Inspection on 31/01/08 for Allington House

This inspection was carried out on 31st January 2008.

CSCI found this care home to be providing an Adequate service.

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 House 17/02/10

Allington House 17/12/08

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Allington House Marsh House Avenue Billingham Cleveland TS23 2HB Lead Inspector Jackie Herring Key Unannounced Inspection 31 January 2008 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 Allington House DS0000070601.V353922.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 House DS0000070601.V353922.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Allington House Address Marsh House Avenue Billingham Cleveland TS23 2HB 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) 01642 565 839 Southern Cross OPCO Ltd Karen Ruth Johnson Care Home 46 Category(ies) of Dementia (24), Old age, not falling within any registration, with number other category (46) of places Allington House DS0000070601.V353922.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with Nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the Home fall within the following categories: Old Age, not falling within any other categories, Code OP- maximum number of places 46 2. Dementia, Code DE, maximum number of places 24 The maximum number of service users who can be accommodated is: 46 Date of last inspection Brief Description of the Service: Allington House is a purpose built, two storey care home situated on the outskirts of Billingham. It provides nursing care for older people and personal care for older people with dementia in two clearly defined units. The home is well located for ease of access to the local town centre and in very close proximity to a local pub. All of the rooms are single rooms with ensuite facilities and a good amount of communal space. Garden areas are available and in the process of being developed further for the safe use of all. The charges currently were not available at the time of the inspection. Confirmation will be obtained prior to the report being finalised. Allington House DS0000070601.V353922.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This is the first inspection of Allington House, which was registered in September 2007. It was an unannounced Key Inspection on day one. All of the key standards relating to older people were looked at. This was to check that the home meets the standards that the Commission for Social Care Inspection say are the most important for the people who use the services, and that it does what the Care Standards regulations say it must. The visit to the home was conducted across two inspection days. During the visit to the home, a number of records were looked at, including records of people who use the service, along with medication records, staff records, training records and maintenance information. Time was spent talking to people who use the service, relatives and staff. Time was also spent walking around the home, observing interactions and generally finding out what Allington House was like for people living there and for staff. Discussion also took place with the temporary manager and there was discussion with the Operations Manager. Surveys were sent to the home for completion, a number had been completed and returned by people who live at Allington House and some relatives. The previous manager has completed the Annual Quality Assurance Assessment (AQAA), the services self-assessment of how well they think they are meeting standards. This was received prior to the inspection and it was then used as part of the inspection process. The previous manager needed some support and guidance to complete the AQAA. Some of information has been reflected within the report to support the judgements made. During discussion with the Operations Manager, further plans to develop the dementia care unit were discussed. They said that the organisation had developed a number of Dementia Houses and would be doing the same at Allington House. Allington House DS0000070601.V353922.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: This was a good first inspection. There is however a number of areas identified as in need of further development, which will enhance what has already been achieved. There is the need to appoint a manager who will provide the leadership and management of the home. The hot water to baths and showers is tested and recorded monthly. Consideration should be given to increase this to weekly. There is the need to also ensure that all staff have the required health and safety training and that all of this training is recorded. Some additional checks are needed in regard to the medication storage and the temperature that the medication is stored at. Some additional attention to detail is needed with any medication that is handwritten on the medication administration record. Audit of controlled drugs are also needed. Allington House DS0000070601.V353922.R01.S.doc Version 5.2 Page 7 Assessment of need and care records whilst in place for everyone are in need of some additional detail to capture more person centred information. Staff numbers need to be reviewed to ensure that these are appropriate to meet the nursing and personal care needs of people living at the home. People who have the personal allowances looked after by the home need to have access to this at all times should they require it. 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 House DS0000070601.V353922.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 House DS0000070601.V353922.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: 3 & 6 were looked at. People who use the service experience good quality outcomes in this area. People have their needs assessed before being admitted to the home and they were assured those needs would be met. