Inspection on 09/06/05 for Allison House

This inspection was carried out on 9th June 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 11/10/05

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 9 June 2005 10:30 am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Allison House B51-B01 S140 Allison House V231441 090605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Allison House Address Fudan Way Teesdale Thornaby Stockton-on-Tees TS17 6EN 01642 675983 01642 675985 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Cleveland Alzheimers Residential Centre Care Home 38 Category(ies) of DE(E) Dementia - over 65 (38) registration, with number of places Allison House B51-B01 S140 Allison House V231441 090605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th October 2004 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 B51-B01 S140 Allison House V231441 090605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection commenced at 10.30 a.m. and concluded at 3.00 p.m. Two Resident, one visitor and three members of staff were spoken to during the inspection. There is a new Manager in post whose application for registration is currently being processed by the Commission for Social Care Inspection. However, she was not on duty on the day of the inspection. Due to the nature of their mental health problems the majority of the Residents were unable to voice their opinions of the home. However, observation showed that the staff cared for the Residents with respect and courtesy. What the service does well: What has improved since the last inspection? The quality and quantity of the food served has improved since the last inspection. There has been some improvement in the recording within the Residents care documentation. Decorating of the corridors has commenced. Fund raising has given the home sufficient money for the purchase of a new pressure-relieving mattress. Allison House B51-B01 S140 Allison House V231441 090605 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Allison House B51-B01 S140 Allison House V231441 090605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Allison House B51-B01 S140 Allison House V231441 090605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 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: Four of the Residents care files were audited and all contained assessments carried out by Nurses from the discharging ward or Social Workers if the Resident was being admitted straight from their home. Pre admission assessments had been carried out by staff from the home prior to admission. However, 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 B51-B01 S140 Allison House V231441 090605 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 and 8 The Residents nursing and personal care needs are not recorded fully in individual care plans. Resident’s health care needs are met. EVIDENCE: Four Residents care plans were audited. Although the recording in the files had improved there is still some work to do. When a care plan is formulated the actions that are required are not always taken. For example one plan stated that a all of the food that the Resident had eaten over the day would be recorded; this recording stopped on 2/6/2005 but staff had not recorded if the they no longer needed to monitor the amount food the Resident had taken so it appeared that they had forgotten to make an entry regarding food consumption. The sleep chart that should have been completed each night by the staff to record the amount of sleep the Resident had had, was not available. Care plans relating to wounds should be more specific, e.g. the size of the wound should be measured so that there is evidence that it is improving or not. Allison House B51-B01 S140 Allison House V231441 090605 Stage 4.doc Version 1.30 Page 10 Evaluation of the care plans 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 On a positive note care plans are now predominantly formulated once a care need has been identified. There was a care plan that stated the Residents blood Sugar would be recorded regularly and it had been. Doctors, Opticians, Chiropodists etc are requested to visit the Resident as and when necessary. Allison House B51-B01 S140 Allison House V231441 090605 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 and 15 Therapeutic activities do not take place. The Residents receive a wholesome and appealing diet. EVIDENCE: There is no designated activity person in the home so the staff try and do some form activity for the Residents if they have the time. There was no evidence of activities taking place on the day of the inspection. The visitor who spoke to the Inspector that lack of activities had worried her when her Father was first admitted to the home; however she now knows that her Father would not participate anyway as he prefers his own company and to stay in his bedroom. The staff and Residents were complimentary about the food that is now served in the home. One Resident stated that her lunch was absolutely beautiful and did appear to be enjoying it. The visitor who spoke to the Inspector stated that the food always looks alright and her Father had never complained about it. On the day of the inspection the lunch was pork and apple casserole with turnip and mashed potatoes with an apple and cream whip for dessert. Allison House B51-B01 S140 Allison House V231441 090605 Stage 4.doc Version 1.30 Page 12 A visit to the Kitchen showed that it was