Inspection on 04/10/07 for Allington Court

This inspection was carried out on 4th October 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

Allington Court 01/10/09

Allington Court 21/01/09

Allington Court 16/10/06

Allington Court 05/10/05

Allington Court 03/02/05

Allington Court 31/08/04

Allington Court 11/03/04

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

CARE HOMES FOR OLDER PEOPLE Allington Court Lye Lane Bricket Wood St. Albans Hertfordshire AL2 3TN Lead Inspector Pat House Key Unannounced Inspection 4th October 2007 11:15 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 Allington Court DS0000019266.V352313.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. Allington Court DS0000019266.V352313.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Allington Court Address Lye Lane Bricket Wood St. Albans Hertfordshire AL2 3TN 01923 894542 01923 894544 naylor@bupa.com www.bupa.com BUPA Care Homes (BNH) Ltd 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 Angela Naylor Care Home 44 Category(ies) of Dementia (10), Dementia - over 65 years of age registration, with number (44) of places Allington Court DS0000019266.V352313.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th October 2006 Brief Description of the Service: Allington Court is registered to provide accommodation and nursing care to 44 older people with dementia, 10 of who may be below 65 years of age. It is owned and operated by BUPA Care Homes Limited and is situated in extensive grounds, adjacent to another BUPA care home in a semi-rural location in the village of Bricket Wood, within easy access of the M25 and M1 motorways. There is ample parking space provided at the font of the building. The home was purpose built for this service user group and is in the form of a hexagon with two internal courtyards, which, together with the attractive and secure grounds provide ample additional communal space where service users can walk and exercise, or simply sit and enjoy the gardens and views. The majority of service users are accommodated in single rooms and there are four lounges, an activity room and dining room. There is an information folder/Service User’s Guide in the reception area of the home, which includes contact details of the Commission for Social Care Inspection, (CSCI), and information about charges for the home. The last CSCI inspection report and the home’s Statement of Purpose are kept in the office and are available on request. Current weekly fees are £1400. Additional charges apply for hairdressing, personal toiletries and newspapers and for any chiropody, dentistry and opticians’ services where these are subject to charge. Allington Court DS0000019266.V352313.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one day, with one inspector present for the whole period and an additional inspector present for the first two hours. Residents were observed and spoken with, although most had limited means of communication. Staff and two visitors were also spoken with and all communal areas of the home were visited briefly. The midday meal was served and observed during the visit and a selection of records was examined. The manager had previously completed an Annual Quality Assurance Assessment and returned this document to the CSCI. Details from this document are included throughout this report. CSCI questionnaires have been sent to the relatives of some residents and some staff questionnaires were given out during the inspection. Questionnaires were also left at the end of the inspection so that staff could assist any residents who wanted to in completing these forms in quiet moments. Information from these questionnaires will be included in the next inspection report. What the service does well: The home provides a very positive environment for people with varying levels of confusion and has been designed and built with these service users in mind. Residents spoken with, who could voice an opinion, said they were happy living in the home and praised the staff team and the manager. The visitors spoken with said that the care provided for their relatives was extremely good and that they felt all residents were well looked after. Staff generally took pains to communicate with residents, even when simply walking past where they were sitting, and residents were seen treated as individuals and with respect. The home receives advice and input from a dementia specialist and staff are well trained in providing services for people who are confused. Staff training is given a high priority and the training co-ordinator takes pains to ensure that training is thorough, understood and put into practice by staff. Techniques observed for assisting residents with mobility problems to transfer Allington Court DS0000019266.V352313.R01.S.doc Version 5.2 Page 6 were safely completed and in all cases staff took time to explain what was about to happen to the residents, thus putting them at ease. A wide variety of daily activities is provided for residents and the activity coordinators provide events with enthusiasm and dedication. Good levels of stimulation are provided daily for the residents of the home. The meals provided are of a high standard and the chef ensures that all meals contain the correct balance of nutrition as recommended in current guidelines for promoting the health of older people. Thorough systems are in place to ensure that all staff concerned with providing food are aware of every individual who needs a