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The AQAA detailed the pre admission assessment process. It was stated, “Prior to admission a comprehensive assessment is carried out and a copy of their social service care plan is obtained”. It also detailed opportunities for informal visits such as having a meal and spending time within the home prior to admission. Four sets of care records of people who use the service were looked at, two from the nursing unit and two from the EMI unit. There was a pre admission assessment in place in all four records along with a care management assessment. On the first day of the inspection, two community matrons were visiting. They commented on the planned admission process and also about the welcome Allington House DS0000070601.V353922.R01.S.doc Version 5.2 Page 10 baskets in the bedrooms, which they said was a very thoughtful and welcoming touch. Allington House does not provide intermediate care. Allington House DS0000070601.V353922.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 & 10 were looked at during this inspection. People who use the service experience good quality outcomes in this area. People receiving the service are happy with the way in which care is delivered by staff. Some of the records detailing how health and personal care is to be delivered and associated risks need more detail and information. The system for managing medication is generally good however some areas need to be strengthened. Only staff who have received the appropriate training have any involvement with medication. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The same four sets of records were looked at in more detail. The actual format in terms of information flow was good, leading from assessment to care plans, related risk assessment and daily records. The records of the two people receiving nursing care were very detailed, with well laid out care plans containing clear and specific interventions. Informative evaluations of care were also taking place but these need to take place monthly rather than two monthly. Allington House DS0000070601.V353922.R01.S.doc Version 5.2 Page 12 The records looked at for two people living within the EMI unit generally contained the information needed. It was however identified that some additional detail was needed and that by increasing the level of personal detail this would enhance the records further and create a more person centred plan of care. A range of supporting risk assessments are in place, including amongst others, one for nutrition, moving and handling and pressure risk. It was advised that some care is needed with the bed rail risk assessment, as in one of the records looked at it had only one staff members signature and did not look like it had been agreed within a multidisciplinary way. It was confirmed through discussion with the Operations Manager that it would be usual practise for the manager of the home to be involved in this risk assessment and decision making process. Discussion took place about the need to involve the person receiving the care or a relative. In all four of the records looked at, there was no evidence to show that people who use the service or their relatives have been involved in the assessment or care planning process or that they had agreed the plans of care. There are clear records that detail the involvement of other people such as GP’s, District Nurses, Optician and Continence Advisors. One of the resident said, “I am really quite happy here, staff are helpful and kind, they are very good to me, I wouldn’t change anything”. Another said, “My needs are being met, the nurses are very good”. One relative said, “”They take an interest in everyone, considering their needs as individual”. Staff spoke positively about their job roles. One person said “We try to keep them cheerful, promote their independence and try to motivate and encourage choices”. “It is important that we know our clients we can for continuity of are, getting to know their ways and their habits”. Another member of staff said, “It is about individual clients, that they are allowed to do things at their own pace, make their own decisions”. The medication system was looked at and there was discussion with one of a qualified nurse for the system in place within the nursing unit and with a senior care assistant for the system in the EMI unit. The system was generally good in terms of ordering, storage and administration. Medication records are fully completed, contain required entries, and are signed by appropriate staff. It was confirmed that only qualified nursing staff were involvement in the administration of medication within the nursing unit and staff who have completed safe handling of medication training are involved in the administration of medicines and this tends to be the senior staff within the home for the EMI unit. Attention to detail is needed when handwriting on the Allington House DS0000070601.V353922.R01.S.doc Version 5.2 Page 13 Medication Administration Record as there are entries when there is not a double signature. Audits are in place for the main medication system, within Southern Cross’s main audit; however Controlled Drug audits also need to be carried out. The medication room on the ground floor is quite small and was really quite warm. The temperatures is being monitored, this needs to continue and action would need to be taken if it is continually higher that 25 degrees centigrade. Where medication is stored in the fridge, the fridge needs to be kept locked. Allington House DS0000070601.V353922.R01.S.doc Version 5.2 Page 14 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, 15 were looked at during this inspection. People who use the service experience adequate quality outcomes in this area. People who use the service have some opportunity to take part in activities. They are supported to live in a flexible environment where there is choice of routines and independence. The food provided is of a satisfactory quality and meets the dietary and cultural needs of the people who use the service. