Inspection on 11/10/05 for Allison House

This inspection was carried out on 11th October 2005.

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

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

Other inspections for this house

Allison House 09/05/07

Allison House 23/06/06

Allison House 09/06/05

Allison House 08/11/04

Allison House 01/06/04

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

CARE HOMES FOR OLDER PEOPLE Allison House Fudan Way, Teesdale Thornaby Stockton-on-Tees TS17 6EN Lead Inspector Julia Connor Unannounced Inspection 09:30 11 October 2005 th 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 Allison House DS0000000140.V253947.R01.S.doc Version 5.0 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. Allison House DS0000000140.V253947.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Allison House Address Fudan Way, Teesdale Thornaby Stockton-on-Tees TS17 6EN 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) 01642-675983 01642 675985 Cleveland Alzheimers Residential Centre Mrs Angela Jane Blythe Care Home 38 Category(ies) of Dementia - over 65 years of age (38) registration, with number of places Allison House DS0000000140.V253947.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of 8 places can be used for people with dementia aged 50 . 9th June 2005 Date of last inspection Brief Description of the Service: Allison House is a care home providing nursing care for older people with mental health needs. It is a single storey purpose built home, all bedrooms are for single occupancy; bedrooms are not en-suite. The bedrooms are a minimum of 10 sq.m. There are two dining rooms and several lounges. The home is on a bus route and close to the local town centre. Car parking facilities are provided. Allison House DS0000000140.V253947.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection commenced at 9.30 a.m. and concluded at 4.15 p.m. visitors’ and two members of staff were spoken to during the inspection. Two Due to the nature of their mental health problems the Residents were unable to voice their opinions of the home. However, the wives of two Residents’ spoke to the Inspector. Two Relative/Visitor comment cards were returned to CSCI; both of the respondents were satisfied with the care their relative received. The Inspector was concerned that she was allowed into the building without a member of staff checking that she was who she stated she was or checking her identification card. This was discussed with the Manager who stated that she would speak to staff about security within the home. What the service does well: Several of the staff have worked at the home for many years and have a good knowledge of the Residents’ they care for. One wife stated that the staff were ‘affectionate with her husband and spent time with him’. She stated that she knew that when she was not at the home with her husband he was still well cared for. She stated that her husband was always nicely dressed and she felt that he was treated with respect and dignity. She stated that she was always informed of her husband’s condition or if he had sustained any accidents. The second wife stated that her husband was new to the home but had settled in. She stated that the staff were good with her husband and she liked the way the staff spoke to her husband. She stated that on her first visit to the home she was nicely greeted and got a ’good feeling’ about the home. She stated that the staff would always let her know what was happening regarding her husband and that made her feel as if she was still part of her husband’s care. She stated that she had worried at first but now she knew that she had done the right thing and knew that her husband was well cared for. Allison House DS0000000140.V253947.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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. Allison House DS0000000140.V253947.R01.S.doc Version 5.0 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 Allison House DS0000000140.V253947.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 The Resident has their needs assessed prior to their admission to the home, however there was no evidence that they had been involved in the assessment process. EVIDENCE: Three of the Residents care files were audited and all contained assessments carried out by Nurses from the discharging ward or Social Workers. Pre admission assessments had been carried out by staff from the home prior to admission. There was no documentation in place to show that the Resident or their family member had been involved in the assessment that took place. Allison House DS0000000140.V253947.