special diet. Attractively presented snacks are also available throughout the day, so that those people who have difficulties eating a full meal are provided with nutrition in other ways. The meal observed during the inspection was enjoyed by residents and provided another pleasant experience for the residents concerned. What has improved since the last inspection? What they could do better: Lack of storage space was identified as a problem at the last inspection and a recommendation was made that the manager should address this issue. Bathrooms were seen with inappropriate equipment and furniture stored in them on this occasion and so the recommendation is carried forward in this report. The manager will also review the system of locking residents’ bedroom doors and bathroom doors, when no one is in the rooms. The manager will review the procedures used in light of the Mental Capacity Act. Allington Court DS0000019266.V352313.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Allington Court DS0000019266.V352313.R01.S.doc Version 5.2 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 Allington Court DS0000019266.V352313.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 3 and 4. Standard 6 does not apply to this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed information about the home is provided for all prospective residents and full assessments are completed so that all parties can be sure the home can meet the individual’s needs. Procedures followed in all areas of the home ensure that appropriate services are provided for people with a dementia. EVIDENCE: Appropriate details about the home are provided in a brochure, which is given to all residents, prospective residents and their families. Fees for the home and what the fees include are clearly set out. All residents also have a written contract, which states the room to be occupied and how fees are to be paid. The residents’ records examined during the visit contained copies of care summaries from referring agencies and written assessments of needs, Allington Court DS0000019266.V352313.R01.S.doc Version 5.2 Page 10 completed by senior staff in the home. Initial individual care plans had been completed using this information. The home provides care for people with a dementia and all staff have received training in aspects of dementia care. The building is constructed to provide a safe yet accessible environment for individuals who are confused and the grounds are attractive and secure. BUPA, the owning company, commissions the services of a professional specialist in dementia care and research. Evidence was seen of visits to the home from this specialist who also gives regular talks to residents’ families and friends. Allington Court DS0000019266.V352313.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All individual needs are detailed in residents’ care plans enabling staff in the home to be aware of the needs and to ensure that they are appropriately met. Procedures followed in the home ensure that medication is safely administered and that residents are treated with dignity and respect. This means that residents are protected from harm and still feel valued as individuals. EVIDENCE: A selection of care plans was examined after the individuals concerned were spoken with or observed. A new format, introduced by the owning company, was being used and so some of the recording had been recently completed or was in progress. A “Map of Life” is now included in all plans and, when finally completed, these charts will highlight the important events and preferences in the individual’s life and enable staff to better understand the needs of the residents, many of whom have limited communication abilities. The care plans Allington Court DS0000019266.V352313.R01.S.doc Version 5.2 Page 12 examined had been signed by the residents or their relatives and updated risk assessments were in place. Work is still going on to ensure that recording in the care plans is meaningful and more risk assessments and behaviour management plans will be needed as situations, such as changes in a resident’s behaviour or health, present new difficulties for staff management. When completing daily records care staff should also be careful to evidence that an agreed plan of care has actually been followed and details should be recorded. Individual dietary needs had been assessed and recorded in care plans and subsequent directions for any special diets were seen clearly listed in the home’s kitchen. The chef was fully aware of all dietary needs and had implemented systems to ensure that the correct food was provided. Some residents had been assessed as needing a “soft” diet and it was recommended that reasons for this were made clear in care plans and that details of the actual foods which should and should not be given is documented in care plans and in the kitchen, so that no one is put at risk of harm from eating food of the wrong consistency. Care plans contained evidence that individual health needs were monitored and met and some residents spoken with were able to confirm that they had visits from a chiropodist and saw the dentist. One resident was due to have a visit from an optician on the afternoon of the inspection. Care records showed that all residents had their weight regularly checked and that any resulting concerns resulted in close dietary monitoring. During the visit staff were observed using a variety of equipment to assist residents to transfer from and