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: An activities person is in post who discussed the range of activities currently underway within the home. They said that they had done some arts and crafts and home baking. That there are music sessions, skittles, bowls and dominoes. A recent visit from the local library had taken place. Time is also spent with people on an individual basis, talking to them or reading. They said that there is no specific budget for activities. They said that it would be good to bring in some outside entertainers but not enough money has been raised for this as yet. Plans are underway for a Valentine supper and there will be a raffle and tombola. There were some mixed thoughts about the activities; some people thought there was sufficient, whilst other thought more could be developed. Some staff who said, “Activities is something that needs to be addressed, Allington House DS0000070601.V353922.R01.S.doc Version 5.2 Page 15 entertainers are few and far between”, “More activities would be beneficial to the residents”. Activities should be linked to people’s interests and lifestyle. A person who lives at Allington House said that they received a daily newspaper but felt they were lacking in companionship, as there was limited socialisation and communication with others. Visitors were seen on both inspection days and were clearly welcomed into the home. They spoke of the kindness of the staff to both themselves and their loved ones. Some of the people living at the home had telephones in their rooms and one person spoken to was very glad of the regular contact they could have with their family. A relative stated, “They are very welcoming. Extremely pleasant and helpful, every member of staff we have come into contact with have been excellent”. There was some mixed views about the meals, some people were very satisfied with them, whilst others thought that there was some room for improvement particularly with the meat that was described as, “a bit tough and grizzly at times”. A number of comments were made within the surveys, they said, “More variety would make the meals more appealing”. “The meals are usually too repetitive, especially he mince meat, which sometimes is served in various ways meal after meal”. “Cannot always finish meal, as it goes cold due to plates not being warmed. Sometimes sliced fruit is cold and hot custard put over the top. Not much variety and no second choice available”. A menu was made available, which showed two choices. On the first day of the inspection, staff said that the two choices were not fully in place however this was in the process of happening. On the second inspection day, choice was clearly being offered to people who use the service. Dining rooms were observed to be pleasant and table cloths; condiments and flower decorations were in place. Allington House DS0000070601.V353922.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 & 18 were looked at during this inspection. People who use the service experience adequate quality outcomes in this area. A complaints procedure is available within the home. It is unclear if complaints are being fully recorded or logged. Some staff have had training around safeguarding adults, but records are not in place to show that all staff have had this training We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The AQAA detailed that there had been no complaints since the home was registered. When asked to look at the complaints file on the first day of inspection, it was not available and people did not know if there had been any complaints or not. The complaints procedure was on display within the main reception of the home. On the second inspection day, the complaints file was available and a complaint had been recorded following the first inspection day. Although the company audit completed by the previous manager detailed there had been no complaints made, there was very limited information detailed within actual audit form. It is unclear up until the first day of inspection how active people were in recording concerns raised. The surveys showed that some minor issues had been raised, however these had not been recorded. People who use the service also said they had raised some issues but again these were no records of this. One person said, “I have raised a small number of concerns amongst them, the frequency of bed-changing and bathing, these are better now that it has been organised”. Allington House DS0000070601.V353922.R01.S.doc Version 5.2 Page 17 Staff said that they had received training in regard to Protection of Vulnerable Adults, however the training records were in need of updating. Allington House DS0000070601.V353922.R01.S.doc Version 5.2 Page 18 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, 20, 24, 26 People who use the service experience good quality outcomes in this area. People live in a safe and very well maintained environment. Allington House is clean, well decorated and extremely homely. There is a good range of equipment in place to support residents with mobility needs. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: People who live at Allington House enjoy living in a very clean, fresh and spacious home. The home is well decorated and offers a very pleasing environment for the people to live. There are a lot of homely touches throughout the home, including ornaments, pictures, tables and mirrors all of which create a tasteful and homely place for people to live. Resident’s rooms have letterboxes and door knockers. People are encouraged to bring their own belongings with them to the home and there was evidence of personalisation of a number of the bedrooms visited. There is a good amount of communal and sitting space around the home. Allington House DS0000070601.V353922.R01.S.doc Version 5.2 Page 19 All bedrooms are nicely decorated and furnished and well equipped and all have an accessible ensuite. Telephone sockets are available and in some of the rooms visited resident’s had their own phones, which helped them maintain contact with friends and family. A relative stated, “The home is constantly clean and the staff do their best to keep the standard that a care home should be”. Some improvement is needed to increase the level of privacy to some of the ground floor rooms. A footpath is laid around the home, however children from the local community are using this for public access and a cut through. This is extremely close to some of the bedrooms and people do not feel they have the privacy they need. It was confirmed that gates are to be erected, which