Inspection on 07/11/06 for Alver Bank

This inspection was carried out on 7th November 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Alver Bank 10/01/06

Alver Bank 12/08/05

Alver Bank 20/01/05

Alver Bank 16/06/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Alver Bank Alver Bank 17 West Road Clapham London SW4 7DH Lead Inspector Pam Cohen Unannounced Inspection 7th November 2006 09:00 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 Alver Bank DS0000022717.V318442.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. Alver Bank DS0000022717.V318442.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alver Bank Address Alver Bank 17 West Road Clapham London SW4 7DH 0207-627-8061 02077202150 Lipnicka.Margaret@salvationarmy.org.uk 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) The Salvation Army Ms Malgorzata Lipnicka Care Home 27 Category(ies) of Dementia (5), Old age, not falling within any registration, with number other category (22) of places Alver Bank DS0000022717.V318442.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th January 2006 Brief Description of the Service: Alver Bank is a home for older people owned by the Salvation Army Housing Association and managed by the Salvation Army Social Services. It is located in an historic listed building set in large, landscaped grounds. Within the same grounds and adjoining the home, there is a sheltered housing complex, as well as independent flat and a community centre. The home is situated between Brixton and Clapham and has good transport links. It offers some parking at the front and side of the home and on street parking. There is accommodation in single rooms, for 27 older people, 5 of whom may suffer from dementia. There is also ample communal space. The home and grounds are fully wheelchair accessible. On the day of inspection there were 4 vacancies and the weekly fees were £575.25. Alver Bank DS0000022717.V318442.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place during the day of 7th November. The manager was in the home and facilitated the inspection. The inspector also checked documentation and care plans, toured the building, spoke to service users, a visiting relative and a visiting District Nurse. What the service does well: 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. The summary of this inspection report can be made available in other formats on request. Alver Bank DS0000022717.V318442.R01.S.doc Version 5.2 Page 6 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 Alver Bank DS0000022717.V318442.R01.S.doc Version 5.2 Page 7 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): 1,3,4,5,6. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home has good information for prospective service users and assesses them well before admission, giving them every opportunity to make sure they wish to go to Alver Bank. EVIDENCE: The home has a detailed Statement of Purpose and Service User Guide, which contain all relevant information for prospective service users and their relatives. The manager confirmed that she assesses all prospective service users before admission and only after she has full assessments from relevant professionals. She is committed to all service users visiting before admission and said that 90 of service users do so. In the past year the home has changed its registration to include care for 5 service users suffering from dementia. The registration officer visited and was Alver Bank DS0000022717.V318442.R01.S.doc Version 5.2 Page 8 satisfied that the home is able to meet the needs of this service group, as it does for those not suffering from dementia. The home does not accept people for intermediate care. Alver Bank DS0000022717.V318442.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Medication is dealt with well and service users feel they are treated with respect. Health care needs are also well looked after. However service users are not fully protected by care plans which do not cover all necessary areas. EVIDENCE: Service users said that they receive good care and all looked well cared for. A relative said that staff deliver good and appropriate care to her husband who has multiple needs. All service users have a care plan and there was evidence that these are drawn up with service users. A relative confirmed that she had also been involved; reviews of the care plans are held regularly. However there are several areas where care plans need improving. They do not always fully detail service users’ personal care needs, emotional and social needs, or the needs that suffering from dementia presents. The care plans are also often generic rather than individual, addressing for instance, the needs of “a” service user with hearing impairment, not “the “ particular user’s needs. Care plans did also not include full life histories which are an important part of delivering Alver Bank DS0000022717.V318442.R01.S.doc Version 5.2 Page 10 care to older people. A service user who had been in the home for some months did not have a fully completed care plan. Risk assessments for areas of risk were not always in place. There are also two different formats of care plan in the home. Those for the same person had different information and this is confusing and could be dangerous. The inspector spoke to a District Nurse who was visiting the home who said that she had no worries about service users’ health care. Documentation bears this out, but needs to be completed in such a way that it is possible to see if and when service users’ health care needs have been referred to the appropriate professional. There is a good system for administering medication and recording is good. The member of staff administering medication was knowledgeable about the medicines that service users are taking. All service users have a risk assessment on admission to see if they wish, and are able, to keep charge of their own medication. Staff were seen to interact appropriately with service users, and service users said that they felt that their dignity was well respected by the staff. Alver Bank DS0000022717.V318442.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users enjoy a varied and nutritious diet. They are helped to live as they choose and visitors are welcomed. It is not clear whether the activities provided meet the wishes of the service users. EVIDENCE: The home has a variety of good social activities including board games, arts and crafts, sing-a-longs and one-to-one activities. These happen each afternoon and are displayed on a board in the hall. There are also day trips arranged and special activities such as a firework display which had just taken place. However, service users’ past interests and present wishes for recreational activity are not fully assessed as part of care planning. It is therefore not possible to be sure that their aspirations in this area are met. There is an optional Salvation Army service every morning and clergy from other denominations also visit the home. Service users are encouraged to keep up contacts with friends and relatives; one visitor said that she comes every day and is always made welcome. From speaking to and observing service users it is clear that they are encouraged and supported make choices about how they spend their time. Alver Bank DS0000022717.V318442.R01.S.doc Version 5.2 Page 12 Service users are offered a varied and nutritious menu with a choice for both the main meal and the desert, and a jug of cold drink is available on each table for self-service, with a hot drink offered after the meal. Some AfricanCaribbean food is available. Service users said that they liked the meals and could also get snacks and drinks outside mealtimes. Apart from breakfast, lunch and supper, residents are also offered drinks and a snack mid morning, mid afternoon and later in the evening. Special diets are provided where needed Alver Bank DS0000022717.V318442.