to chairs and beds. All such assistance was provided in a professional manner and approved techniques were being followed by staff, thus ensuring everyone’s safety. In all cases staff explained what would be happening to the resident concerned and were able to prevent anyone being alarmed about being moved. It was good to see that staff training in Moving and Handling residents was being properly followed in practice. Procedures for administering medication in the home were checked and storage and recording complied with all current guidelines. Most medication is pre-packed by the pharmacist but some is provided in individual boxes or containers. One packet of tablets was spot checked and the amounts counted corresponded with the completed drug records. It was just recommended that actual amounts of any medication carried forward for administration and recording onto a new month’s record, is recorded on the new chart so that audits can take place more easily. Staff in the home audit medication procedures every Sunday and visiting area managers complete regular audits when they visit the home unannounced. Residents spoken with who were able to express an opinion all said that staff treated them with dignity and respect and that their privacy was respected. These views were confirmed by the interaction between staff and residents, observed during the inspection. Allington Court DS0000019266.V352313.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Procedures followed in the home ensure that residents are provided with appropriate stimulation and recreation and that staff promote contact with families and friends. This support and provision, together with plentiful, well balanced meals mean that residents can enjoy the best possible lifestyle and can still feel included in the wider community. EVIDENCE: The home has three activity co-ordinators and has a large, dedicated activity room, which is bright and full of pictures, craft work and equipment and is clearly a popular place for residents to spend time. The room has its own washing and tea making facilities and snacks are provided when required, and especially in the afternoons. There was a fish tank in the room and fresh flowers adding to the pleasant atmosphere. During the inspection some residents were sitting in recliner chairs in the room and some were seated around the table, busy with craft occupations. Photographs of recent trips out were displayed on walls. The co-ordinator spoken with was very enthusiastic Allington Court DS0000019266.V352313.R01.S.doc Version 5.2 Page 14 about planned events and clearly had a real understanding of the individual characters and needs of the residents. The planned activities for the week were advertised on the notice board, but the co-ordinator explained that events could change on the day, if staff felt that a different activity would better suit the mood of the residents. Listed activities included art, cooking and special “themed” lunches. An “Italian Lunch” was planned for later in the month. One member of staff had brought her small dog into the home for the day and residents spoken with said this was a popular, regular event. One inspector spent time, during the visit, sitting in one of the lounges and observing the interaction of staff with the residents sitting there. Care and nursing staff were seen, on the whole, taking pains to communicate and acknowledge the residents. Even those staff passing through the room took time to talk to residents as they went and residents were not ignored by staff talking to one another. We felt this culture of inclusion and respect added to the well being of the residents in the home. The notice board also had details of events which include relatives and friends and the there are regular evening talks provided by a well known expert in Dementia care, who also provides dementia training and advice for the BUPA company as a whole. Staff confirmed that the residents’ visitors are welcomed in the home at all times and can see their relatives in private if they wish. Two visitors spoken with confirmed their involvement in the care of their relatives and praised the staff and all aspects of care provision. None of the current residents are able to handle their own finances and the manager said that all have family or advocate support for this. Staff also confirmed that residents were encouraged to bring personal possessions into the home and to personalise their bedrooms wherever possible. The mid-day meal was seen served and eaten in the dining room and this meal was plentiful, and looked nutritious and was served while still hot. Residents said they enjoyed the food in the home. The chef joined with the staff assisting in the dining room and clearly knew the residents and their preferences for food. Staff confirmed that the chef always came into help and see residents at meal times and the whole eating experience looked a pleasant and enjoyable occasion. There are always two cooked meals served to residents, except on Sundays, when tea is usually a variety of sandwiches and cold foods. During the other six days the lunches are two-courses and the evening meal has three courses. There is a four week rolling menu which is checked against the BUPA “Menu Master” guidelines to ensure meals are appropriately balanced and provide all appropriate nutrition as required by older people. The home also provides “Night Bite Menus” where night staff have access to appropriate snacks which can be