will diminish this problem. One of the surveys contained the following statement, “There is not enough privacy within the rooms and some of the clients must feel as though they are in a goldfish bowl on public view, as visitors can see straight into their rooms. Vertical blinds would assists, not only for privacy but keeping the sun out so when it is sunny clients don’t have to sit with the curtains closed all day”. A person living at the home said, “Outside of my room window is a thoroughfare, I believe there are plans to put a high wooden gate up, the view could also do with improving, it needs to be softened as it only a bare fence”. The gates would also be needed to create an accessible and safe environment for people who live within the EMI unit to use. Some improvements are needed to the staff stations on the ground and first floor as these areas potentially do not promote confidentiality of information, such as telephone calls to GP’s, district nurses and family members. Allington House DS0000070601.V353922.R01.S.doc Version 5.2 Page 20 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 & 30 were looked at during this inspection. People who use the service experience adequate quality outcomes in this area. People are generally satisfied with the care they receive, but there are times when they may have to wait to have their needs fully met. The temporary manager recognises the need to ensure all staff are well trained although records to support this need further development. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: A number of surveys had been received prior to the site visit to the home and there was also a telephone discussion with a relative. There was some concern expressed about the staffing levels within the home. People thought they were insufficient to fully meet the needs of the people living there. On the first day of inspection, this was discussed with the temporary manager, who agreed with the comments made particularly on the basis of the more dependant and complex needs of some of the people using the service. There was discussion about required staffing levels, as through discussions there were perceptions that CSCI or the government set the staffing levels needed. The inspector confirmed the staffing levels needs to be determined primarily by the needs of the people who use the service; the layout of the building also needs to be considered, as does the number of people within each of the units. The providers and not CSCI determine staffing levels. A relative survey stated, “Whilst the staffing levels may (although not always) met the government guide levels, this is not sufficient to cater for the needs of numerous highly dependent clients”. Allington House DS0000070601.V353922.R01.S.doc Version 5.2 Page 21 People said, “There are not always enough staff on duty to be available when needed and patients have to wait for them to become available”. “Although all of the staff give the care support required when possible, there is not always enough staff on duty to meet the needs of highly dependent patients”. Staff who were spoken to on the second day of inspection said that they had been struggling to meet the needs of people, however since the first inspection day, staffing numbers had increased on both units and this was much better for everyone. Staff said, “There is a good team here, although we haven’t got enough staff, we do all help each other and everyone is doing their best”. During the inspection, further recruitment was taking place and would continue as the number of people being admitted to the home increases. A number of staff files were looked at and in the main contained the required information such as application forms, references and details of Criminal Records Bureau checks. An area that was of some concern was the number of people who had commenced employment on a POVA First rather than a full CRB. The interim manager confirmed that this was not the usual procedure and they would always try to ensure that the full CRB was in place prior to commencement of employment. It was also identified that a system to ensure that qualified nurses were eligible to practise through confirmations made with the Nursing and Midwifery Council was needed. The AQAA detailed that at the time of completing, 56 of care staff were qualified to NVQ Level 2. Training records were looked at and it was agreed with the temporary manager and Operations Manager that further work was needed with them to show accurate and up to date records for all of the staff training. A rolling programme for mandatory training was discussed and it was confirmed that some of this training was now being rolled out. The Operations Manager showed a sample of the training records that would be in place in the future, these were very clear and detailed what was needed. On day one of the inspection it was unclear if staff who did not have NVQ Level 2 if they then did the Skills for Care induction. The Operation Manager on the second day of inspection confirmed that this was the case. Allington House DS0000070601.V353922.R01.S.doc Version 5.2 Page 22 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 & 38 were looked at during this inspection. People who use the service experience adequate quality outcomes in this area. There is currently no registered manager in post. A number of areas require further development to ensure good management systems are in place and that health and safety is fully promoted. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There is currently no registered manager in post at Allington House. The manager who was registered has since left. Interim arrangements have been put into place pending successful recruitment into post. The arrangements are that a manager from another Southern Cross home is covering both their own care home and Allington House. On the second inspection day, a perspective manager was being shown around the home. The Operation’s Manager said that it is hopeful that the new manager would be commencing employment in the near future. Allington House DS0000070601.V353922.R01.S.doc Version 5.2 Page 23 Staff did speak about the management turnover and expressed some concern about this. They said that the manager and two deputy managers had left and that the administrator was also leaving. They spoke of the need for stability within the home. Positive comments were made about the current temporary manager, they said, “She has been really good, marvellous, she listens, is fair and straightforward”. A person living at the home also spoke of the need for stability. They said after some discussion, “I like the place and the people, I think it will settle”. A range of audits systems are operated by Southern Cross as described both in the AQAA and by the Operations Manager. These will be looked at in more detail at the next inspection. The personal allowances of people who live at the home were looked at. All of the money looked after on behalf of the people who live at the home was pooled together. Financial transaction sheets were in place and these detailed income, expenditure and were supported by receipts. There is national agreement with how personal allowances are managed by Southern Cross; the Provider Relationship Manager confirmed this. When asked how people had access to their money out of office hours, the answer was that they did not. This is unacceptable and people should be able to access their money at all times. The Operations Manager said that a float of money should be available for these times, however this had not been operated in Allington House since registration. It was agreed that this would be addressed straight away. Maintenance records were looked at. Southern Cross has a range of manuals in which details of checks and maintenance are recorded. A sample of maintenance records were looked at and showed that weekly fire checks take place. It also detailed that further work was needed with fire drills and the zone locations. Water temperatures are also checked, however there is the need to have more detail in the recording and the bath and shower needs to be checked more frequently, currently this is monthly. Whilst it is acknowledged that mandatory training is in the process of being implemented, training records need to be improved to show that staff are up to date with all aspects of health and safety within the home. Allington House DS0000070601.V353922.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X 2 X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 X 2 2 Allington House DS0000070601.V353922.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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 OP16 Regulation 22 Requirement The actual system for recording complaint and concerns must be reviewed to ensure that staff have access to the system used and that they are being appropriate recorded, addressed and audited. This will ensure that people’s concerns are listened to and addressed. The numbers of staff must remain under review to ensure that they are appropriate and able to meet the needs of the people who use the service and category of care provided. This will ensure that people’s needs are fully met. The management arrangements must be formalised and the stated action must be taken for there to be a manager registered with CSCI. This will ensure leadership and management of the home for all. People must be able to have access to their personal allowances, giving them choice and flexibility. Timescale for action 29/02/08 2. OP27 19(1) 29/02/08 3. OP31 8(1) 01/05/08 4. OP35 17(2) 29/03/08 Allington House DS0000070601.V353922.R01.S.doc Version 5.2 Page 26 5. OP37 17 6. OP38 13/23 The staff work station must provide confidentiality and ensure that records and information about people in kept in accordance with the Data Protection Act 1998 All staff must receive mandatory training and this must be fully recorded. This will ensure both people who live at the home and staff are protected and safe. 31/07/08 30/05/08 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 OP7 Good Practice Recommendations Care records should be developed further, with more personal details; this would enhance the records further and create a more person centred plan of care. People who use the service and/or their relatives should be involved in the assessment process and should agree with the plan of care. Bed rails risk assessment tools should be fully completed by appropriate individuals and as far as possible be multi disciplinary. Where medication is handwritten on to the Medication Administration Record, this should be signed for by one staff member and signed and witnessed by another. When medication is stored in the fridge, the fridge should be locked. The temperature of the ground floor medication room should be regularly monitored to ensure that it is not too hot. If it continues to be then action needs to be taken to reduce the temperature. An audit system should be developed and introduced for controlled drugs. Allington House DS0000070601.V353922.R01.S.doc Version 5.2 Page 27 2. OP9 3. 4. OP12 OP15 Social and recreational activities should continue to be developed in line with peoples needs. The menu must be reviewed to ensure that people have a choice and have a variety of meals available to them, ensuring that nutritional needs and preferences are catered for. This will ensure satisfaction with the food provided and that it is balanced, nutritious, varied and sufficient in quantity. All staff should have safeguarding training and this needs to be recorded. The planned work to increase the level of privacy to a number of bedrooms should be carried out. There must be an up to date programme that details the training in place for staff. Staff need to undertake training that gives them the knowledge and skill to meet the needs of the people they are caring for. Bath and shower water temperatures should be checked and recorded in line with the Health and Safety Executives recommendations ensuring more safety in these areas for people who use the service. 5. 6. 7. OP18 OP24 OP30 8. OP38 Allington House DS0000070601.V353922.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 House DS0000070601.V353922.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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