Inspection on 11/10/06 for Alvony House

This inspection was carried out on 11th October 2006.

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

Alvony House 20/07/07

Alvony House 09/01/06

Alvony House 14/07/05

Alvony House 07/03/05

Alvony House 06/08/04

Alvony House 25/02/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Alvony House 25 Linden Road Clevedon North Somerset BS21 7SR Lead Inspector Pippa Greed Key Unannounced Inspection 11th October 2006 09:10 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 Alvony House DS0000008137.V312454.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. Alvony House DS0000008137.V312454.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alvony House Address 25 Linden Road Clevedon North Somerset BS21 7SR 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) 01275 875573 01275 349655 His home address is his mother in laws Mr Alec Rendall Mrs Veronica Rendall Mrs Veronica Rendall Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Alvony House DS0000008137.V312454.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. May accommodate up to 27 persons aged 65 years and over requiring personal care only May accommodate one named person aged 50 years or over. This exemption is specific to one individual and will lapse when that person attains the age of 65 years or leaves the home. May accommodate one additional person for periods of respite; total persons accommodated during periods of respite should not exceed 28. May admit one additional person aged 58 years and over subject to a satisfactory trial period. This condition is specific to a named person and lapses when that person leaves. 9th January 2006 Date of last inspection Brief Description of the Service: Alvony House consists of two Victorian properties joined by a linking corridor. The home is registered by the Commission for Social Care Inspection to provide residential care for 27 residents aged 65 years and over, with low dependency needs. At the present time there is a condition of registration covering one named resident under the age of 65 years. Alvony House has a warm, friendly and homely atmosphere. Accommodation is provided over three floors with access to all floors provided by a stair lift. The Home is situated a short walk from the local shops and bus route. Dedicated sitting areas and a patio area in the rear garden allow for good weather activities outside. Garden furniture is provided. Provision is made within the home for a variety of activities and outings, which also enables close links with the local community to be maintained. The current fee levels are between £336.65 and £420.00 per week. Alvony House DS0000008137.V312454.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The last inspection was conducted on 9th January 2006. Six requirements and four recommendations were made at that inspection. The inspection was unannounced and took place over the course of one day (8.5hrs) on 11th October 2006. It was conducted by Regulation Inspector Pippa Greed. The inspector spoke to ten service users, and two staff. The inspector was also assisted by the manager, Mrs Veronica Rendall for parts of the inspection process. Four service users files were sampled. As part of the inspection process the inspector used ‘case tracking’ as a means of assessing some of the national minimum standards. This process allowed the inspector to focus on a small group of people living in the home. All records relating to these people were inspected, along with the rooms they occupied in the home. Three staff files were checked and documents related to the running of the home were examined. A tour of the building took place and the communal areas and some service users’ rooms were viewed. Mrs Veronica Rendall is the registered manager and she is supported by one deputy. Surveys were sent out to thirteen service users, three relatives, ten staff, two social workers and three GPs. Seven surveys were received from service users. One service user survey commented ‘Staff are always polite’. Five staff surveys were received and reflected positively on the service. Two comment cards were received from relatives. All comments received from relatives were, overall, positive. A relative wrote ‘Very glad to see my mother looking so well at Alvony House’. Three comment cards were received from GP’s, which confirmed that the home works closely with medical professionals. All the comments received from service users on the day of the inspection and through anonymous surveys were complimentary about the home and included comments such as ‘The staff are very good here. No complaints. I would recommend this place to anyone’. The inspectors would like to thank the service users, staff and the manager for their support and assistance with the inspection process. What the service does well: Alvony House DS0000008137.V312454.R01.S.doc Version 5.2 Page 6 Service users live in a very comfortable, safe and homely environment. The staff team are professional and provide care in a kindly, respectful manner. Service users told the inspector that they were very well cared for. Service users spoken to were complimentary about the staff team. The home has a minibus, which enables the staff to take service users on outings. Trips have been arranged to see up coming shows at the Bristol Hippodrome. The home has recently installed a new summerhouse in the back garden to cater for service users recreational needs. 