provided for residents as they wish. The chef confirmed that snacks were always available for residents and there was a large tray of a variety of sliced fruit prepared and ready for the residents to help themselves to during the afternoon and evening. There had been an inspection of the Allington Court DS0000019266.V352313.R01.S.doc Version 5.2 Page 15 kitchen by the Environmental Health Officer earlier in the week when no requirements had been made. All kitchen staff are trained in Food Hygiene and have appropriate certificates available for inspection. Allington Court DS0000019266.V352313.R01.S.doc Version 5.2 Page 16 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 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures followed in the home ensure that any concerns or complaints will be appropriately investigated and that residents are always protected from abuse. EVIDENCE: The home has written policies on making a complaint, Safeguarding Adults and Whistle blowing. Staff spoken with said they were aware of these policies and had summaries of all the home’s policies provided in the staff hand book. The complaints policy is included in the home’s brochure, which is given to all residents, prospective residents and relatives and the policy is also displayed on the notice board in the entrance to the home. Staff spoken with confirmed they had received training in all aspects of Adult Protection and said they understood the corresponding procedures. There had been one recent Serious Concerns Meeting and one Strategy Meeting held with the Local Authority to consider two separate issues which had occurred in the home. All appropriate procedures connected to these investigations had been followed by the manager. The manager confirmed that one former member of staff had been referred to the Protection of Vulnerable Adults body for further investigation, so that all residents in care homes could continue to be protected from abuse. Allington Court DS0000019266.V352313.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 22 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents in the home benefit from living in a pleasant and well maintained environment and have their health promoted through staff using good infection control procedures. Some restrictions on residents’ access to all parts of the home mean that they are not able to fully decide where to spend time independently although the restrictions have been made in their perceived best interests. EVIDENCE: All areas of the home visited looked clean and well maintained. The grounds looked very attractive and were accessible to any residents wishing to walk or sit outside. The home usually has CCTV surveillance covering the grounds, for the protection of residents. However, this equipment is currently broken and the manager is waiting for a replacement. Allington Court DS0000019266.V352313.R01.S.doc Version 5.2 Page 18 A domestic assistant was cleaning bedrooms during the inspection and those rooms seen at this time were bright, clean and well decorated. However, all rooms not in use were locked and could only be opened by staff, who all carry keys. Staff confirmed that it had been agreed with the relatives of the current residents that residents’ bedrooms would be kept locked so that those who were confused would not wander into other people’s rooms and disturb their belongings. Bathrooms were also being kept locked so that residents would not be able to leave taps running, which had, in the past, led to flooding. These procedures were discussed with staff who felt that locking rooms was beneficial to all residents and said that anyone wanting to go to their rooms or to the bathroom would be taken there by staff and that several residents rested in their rooms in the afternoons. The policy of locking doors was discussed with the manager and it was agreed that the situation would be further reviewed. Any new residents would need to be in agreement with this policy, and documentation would be needed for all residents concerned. Should the home adopt the practice of locking doors as a policy, this should be stated in the home’s Service User’s Guide. However, it was agreed that the manager would discuss the matter further, especially in light of the implications of the Mental Capacity Act and its related requirements. Lack of storage areas in the home, as outlined in the report from the previous CSCI inspection, continues to be a problem and some bathrooms visited had inappropriate equipment left in them. One bathroom was “out of action” as the wardrobe and belongings of a resident was stored in this locked room. The resident concerned had previously pulled the wardrobe over, putting himself at risk and it had been agreed to remove the belongings and wardrobe for safety. The bedroom concerned was not seen on this occasion but staff should endeavour to consider ways to provide some belongings for this resident and should ensure that the whole situation is risk assessed and kept reviewed. It is not really acceptable to other residents who have bedrooms near the locked bathroom, not to have this facility near their rooms and more appropriate storage space should be found. The manager should include general storage problems in her assessment of the needs of the home and ensure findings are included in her reports to Head Office for further consideration. Relatives spoken with said that the laundry system in the home was good and that their relatives always had their own clothes returned from washing. The bathrooms seen had containers with liquid soap and paper towels in dispensers, as recommended in current guidelines for infection control. A domestic assistant spoken with confirmed that she had received training in infection control and could always access disposable gloves and aprons. Allington Court DS0000019266.V352313.