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies and training show that every effort is made to respond to complaints and to protect service users from abuse. EVIDENCE: The home has a complaints procedure which is given to all service users and displayed in the hall. A relative said she had seen this but that she had never had a complaint. The Commission has received no complaints about Alver Bank. The home has a vulnerable adults policy and other necessary documentation. Training on working with vulnerable adults is part of induction and ongoing training. Alver Bank DS0000022717.V318442.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,26.Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in safe, accessible and homely surroundings, with ample personal and communal space. EVIDENCE: Service users all have single bedrooms which are well furnished and decorated. There are also ample communal areas with two lounges and a dining room which the manager is planning to reconfigure in order to give maximum flexibility of space. The furnishing is good but when hot drinks and biscuits were given out, service users had nowhere to put these down and so more side tables are needed. All areas are fully accessible, including the grounds, and all areas are decorated in a bright and homely manner. Aids and adaptations are provided throughout the home as needed. There are also ample, modern bathrooms and work is going forward on making them all accessible. All areas were seen to be safe, but the manager reported that there had been an incident of a window being broken the night before and when CCTV footage Alver Bank DS0000022717.V318442.R01.S.doc Version 5.2 Page 15 was examined, it was not useful because the lighting in the area was not sufficient. On the day of inspection the home was clean and hygienic throughout. Alver Bank DS0000022717.V318442.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported and cared for by well-trained staff deployed in sufficient numbers. The recruitment process is a good one, which with small changes will fully protect service users. EVIDENCE: Staff numbers on all shifts are appropriate for the number and needs of service users. There are 3 carers and a senior carer as well the manager or her deputy and the administrator, during the week. There are two night staff on duty each night. The percentage of staff trained to NVQ standard is nearing 60 with other staff in the process of gaining the qualification. The manager described a good process for recruitment and said that where possible a service user is included on the panel. Notes of the interviews need to be kept to ensure that Equal Opportunities legislation is being adhered to. Documentation for two newly recruited staff was checked. This was mostly in order but all gaps in employment need to be explored. Other necessary checks are all being done. Staff training needs are identified at annual appraisals and a satisfactory training programme is in place, together with induction training for new members of staff. Alver Bank DS0000022717.V318442.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33,38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from good management and their views on the service are sought and taken into account. Health and safety systems generally work to protect service users. EVIDENCE: The manager is experienced and has an excellent range of qualifications for the post including NVQ 4 in management. She described good processes for keeping staff informed of forthcoming changes in the management structure of the home. There continue to be good methods for finding out and learning from the views of service users and other interested parties. The annual report that is compiled from these surveys and questionnaires should be supplied to the Alver Bank DS0000022717.V318442.R01.S.doc Version 5.2 Page 18 commission. There is an annual development programme in place, which should be expanded to include all interested parties. Service users’ finances were not checked at this inspection but were found to be in good order at the inspection earlier this year. All health and safety systems checked were found to be in good order except for moving and handling training which must be updated for all members of staff annually. Alver Bank DS0000022717.V318442.R01.S.doc Version 5.2 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 4 X 3 3 4 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 2 3 3 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 2 Alver Bank DS0000022717.V318442.R01.S.doc Version 5.2 Page 20 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 OP7 Regulation 15(1) Timescale for action The Registered Person must 31/01/07 ensure that care plans are fully completed and cover in detail all aspects of service users’ personal, social and emotional care needs as well as those needs that suffering from dementia may bring. The Registered Person must 31/12/06 ensure that there are risk assessments to cover all assessed areas of risk. The Registered Person must 28/02/07 ensure that service users wishes about social activities are assessed, recorded, and where possible provided for. The Registered Person must 31/03/07 ensure that external lighting enables the CCTV cameras to be used. The registered person must 31/03/07 ensure that there are sufficient side tables for service users to put down hot drinks. The Registered Person must 31/03/07 ensure that the controls in the disability shower room are DS0000022717.V318442.R01.S.doc Version 5.2 Page 21 Requirement 2. OP7 13(4)(b) (c) 16(2)(m) (n) 3. OP12 4. OP19 13(4)(c) 5. OP20 23(2)(n) 6. OP21 23(2)(n) Alver Bank 7. OP29 19(1)(a) 8. OP38 13(5) positioned so that they can be operated independently by residents whilst in wheelchairs. Target date of 31/07/07 not met. The registered person must 31/01/07 ensure that notes are kept of staff interviews and that at interview, gaps in employment are explored and reasons noted. The registered person must 31/01/07 ensure that all staff have up-todate moving and handling training. 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. 3. 4. Refer to Standard OP7 OP7 OP8 OP33 Good Practice Recommendations It is recommended that there are life histories, where possible, for all service users. It is recommended that the registered person either ensure that the two care plan formats in use contain the same information or that only one is used. It is recommended that recording shows clearly if and when service users have been referred to health care professionals. It is recommended that the annual report that is compiled from surveys and questionnaires should be supplied to the commission and that the annual development programme is expanded to include all interested parties. Alver Bank DS0000022717.V318442.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 Alver Bank DS0000022717.V318442.R01.S.doc Version 5.2 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. 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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