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. Alvony House DS0000008137.V312454.R01.S.doc Version 5.2 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 Alvony House DS0000008137.V312454.R01.S.doc Version 5.2 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): 1, 3, 4, 5 (6 not applicable) The quality in this outcome group is adequate. Prospective service users are provided with information about the home. Prospective service users have the opportunity to visit the home. Most prospective service users are assessed prior to moving into the home with the exception of one. Service users are encouraged to maintain their independence. EVIDENCE: The home considers the needs of each prospective service user before agreeing admission to the home. Prospective service users have the opportunity to visit and spend time in the home before agreeing to trial admission. The prospective service user had the opportunity to meet with the people who live in the home and also meet the staff. The manager had sought relevant Alvony House DS0000008137.V312454.R01.S.doc Version 5.2 Page 9 information from the local authority. The manager met with the prospective service user and nurse assessor in order to consider the service user’s needs within the home and assessment was made taking into account the social and health care needs. Two service users have recently been admitted to the home. One is currently on short-term respite pending the outcome of placement agreement. An assessment conducted by Social Services was present in this service user’s care plan. Another service user has been assessed and appropriately placed within the home. The home has arranged a large basement bedroom and installed a new en-suite in order to meet the service user’s needs. Further consideration has been given to provide and meet the service user’s preference. The home has a no smoking policy but has been willing to provide a new summer house to the rear of the property in order to provide a smoking space for the service user. A full assessment process had been completed for one of the care records sampled. The manager informed the inspector that one service user has been admitted on an emergency basis, using information from a hospital discharge letter. Although they do complete pre-admission assessment, however on this occasion, one emergency admission did not contain details in the care plan. This was also raised in the last inspection report. It is recommended that the manager writes a detailed assessment for the named service user. Admissions to the home are on a trial basis and reviewed, after a settling-in period, by the home, service user and the funding authorities if appropriate. The Statement of Purpose stated that service users undergo a month’s trial before residency becomes permanent. The Statement of Purpose makes it clear as to what is included in the homes fees such as staffing, laundry and home cooking. It also lists what the service user is responsible to pay for, e.g. hairdressing, dry-cleaning, newspapers and private chiropody visits. The Statement of Purpose was sampled and this has been updated in parts. The Service Users contract (residents agreement) and Service User Guide were also sampled. These were found to be clear and user-friendly. However, the Statement of Purpose and Service User’s Guide would benefit from updated contact details for the Commission of Social Care Inspection. The service users contract contains different contact details to those displayed on the Complaint Procedure displayed in the hallway. The service user’s contract and guide has the Bristol address whereas the Complaint procedure has the Taunton address. There is currently no vacancy at the home. Alvony House DS0000008137.V312454.R01.S.doc Version 5.2 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 the following standard(s): 7, 8, 9, 10, 11 The quality in this outcome group is good. The Care plan sampled evidenced good medical and personal care provided by the home. Hand transcribed entries were supported by two staff signatures. Care plans included service users’ social history, which were detailed. Some care plans included information about the service users’ death and dying wishes. EVIDENCE: The inspectors sampled four care plans all of which evidenced detailed medical and personal care provided by the home. They contained up to date care plans, risk assessments in relation to falls, chair lift, steps, bath, windows and gardens. One care plan has a falls risk assessment dated September 2005, which has not been reviewed. This will need updating in order to reflect the current situation. Alvony House DS0000008137.V312454.R01.S.doc Version 5.2 Page 11 Records are in place to show that service users receive or attend visits with appropriate healthcare professionals such as chiropodist, audiologist, optician and dentist. A daily record was on each file that gave details of how service users were and noted any changes in their physical or mental health or circumstances. Not all care plans had a photograph of the service user. Each person has a key worker who is responsible for monitoring the person’s needs monthly. One staff member spoken with clearly demonstrated a good understanding of service user’s changing health needs and how best to support this. All the service users spoken to were clear that staff treated them with respect and felt that the day-to-day routines in the home respected their dignity. This was evident through courteous interaction between staff and service users and staff were observed asking service users how they wished to be supported with a task. This was confirmed by all of the service users surveys returned which stated that they received the care and support from staff that they needed. The inspectors observed staff interacting with