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home are well trained and employed in sufficient daily numbers to ensure that all residents’ needs can be met. Thorough recruitment procedures are followed, which helps to protect residents from abuse by unsuitable staff. EVIDENCE: There were three Registered Nurses on duty during the inspection and the manager said there were always at least two Nurses employed on every shift. During the visit there appeared to be sufficient numbers of care staff on duty at all times to provide assistance and stimulation for the residents. Residents and relatives spoken with said they felt there were always enough staff on duty in the home. The recruitment records of five staff members were examined, all of whom had started work since the last inspection. Evidence of all appropriate recruitment checks was seen on these files. Staff spoken with said they received high levels of training and staff records checked, contained copies of training certificates. The home has a senior member of staff, dedicated to providing staff training. This co-ordinator ensures that individual training is kept up to date and there were very clear Allington Court DS0000019266.V352313.R01.S.doc Version 5.2 Page 20 records showing an overview of training in the home. Induction training is comprehensive and all new staff are given a “portfolio” or hand book which contains information and copies of the home’s procedures. Induction training for all levels of staff lasts for two weeks and is only finished when the trainee and trainer both sign the final records. A domestic worker spoken with confirmed that ancillary staff are included in all staff training and staff meetings. Training is clearly given a high priority in the home and is provided in a timely and professional manner. Care staff are encouraged to undertake NVQ training. Currently the home has not achieved the aim of having 50 of staff trained to NVQ level 2 or above, but staff are working towards that target. Allington Court DS0000019266.V352313.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a stable environment which is well managed and where their interests are given priority. Procedures followed in the home ensure that residents’ finances are protected and where their welfare and that of the staff are promoted by safe practices being followed. EVIDENCE: The manager is registered with the CSCI and staff and residents spoken with praised the management of the home and said they felt supported and could speak with the manager at any time. Allington Court DS0000019266.V352313.R01.S.doc Version 5.2 Page 22 The manager sends out Quality Questionnaires to families and other stakeholders at regular intervals. The manager also completes monitoring reports on all aspects of the day to day running of the home and sends monthly reports of outcomes to the Head Office. The manager confirmed in the Quality Self Assessment report sent to the CSCI that all policies and procedures in the home have been recently reviewed. Residents all have relatives or advocates who handle their finances, but small amounts of money are also held at the home for the residents to use for daily expenses. Families send amounts to the home and this money is deposited in a bank account. Statements of this account were seen and records of the individual residents’ share of this money was also seen recorded and balanced with the total amount. Receipts are kept showing how all money spent for or by residents is accounted for. Staff spoken with confirmed that formal supervision now takes place and that this happens about every six weeks at present. Annual staff appraisals also take place and all supervision is recorded and signed. Staff confirmed that regular fire tests and drills take place and no hazardous substances were seen left in accessible places during the visit. All staff spoken with said they had received training in Health and Safety, Fire safety and Moving and Handling. The home has a written Health and Safety Policy and general risk assessments for the home have been completed. Allington Court DS0000019266.V352313.R01.S.doc Version 5.2 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 3 3 3 3 x 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 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x 2 x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 3 x 3 Allington Court DS0000019266.V352313.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP19 Good Practice Recommendations The storage needs of the home should be audited by the manager and action taken to address any shortcomings revealed. THIS RECOMMENDATION WAS MADE IN THE LAST INSPECTION REPORT BUT HAS NOT YET BEEN ADDRESSED. The policy of locking bedroom and bathroom doors in the home when residents are not in these rooms should be reviewed and outcomes documented. 2 OP22 Allington Court DS0000019266.V352313.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 Allington Court DS0000019266.V352313.R01.S.doc Version 5.2 Page 26 - 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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