clean and tidy. There was a good stock of food both fresh and dried. There were homemade sausage rolls, as well as one large cake and a tray of small homemade cakes. Allison House B51-B01 S140 Allison House V231441 090605 Stage 4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 Procedures are in place for the protection of the Residents. The staff have a good knowledge of the action to take should they become aware of abuse within the home. EVIDENCE: Policies and procedures are in place in relation to adult protection and prevention of abuse. There is also a policy on whistle blowing and staff spoken to stated that they were aware of these policies and explained the action to take should they witness any form of abuse taking place within the home. The home has a copy of the Teeswide No Secrets Protection of Vulnerable Adults guidance. Allison House B51-B01 S140 Allison House V231441 090605 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20 and 24 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 they are not well decorated. EVIDENCE: The corridor on Aspen unit is being decorated and the Willow corridor has been completed. The Aspen dining room has been decorated with new light fittings; the dining room on Willow is still to be done. New carpets are planned for the lounges but they need decorating first, new lounge chairs will then be purchased; new lounge chairs have been required for some time. There are bedrooms that require decorating, when this was discussed with the Deputy Manager she stated that there was a decorating programme and that the bedrooms were included in it. Nineteen bedrooms have a commode that needs to be replaced; this has been documented in the last two inspection reports. Allison House B51-B01 S140 Allison House V231441 090605 Stage 4.doc Version 1.30 Page 15 One Resident told the Inspector that the staff had provided her with a special chair to make her more comfortable. Bathroom two on Aspen unit has woodwork that requires painting. Bathrooms’ two and four on Willow unit need decorating. The visitor who spoke to the Inspector stated that she was satisfied with the décor of her Fathers bedroom. Allison House B51-B01 S140 Allison House V231441 090605 Stage 4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28 Staff are being trained to NVQ level 2 that should ensure that they can meet the Residents needs. EVIDENCE: There are twenty-one care assistants working at the home; ten staff currently have their NVQ Level 2 or 3. A further six members of staff are doing their NVQ training. The home has done well to go from 28 of NVQ trained staff to 48 since the last inspection in October 2004. Allison House B51-B01 S140 Allison House V231441 090605 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 and 33 At the time of the inspection visit there was no registered manager at the home, an application for the registration of a manager has been received by the Commission for Social Care Inspection. There is no effective quality assurance and quality monitoring system in place within the home. EVIDENCE: The Commission for Social Care Inspection is currently processing the application of Ms Angela Blythe to become the Manager of Allison House. Allison House B51-B01 S140 Allison House V231441 090605 Stage 4.doc Version 1.30 Page 18 There was no quality audit documentation within the home for the Inspector to read. The Deputy Manager was unaware if a quality audit took place or not. Regulation 26 visits are carried out by several of the Trustees, the completed assessment tool is sent to the Commission for Social Care Inspection. The visitor who spoke to the Inspector stated that she had been sent a questionnaire which she had completed but did not know what happened to the information she gave. Allison House B51-B01 S140 Allison House V231441 090605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 2 x x x 2 x x STAFFING Standard No Score 27 x 28 2 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 2 x 2 x x x x x Allison House B51-B01 S140 Allison House V231441 090605 Stage 4.doc Version 1.30 Page 20 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 2 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 2005 INSPECTION The registered person must ensure that all parts of the home are kept reasonably decorated. The registered person must provide adequate furniture, bedding and other furnishings suitable to the needs of the Residents. The registered person must establish and maintain a quality audit system. THIS IS OUTSTANDING FROM THE OCTOBER 2004 INSPECTION B51-B01 S140 Allison House V231441 090605 Stage 4.doc Timescale for action 30TH September 2005 2. 7 15 30th September 2005 3. 4. 19 20 & 24 23 16 31st October 2005 31st October 2005 31st October 2005 5. 33 24 Allison House Version 1.30 Page 21 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 12 28 Good Practice Recommendations Activities should be provided on a regular basis to provide stimulation. 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 Allison House B51-B01 S140 Allison House V231441 090605 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Unit B, 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. Extracts may not be used or reproduced without the express permission of CSCI Allison House B51-B01 S140 Allison House V231441 090605 Stage 4.doc Version 1.30 Page 23 - 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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