Inspection on 03/06/05 for Althorpe Care Home

This inspection was carried out on 3rd 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

Althorpe Care Home 09/02/09

Althorpe Care Home 31/10/06

Althorpe Care Home 17/01/06

Althorpe Care Home 15/12/04

Althorpe Care Home 31/08/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Althorpe Care Home 3 Main Street Althorpe Scunthorpe North Lincs DN17 3HJ Lead Inspector Stephen Robertshaw Unannounced 3 June 2005 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. Althorpe Care Home J54 Althorpe 59503 UI V233873 3 June 05 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Althorpe Care Home Address 3 Main Street Althorpe Scunthorpe North Lincs 01724 783363 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) Complete Care (UK) Ltd Mrs Sandra Kirk Care Home 23 Category(ies) of OP (23) registration, with number of places Althorpe Care Home J54 Althorpe 59503 UI V233873 3 June 05 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: There are no conditions of registration at the home. Date of last inspection 15 December 2004. Brief Description of the Service: Althorpe Care home is situated in the village of Althorpe, which is close to Scunthorpe. The home is registered to care for twenty three individuals over sixty five years in the category of old age, not falling into any other category. The building is said to be over two hundred years old and has had the benefit of an extension that was built approximately twelve years ago. Nineteen single and two shared bedrooms are accommodated on two floors accessed by a stair lift. However, as there are still some stairs to manoeuvre at one end of the second floor, service users residing in these specific bedrooms would need to be mobile. There is a large, well maintained garden with mature horse chestnut, apple and holly trees. It is easily accessible to all of the service users. There are facilities for car parking in the grounds. The home continues to employ an occupational therapist once a week to offer social activities. They are contracted though the local Social Services department. The management of the home are in discusions with the Social social service department as the occupational Therapst has recently not been honouring the contract. Althorpe Care Home J54 Althorpe 59503 UI V233873 3 June 05 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. What the service does well: What has improved since the last inspection? The staff receive more regular supervision than previously at the home. The statement of purpose and service user guides included the transfer of the Scunthorpe Office of the Commission to Hessle. Nutritional assessments are included in all of the service users care plans that were observed by the inspector. The medication procedures in the home have improved since the last inspection, and service users photos are included with their medication records to ensure that staff administer the medication to the right person. Staff receive more regular supervision to make sure that they are carrying out their duties correctly. Althorpe Care Home J54 Althorpe 59503 UI V233873 3 June 05 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. Althorpe Care Home J54 Althorpe 59503 UI V233873 3 June 05 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 Althorpe Care Home J54 Althorpe 59503 UI V233873 3 June 05 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) Standard 6 is not applicable to the home. 1,3,4 and 5. The homes statement of purpose and service user guides were up to date and included the transfer of the Commissions office from Scunthorpe to Hessle. All service users considering moving to the home have their needs fully assessed by the home before they arrive there. The home offers trial periods at the home for up to three months to make sure that the service users have settled in, and that the home can care for their needs. Althorpe has the capacity to meet the needs of the service users that it is registered for. EVIDENCE: The inspector interviewed professional visitors to the home including a district nurse, and they all confirmed that the home could meet the needs of the Althorpe Care Home J54 Althorpe 59503 UI V233873 3 June 05 Stage 4.doc Version 1.30 Page 9 service users, and that working relationships, and communication with the staff were good, and much improved. The service users social services care plans were seen to be evaluated in the home on a monthly basis. The home needs to develop their own care plans and evaluate them in the same way. The service user case files read by the inspector all included an assessment of their needs that had been completed by the homes staff before they were admitted in to the home. Althorpe Care Home J54 Althorpe 59503 UI V233873 3 June 05 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 and 10 The home must develop its own care plans for individual service users, and evaluate them at least every month. The service users have their nutritional, and psychological needs assessed before they are admitted in to the home. All of the prescribed medication in the home is stored, administered, and recorded correctly. Dignity and respect is upheld at the home at all times. EVIDENCE: The home did not have its own care plans. The staff work to meet the needs identified in the care management care plans. The inspector read three service users case files and they all included full assessments that included nutritional and psychological needs. The assessments were a combination of the homes pre-admission assessments and care management assessments. Althorpe Care Home J54 Althorpe 59503 UI