service users in a friendly, professional and respectful manner. In relation to storage of medication and administration, appropriate levels of medication stock were stored. Controlled drugs and returned medication were found in good order. Hand transcribed entries were supported by two staff signatures. The home documents, on the Medication Administration Record, all medication received into the home. Returned medication is also logged clearly in the home’s returns book. The home has purchased a new medical fridge for appropriate storage of medicine. During lunchtime, two staff were observed to support each other and confirm medication had been given. The storage and administration of medication was, overall, found to be safe and well maintained. It is recommended that photographs of service users should be kept on the Medication Administration Record file, as good practice. It is also recommended that variable dosage is recorded in order to provide a clearer audit trail. Alvony House DS0000008137.V312454.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 14, 15 The quality in this outcome group is good. The routines of the home are planned around the service users’ needs and wishes. Service users are encouraged to personalise their rooms. Appropriate activities are available throughout the home. The service users are satisfied with the meals served at the home. EVIDENCE: The routines of the home were seen to be flexible to meet individuals’ choices and preferences as far as possible. Service users choose to access activities provided by the home or engage in their own hobbies and pastimes. Service users are actively encouraged to keep in contact with family and friends living in the community. Visitors are made welcome at any reasonable time. Service users can choose to entertain visitors in their room, communal lounges, dining room or in the garden. Some service users’ bedrooms are spacious enough to receive visitors comfortably. The home also provides a basement flat which includes a separate lounge with patio doors. Alvony House DS0000008137.V312454.R01.S.doc Version 5.2 Page 13 The home has a no smoking policy. In order to support the service user with their recreational wishes, the home has installed a newly-built summerhouse in order to provide a dry, safe space. The inspector received positive feedback through discussion with service users. Seven service users’ surveys confirmed that the overall care provided at Alvony House is good. The manager informed the inspector that outings have been arranged for service users to see the following shows: Lords of the Dance, Oliver, Peter Pan and Chitty Chitty Bang Bang. One service user told the inspector how she was looking forward to seeing Lords of the Dance the next evening. The home has a minibus, which enables staff to take service users out on trips. The manager informed the inspector that service users had enjoyed a drive in the minibus to Chew Valley Lake the day before. However, four service users spoken to were asked about activity provision and they felt that there were not enough activities being provided in the home. Although the inspector heard verbal anecdotes given by service users about trips out, there is no activity file as such to document it in detail. Service user care plans have an activity log in the form of a tick list with codes to state what type of activity has been undertaken, such as massage/ board games etc. The home also has an activity diary, which records names of service users who attended the activity. Lunchtime routine was observed during the inspection. Staff inform each service user what the lunch time option will be. A choice of two meals and two puddings were offered. The meal was appetising and made with fresh ingredients. The dining area is situated in a bright and spacious room overlooking the front garden. Tables were attractively presented with tablecloth, napkins and salt/pepper pots. There was good-natured banter and interaction between staff and service users. Mealtime was seen to be unhurried, and support was available for service users if needed. Alvony House DS0000008137.V312454.R01.S.doc Version 5.2 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 the following standard(s): 16, 17, 18 The quality in this outcome group is adequate. Service user felt that with support from staff and family their complaints will be listened to. Service users’ legal rights are protected. The home’s recruitment procedures did not fully protect service users from the potential risk of harm or abuse. The home has a detailed complaints procedure, however external contact details are in need of updating. EVIDENCE: Service users spoken with confirmed that they felt able to approach the manager if they had any concerns. They also said they would tell their families if they had any dissatisfaction or concerns. Out of the seven ‘Having your say’ survey forms received, five confirmed that they have a contract and one did not confirm either way. The Statement of Purpose and Service User’s Guide were sampled. The resident agreement clearly details what the service user’s and the home’s responsibilities are. Please also refer to the section ‘Choice of Home’. Alvony House DS0000008137.V312454.R01.S.doc Version 5.2 Page 15 The home has a Complaint policy that includes details of external agencies that service users and their families may contact. However, the contact details will require updating. The Complaint procedure was displayed in the hallway – this was seen to be up to date and included contact details and phone numbers for NCSC Taunton, not CSCI. The Whistleblowing policy is in