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 and10 The Residents nursing and personal care needs are not recorded fully in individual care plans. The Nurse in Charge administers medication to the Residents’. The family of Residents state that their family members are treated with respect and their privacy is upheld. EVIDENCE: Three Residents care plans were audited. Although the recording in the files had improved there is still some work to do. There was documentation that had not been completed fully e.g. the mental health document for one Resident had not been completed. There were risk assessments in place that had not been signed for by the Resident’s next of kin. One risk assessment stated that the Resident would be weighed twice a month but this action did not take place. One Resident had a risk assessment for pressure sores that was not evaluated regularly enough. There was a care plan for two identified problems when really each problem should have had a separate care plan. Allison House DS0000000140.V253947.R01.S.doc Version 5.0 Page 10 The evaluation of care plans and risk assessments do not always take place within the time frame specified. The day in the life of statement is not always updated therefore it was difficult to assess if the Resident still had the previous care needs. There was documentation that did not have the name or signature of the nurse completing it There is a policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. The family members who spoke to the Inspector stated that they felt that their loved one was treated with respect. The staff that spoke to the Inspector was able to demonstrate how they would ensure Residents’ privacy was respected. Allison House DS0000000140.V253947.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Activities take place within the home. Residents’ main contact with their family. Residents are encouraged to make choices. Residents receive a wholesome and appealing diet for breakfast and lunch; the food served for the evening meal is not always of an acceptable standard. EVIDENCE: There is no designated activity person in the home so the staff tries and do some form activity for the Residents if they have the time. There was photographic evidence that activities are now being offered to Residents on a more regular basis; however, planned activities now take place as well as ‘ad hoc’ activities. One visitor confirmed that she had witnessed activities taking place. The staff also confirmed that activities took place on a more regular basis. The family members’ who spoke to the Inspector stated that they were able to visit at any time and were always made welcome. Both of these family members stated that there husbands were encouraged to make choices but due to their illness were often not able to choose what they wanted. The kitchen was clean and tidy and the food stored in the fridge/freezers was dated appropriately, as was the dry goods in the storeroom. Allison House DS0000000140.V253947.R01.S.doc Version 5.0 Page 12 Breakfast and lunch is of an acceptable standard. However the food served for the evening meal is, at times, not of an acceptable standard or the quantity is insufficient. Allison House DS0000000140.V253947.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Relatives are confident that their complaints will be listened to, taken seriously and acted upon. EVIDENCE: There have been thirteen complaints regarding the home in the last 12 months. There is a policy and procedure to follow should a visitor or member of staff wish to make a complaint. The two family members who spoke to the Inspector stated that they had not made a complaint but were confident that if they did the complaint would be taken seriously and action taken. Allison House DS0000000140.V253947.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24, and 26. The Residents do not live in a well-maintained environment. There are lounge chairs and commodes that are well worn. Although the Residents’ bedrooms have been personalised many are in need of decorating. There are areas within the home that have offensive odours. EVIDENCE: The following issues were identified during a tour of the building: The flooring in toilet one, bathroom one and bathroom two requires a good clean. Twenty-six of the bedroom commodes need replacing. The renewal of commodes has been highlighted in the last three inspection reports. The Inspector asked for 3 of the commodes to be taken out of commission, as they were a risk to the Residents as the wood was rotting away. Allison House DS0000000140.V253947.R01.S.doc Version 5.0 Page 15 A shower chair was also put out of commission as it was rusting and so presented a risk to Residents. Twelve of the bedrooms required decorating. There were bedrail covers that had not been cleaned prior to being stored away for the day. Bathroom two on Aspen unit has woodwork that requires painting. Bathrooms’ two and four on Willow unit need decorating. Aspen lounges one and two requires decorating. Willow dining room requires decorating. There is a strange odour form the drain in shower one. The Inspector was showed the order form for the new furniture that the Manager had ordered. There were areas within the home that had an offensive odour. Allison House DS0000000140.V253947.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. The Residents’ needs are met by the number and staff mix of the staff on duty. Staff are being trained to NVQ level 2 that should ensure that they can meet the Residents needs. The Residents are protected by the home’s recruitment policy and procedures. Staff receive training to ensure they are competent to do their jobs. EVIDENCE: The Manager informed the Inspector that there was two trained staff and six care assistants on duty during the day and one trained nurse and eight care assistants on an evening shift; one trained nurse and three care assistants on a night shift. An audit of four weeks of the duty rota showed that the home had the amount of staff on duty as the Inspector had been informed. 