V233873 3 June 05 Stage 4.doc Version 1.30 Page 11 The inspectors discussions with service users, observations and interviews with staff and visitors to the home supported that service users dignity and respect is upheld at all times in the home. Althorpe Care Home J54 Althorpe 59503 UI V233873 3 June 05 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 and 15 The service users at the home are able to make decisions about all areas of their lives including what time to get up in a morning, what time to retire at night, what to eat, and where to eat it, and whether or not to become involved in activities in the home. Althorpe has a range of activities available. Some of these are regular activities, and others are less frequent including clothes parties and outside entertainers. Visitors are accepted at the home at any reasonable time and are always made to feel welcome. This standard was exceeded EVIDENCE: Individual service users have records of all activities that they are involved in, or that they did not wish to join in. Each day each service users are given the opportunity for 1-1 time with the staff.. Visitors to the home stated that the home exceeded its requirements to meet their needs when visiting families and friends at the home. Althorpe Care Home J54 Althorpe 59503 UI V233873 3 June 05 Stage 4.doc Version 1.30 Page 13 The inspector ate a meal with the service users, and the service users, and visitors confirmed that a high standard of meals was provided at all times at the home, and at all meal times a choice of menu was available. Althorpe Care Home J54 Althorpe 59503 UI V233873 3 June 05 Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,17 and 18 There had been no complaints recorded in the home since the last inspection. The service users were supported to vote at the recent local, and general elections. Staff in the home were aware of the policies and procedures for the protection of vulnerable adults. EVIDENCE: The inspector observed the complaints records at the home and there had been no new entries since the last inspection service users spoken to by the inspector stated that they had not made any complaints to the home and were not aware of any complaints made by other service users. The service users in the home are all included on the electoral register if it is appropriate. Service users and staff confirmed that they had been supported to vote at the recent elections. This was undertaken through the postal voting system for some service users, and others were transported to the local polling station to vote. The staff training records and interviews with staff supported that the staff understood the homes policies and procedures for the protection of vulnerable adults. The staff at the home receive protection of vulnerable adult training provided through the local authority. Althorpe Care Home J54 Althorpe 59503 UI V233873 3 June 05 Stage 4.doc Version 1.30 Page 15 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) 19,21,22,23,25 and 26 The majority of the homes health and safety requirements are met. However there is a problem for service users with mobility problems access the rooms on the top floor of the home as the passenger service lift stops three steps short of the top floor. One of the bathrooms was not available fore use as it was being used for storage. In another of the bathrooms the walls were badly marked by damp. The home has not had an overall assessment of the premises to ensure that it can meet the needs of the service users, however individual service users had been assessed for their mobility and moving and handling requirements. The home provides twenty individual bedrooms, two of which are en-suite, and two double bedrooms. The hot water temperatures at the outlets need to be regulated at close to forty-three degrees centigrade to ensure the safety of the service users, and the hot water temperatures must be monitored on a regular basis. The home was clean hygienic and free of offensive odours. Althorpe Care Home J54 Althorpe 59503 UI V233873 3 June 05 Stage 4.doc Version 1.30 Page 16 EVIDENCE: A tour of the premises by the inspector supported the evidence that the home was clean, hygienic and free from offensive odours. One bathroom was not available for use as the area was being used for storage. Observation service users bedrooms evidenced that they had been given the opportunity of personalise their rooms. The inspector sampled the hot water temperatures at the outlets and found that they were not maintained close to forty-three degrees centigrade. These must be corrected and the temperatures must be recorded on a regular basis to monitor them. The washing machines were observed to be programmable to disinfection and sluicing standards. Althorpe Care Home J54 Althorpe 59503 UI V233873 3 June 05 Stage 4.doc Version 1.30 Page 17 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) 27,28,29 and 30 The staff have the necessary skills to care for the service users in the home. The management and staff have a strong commitment to fifty percent of the care staff achieving NVQ 2 in 2005. The management do not receive two written references for all staff before they commence working in the home. The staff undertake induction and foundation training at the home to ensure that they can meet the needs of the service users. EVIDENCE: The homes induction and foundation training meets the requirements of the national training organisation, and has forwarded the training packages to TOPP’s to have them formally approved. Interviews with the manager and staff at Althorpe confirmed that they are all committed