-in detergent and fabric conditioner supply, thus eradicating mess and providing good health and safety practice. There is a well-organised system for ensuring personal clothing is returned to the respective Service User. Domestic washers are also available on each unit to allow for individual delicate washes. The hand wash in the sluice rooms require to be fitted with hot water control either with mixing taps or mixing valve. Allerton Court DS0000004793.V326057.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27 – 30. Quality in this outcome area is good. The home has a stable, well-motivated and trained staff group offering consistency of care and enthusiasm to maximise the quality of life for the service users. Service users are further protected by good recruitment and selection practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The rotas confirm that staff numbers across the 24hour period are appropriate to the needs of service users. The manager identified a planned increase of staff with a second float for the afternoon evening period. Care staff with NVQ qualification at level 2 or above exceeds the 50 requirement of the standard and is currently 71 with further staff due to complete. A sample of three staff files including a recently employed staff, show these to be completed to a good standard with appropriate pre-employment checks being undertaken and the most recent appointee is currently undertaking induction. Staff are issued with the General Social Care Councils code of conduct. Staff each have a training file and have a training needs analysis each year, the files show that all mandatory training is provided and certificates held on file. Supervision and appraisals were seen to be up to date and on target to meet the six sessions for the year. Allerton Court DS0000004793.V326057.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31 – 38. Quality in this outcome area is good. Leadership of this home is good and staff demonstrate an awareness of their roles and responsibilities and service users benefit from this consistency. The ambience of the Home is warm, friendly, and inclusive. Sound financial management of the home and arrangements for safekeeping of their money safeguards service users interests personal and financial. Staff receive supervision and direction to ensure that the service users receive consistent quality care. The best interests of service users are safeguarded by the homes record keeping, policies and procedures. Environment management and staff training in respect of health and safety ensures service users safety and welfare are protected. This judgement has been made using available evidence including a visit to this service. Allerton Court DS0000004793.V326057.R01.S.doc Version 5.2 Page 20 EVIDENCE: The home is managed by a well-qualified and experienced manager who meets regularly with staff and service users. In addition to holding NVQ at level 4 in management the manager keeps up to date and is undertaking the Registered Managers Award. Staff at the home have mostly been in post for many years, are well motivated and experienced. Service users views are regularly surveyed using a range of questionnaires that between them cover all aspects of service. A range of audits are undertaken at all management levels, weekly by the manager, monthly by the area manager and quarterly by the Operations Director. The Home does not act as appointee for service users but do assist service users in keeping their personal allowance safe with full records of all transactions. Audited accounts are held at headquarters and were not available during this inspection. Insurance certification was available and displayed. Supervision notes seen by the inspector demonstrate an effective formal supervision process for staff of at least six times per year. Annual appraisals have also been undertaken. Policies and procedures are available for staff to read. A sample of records required by regulation and the schedules were seen to be maintained and kept up to date. Health and Safety is given appropriate priority with a broad range of monitoring and maintenance in place with all staff receiving training at induction and ongoing at appropriate intervals. During the tour of the building it was observed that all corridors were clear of any obstruction and the premises are kept in a safe condition. Appropriate arrangements are in place for the monitoring, recording and reporting of accidents. An inspection of the service and inspection certificates identified work outstanding to validate the electrical wiring. Allerton Court DS0000004793.V326057.R01.S.doc Version 5.2 Page 21 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 3 3 3 3 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 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 3 3 3 3 3 3 Allerton Court DS0000004793.V326057.R01.S.doc Version 5.2 Page 22 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 OP15 Regulation 16(2)(i) Requirement The registered person must formalise the menus for evening tea and supper and provide choice at each of these meals. The registered person must ensure that hot water is delivered close to 43°c at all service user outlets and antiscald test each mixing valve annually. A small basin for the sole purpose of the washing of hands must be installed in the main laundry. Timescale of 31/03/06 not met. The home requires to renew the electrical wiring certificate. Timescale for action 31/03/07 2. OP25 23(2)(j) 31/03/07 3. OP38 13(3) 31/03/07 4. OP25 23(2)(p) 31/03/07 Allerton Court DS0000004793.V326057.R01.S.doc Version 5.2 Page 23 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 OP3 Good Practice Recommendations The information provided in the data sheets as the homes assessment should be expanded to be more descriptive of the needs identified. The care plans should be expanded to give more detail of the actions required by staff to address assessed needs. The home should information in respect of external advocacy schemes more readily available to service users and their relatives and friends. 2. 3. OP7 OP14 Allerton Court DS0000004793.V326057.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Allerton Court DS0000004793.V326057.R01.S.doc Version 5.2 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. 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