42 of the staff has an NVQ Level 2 or 3 in care. A further six members of staff are currently studying for their NVQ Level 2 in care. Three personnel files were audited; all contained the required information as stipulated in Schedule 2 of the Care Homes Regulations 2001. Mandatory training has taken place since the last inspection – manual handling, fire training and health and safety. Staff have also received training in food hygiene. Trained staff have received training in venepuncture. Staff who spoke to the Inspector confirmed that training took place. However, staff felt that training to cover general nursing issues would be beneficial. Allison House DS0000000140.V253947.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 35, 36 and 38 A person who is fit to be in charge manages the home. There is no effective quality assurance and quality monitoring system in place within the home. Financial viability for this year has yet to be received by CSCI. The home does not take control of the Residents’ personal finances. Staff do not received supervision. The health, safety and welfare of Residents are not always promoted and protected. EVIDENCE: The home now has a registered manager in post; who has the required nursing qualification to ensure that the needs of the Residents’ are met. The Manager is to commence her NVQ Level 4 in management. The staff spoke well of the Manager. Allison House DS0000000140.V253947.R01.S.doc Version 5.0 Page 18 The Inspector was informed that the General Manager was currently writing the quality audit document. Although the Inspector was able to evidence an example of the questionnaires that the staff and visitors were asked to complete there were no completed questionnaire available. The staff at the home does not handle any of the Residents personal finances. The Inspector was informed that supervision had commenced but was not able to evidence any completed supervision documentation. The Inspector was able to evidence that water temperatures and bed rail safety were checked on a monthly basis. There are policies and procedures for the health and safety of Residents and staff. Mandatory training for health and safety takes place. There were commode chairs and a shower chair that were in a poor state and presented a risk to Residents and staff. Allison House DS0000000140.V253947.R01.S.doc Version 5.0 Page 19 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 2 X x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 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 X 18 x 2 2 X X X 2 X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 2 3 2 X 2 Allison House DS0000000140.V253947.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard 3 Regulation 15 Requirement The registered person must ensure that the Service User plan be drawn up with the involvement of the Resident and/or their representative. THIS IS OUTSTANDING FROM THE OCTOBER 2004 INSPECTION. In order to demonstrate the home’s capacity to meet the assessed needs of the Resident, the registered person must ensure that there is sufficient information about Resident in the nursing documentation. Care plans must be evaluated as stipulated. THIS IS OUTSTANDING FROM THE OCTOBER 2004 INSPECTION. The registered person must provide, in adequate quantities, suitable, wholesome and nutritious food, which is varied and properly served. The registered person must ensure that all parts of the home are kept reasonably decorated. THIS IS OUTSTANDING FROM THE JUNE 2005 INSPECTION. The registered person must DS0000000140.V253947.R01.S.doc Timescale for action 31/01/06 2 7 15 31/01/06 3 15 16 Immediate 4 19 23 31/01/06 5 20 & 24 16 31/01/06 Page 21 Allison House Version 5.0 6 26 16 7 33 24 8 34 24 9 38 13 provide adequate furniture, bedding and other furnishings suitable to the needs of the Residents. The registered person must make suitable arrangements for maintaining satisfactory standards of hygiene in the care home. The registered person must establish and maintain a quality audit system. THIS IS OUTSTANDING FROM THE OCTOBER 2004 INSPECTION The registered person must, if the Commission so requests, provide such information to show financial viability. The registered person must ensure that all unnecessary risks to the health and safety of Residents’ are identified and so far as possible eliminated. Immediate 31/01/06 31/12/05 Immediate RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard 28 36 Good Practice Recommendations The registered person should make arrangements for a minimum of 50 of care staff to be qualified to NVQ Level 2 or equivalent by 2005 The registered person should ensure all staff to receive supervision at least 6 times a year and this to be documented. Allison House DS0000000140.V253947.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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