to NVQ training and should meet the national requirement of fifty percent of the staff to have achieved it in 2005. Staff personnel files were observed by the inspector, and not all of them included two written references for individual staff. Althorpe Care Home J54 Althorpe 59503 UI V233873 3 June 05 Stage 4.doc Version 1.30 Page 18 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) 31,32 33,34,36,37 and 38 The manager of the home is currently working towards the registered managers award and should complete this in 2005. The management style of the home is open, accessible and responsive, and the home exceeded the requirements of this standard. The quality assurance programme has improved, and the home and staff are working well to fully establish the system in the home. A business and financial plan was not open for inspection however the proprietor of the home assured the inspector that this would be available very soon. The supervision of staff in the home has improved, and increased in frequency, however not all staff had received the minimum of six formal recorded supervision periods in the previous twelve months (pro-rata). Althorpe Care Home J54 Althorpe 59503 UI V233873 3 June 05 Stage 4.doc Version 1.30 Page 19 The proprietor does not provide regulation twenty six reports to the commission The majority of the homes health and safety requirements were met although there was damage in one of the bathrooms, and the dining room caused by damp. The downstairs passageways had new lighting in position, but the wallpaper needs attention. The homes maintenance plan takes this in to account. EVIDENCE: The home is working closely with the local authority to gain the local authorities Gold award for quality service, and it is thought that the home should achieve this by September 2005. The manager was also able to demonstrate that the home is working towards the Investors in People award and it is hoped that this should be achieved by august 2005. Both of these system’s should support the homes own quality assurance and monitoring systems, including staff supervision and appraisals. The proprietor does not provide regulation 26 reports to the commission. However he does attend monthly staff meeting at the home, meets with the service users and tours the premises. The records of these contacts could be adapted to meet the requirements of regulation 26 reports to be forwarded to the commission on a monthly basis. Althorpe Care Home J54 Althorpe 59503 UI V233873 3 June 05 Stage 4.doc Version 1.30 Page 20 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 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION 2 x 2 3 3 x 2 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 2 4 2 3 x 2 2 2 Althorpe Care Home J54 Althorpe 59503 UI V233873 3 June 05 Stage 4.doc Version 1.30 Page 21 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 7 Regulation 15 Requirement The registered person must ensure that the home develops individual care plans for all of the service users that are resident at the home and these must be evaluated on a minimum of a monthly basis. The rgistered person must ensure that the access to the top floor of the building is risk assessed. the registered person must ensure that at least the same level of baths are available as provided at 31 March 2002.Previous requirement fro 31 March 2005 was not met. The registered person must ensure that the hot water temperatures at the outlets are maintained close to forty-three degrees centigrade to protect the service users. These temperatures must be monitored on a regular basis. The registered person must ensure that two written references are obtained for all staff before they commence to work in the home. If a reference is given verbally this must be J54 Althorpe 59503 UI V233873 3 June 05 Stage 4.doc Timescale for action 10 July 2005 2. 19 16 30 July 2005 30 July 2005 3. 21 16 4. 25 16 30 July 2005 5. 29 18 £0 June 2005 Althorpe Care Home Version 1.30 Page 22 6. 33 24 7. 34 25 8. 36 18 9. 38 23 10. 38 23 followed up by written confirmation The registered person must ensure that the home has an effective quality assurance and monitoring system in position. Original requirement of 31 march 2005 was not met. The registered person must ensure that the home has a cureent business and financiial plan that is open to inspection.Original requirement of 31 August 2004 was not met. The registered person must ensure that all staff are supervised a minimum of six times per year (pr-rata) and these meetings are formally recorded. Original requirement of 10 March 2004 was not met . The registered person must ensure that the areas of the home effected by damp are appropriatly repaired. The registered person must ensure that the downstairs corridors are redecorated 30 August 2005 30 July 2005 30 November 2005 30 July 2005 30 August 2005 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 31 Good Practice Recommendations The registered person must ensure that a minimum of 50 of the homes staff have achieved an NVQ 2 award in care in 2005. The registered person must ensure that the manager of the home has achieved the registered managers award or equivelent in 2005. Althorpe Care Home J54 Althorpe 59503 UI V233873 3 June 05 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Unit 3, Hesslewood Country Office Park Ferriby Road Hessle East Yorkshire HU13 0QF 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 Althorpe Care Home J54 Althorpe 59503 UI V233873 3 June 05 Stage 4.doc Version 1.30 Page 24 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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