place but included out-of-date contact details (NCSC). This leads to confusion as this listed Aztec West, Bristol whereas the Complaint Procedure listed Riverside Chambers, Taunton. The home has an Abuse and Whistleblowing policy, however contact details will need updating. Procedures relating to the recruitment of staff do not fully protect the service users from the risk of harm or abuse. (Refer to Standard 34) Two recruitment files sampled evidenced that staff started work at the home prior to their Criminal Disclosure Bureau (CRB) clearance check being received. No Protection of Vulnerable Adult (POVA 1st) checks were sought prior to start date. Staff awaiting CRB clearance must be supervised at all times, following a robust risk assessment. Alvony House DS0000008137.V312454.R01.S.doc Version 5.2 Page 16 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, 21, 22, 23, 24, 25, 26 The quality of this outcome group is good. The home has a comfortable environment which provides mobility aids and equipment to meet the care needs of the service users. The additional communal space provides service users with choice and scope to meet relatives and friends in privacy and comfort. The home is clean and hygienic. EVIDENCE: Alvony House consists of two Victorian properties joined by a linking corridor. All bedrooms at Alvony House are for single occupancy except for one basement flat suitable for couples. Most rooms have an en-suite facility. Rooms are situated on the basement, ground, first and second floor. There is a stair lift for access to all levels except for basement level. Service user placed on the upper floor has a good level of independent mobility. The home has two communal bathrooms. Service users have the choice of a bath or shower. Alvony House DS0000008137.V312454.R01.S.doc Version 5.2 Page 17 There are sufficient and suitable toilet and bathing facilities available throughout the home. Water temperatures were checked on one bath and one sink and found to be at safe temperature levels. Good infection control practices were evident throughout the home with provision of anti-bacterial liquid soap, paper towels and lidded bins. Staff were observed wearing appropriate protective clothing. Communal space comprises of two lounges and a separate dining room. There are gardens to the front and rear of the property, which were well maintained and attractively presented. Call bells are available in bedrooms, toilets, bathrooms and communal areas. Fire doors were either kept shut or held open by appropriate fire door release mechanisms. Most window restrictors were put in place and those that do not, have an environmental risk assessment in place and disclaimer signed by the service user. However, it is recommended that the window on the top floor is either restricted or appropriately assessed to minimise risk. Although, service users bring in the majority of furnishings, three wardrobes were seen to be unfixed. It is required that all free-standing wardrobes are risk assessed, and where there is an identified risk, the furniture must be secured. The home was clean, tidy with no malodours on the day of the inspection. A tour of the premises was undertaken and the inspectors viewed all the communal areas and some of the service users’ private bedrooms. All service users’ rooms viewed had been personalised to reflect individuals’ choices and preferences. Service users are able to bring in personal items including small items of furniture within the space constraints of their room, and in agreement with the manager. The manager informed the inspector that she arranges for a cleaner to clean the home four times (7.30am-12.30pm) a week. The kitchen area was inspected. The kitchen also has a separate utility area. Foods stored were correctly labelled and fridge/ freezer temperatures were within the correct range. Meals were observed to be freshly prepared on the day. Catering staff spoken with confirmed they understood the service users’ needs and wishes. Special diets were provided and staff will explore new ways of creating appetising and palatable meals. Cleaning schedules were viewed. The kitchen was kept clean. Alvony House DS0000008137.V312454.R01.S.doc Version 5.2 Page 18 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, 30 The quality in this outcome group is adequate. There is good rapport between staff and service users. Staff mandatory training had not been completed for all staff. Staff working practices are monitored effectively and regularly. The home’s recruitment procedures did not fully protect service users from the potential risk of harm or abuse. Under 50 of care staff have completed their NVQ training. EVIDENCE: Service users spoken with confirmed that the staff treat them kindly and with respect. Some of the comments were ‘staff are always polite’ and ‘staff understands us’. Service users informed the inspectors that they felt attended to if they needed help and staff provide good service. Staff observed during the inspection process appeared happy and confident whilst going about their work. On the day of the inspection, there were three care assistants including the manager who was working hands on. Staffing also included one cook, two maintenance staff, and one deputy. The manager confirmed that there would Alvony House DS0000008137.V312454.R01.S.doc Version 5.2 Page 19 be three care assistants on duty during the afternoon/evening and one sleep in duty at night. The inspector spoke with two staff on the day of the inspection and received five staff surveys. Staff spoken with stated they felt supported by the manager. One staff survey stated ‘management are always so very helpful and treat all with respect, dignity and will always listen’. Staff are supervised regularly in the form of working practice observations. The manager conducts regular observations and monitors the staff’s skills and performance. Details of 1:1 formal supervision between manager and staff were not documented. However, National Minimum Standards states that the home should provide staff with at least six formal supervisions a year. This will need to be considered by the manager. Four staff files were sampled. These recruitment files contained details required by Schedule 2, Care Homes Regulation 2001 and induction training has been provided. However, two files seen did not meet with regulation requirements. Two members of staff had commenced work at the home prior to their Criminal Records Bureau (CRB) clearance being received and no Protection of Vulnerable Adults (POVA1st) checks were carried out prior to their start dates. Six out of nineteen staff have NVQ 2 and above which is under 50 of the total number of staff. Four staff from nineteen are first aid trained. The staff team will require updates in mandatory training. The manager has stated in the Pre-Inspection Questionnaire that First Aid and Food Hygiene training is presently being arranged. Alvony House DS0000008137.V312454.R01.S.doc Version 5.2 Page 20 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, 32, 33, 34, 35, 36, 37, 38 The quality in this outcome group is adequate. Service users’ finances are safeguarded by the homes procedures. Staff are monitored regularly and the manager provides demonstration of correct working practice. The home policy and procedure would benefit from updates in order to provide clear instructions and contact details. Some areas of Health and Safety will require improvement. EVIDENCE: The registered manager is Mrs Veronica Rendall. Mrs Veronica Rendall co-owns the home with her husband Mr Alec Rendall. The manager was working on shift on the day of the inspection. The manager was seen to give clear guidance and Alvony House DS0000008137.V312454.R01.S.doc Version 5.2 Page 21 support to staff. Service users and staff spoken with were complimentary about the management support and found them to be helpful. Some service users are able to take responsibility for their own finances. Five service users’ finances are looked after by the home. The finance record was checked. Improvements have been made to the finance systems since the last inspection. The manager has implemented a new finance book to record clearer details. All transactions are supported with two staff signatures. The manager informed the inspector that she is currently setting up new bank accounts for these five service users. This will need to be implemented in order to provide further safeguards for their financial interests. The accident book was checked. Accidents are recorded in detail and action taken is outlined. The recordings were analysed and the incidents for one month (September 2006) appeared high, numbering twenty six. Although the remainder of the year appeared normal, it is stressed that the manager needs to monitors unusual levels and update care plans to reflect any changes. A tour of the premises was made and areas seen were generally free from hazards. In order to determine whether previous recommendations were completed, window restrictors were checked on 1st floor and found to be in place. However, one top floor bedroom did not have this in place nor had an environmental risk assessment or disclaimer been put in place. The manager was made aware of this and will address accordingly. The maintenance book was sampled. The details recorded identified some areas of concerns. Portable Appliance Testing (PAT) will require evidence of having been tested by an approved electrical engineer supported by a test certificate. A visual check is good practice for checking plugs and cables but this does not provide sufficient safeguards against electrical functions/ circuits. The water temperature record in the maintenance record was inadequate. The record showed that, originally, weekly checks had been in place but had been replaced by quarterly ones. The water temperature has been checked on two occasions this year with the last recording being 3rd July. It is recommended that water temperatures are recorded weekly. It is also recommended that the home arrange for an external contractor to provide Legionella checks and take water samples. The inspector sampled records relating to chair lift maintenance. The last chair lift check was conducted on 22nd March 2006. Whilst previous records evidence that the lifts were checked regularly, it is recommended that this be carried out every six months. Wardrobes throughout the home were not secured, nor were radiators covered therefore posing a potential risk. It is required that wardrobes are made secure Alvony House DS0000008137.V312454.R01.S.doc Version 5.2 Page 22 in line with an environmental risk assessment. It is also required that radiators and unrestricted window are risk assessed. Alvony House DS0000008137.V312454.R01.S.doc Version 5.2 Page 23 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 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 Score 3 X 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 2 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 2 2 1 Alvony House DS0000008137.V312454.R01.S.doc Version 5.2 Page 24 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 OP38 Regulation 13 4(a) Requirement It is required that the manager arranges Portable Appliances Testing by an approved electrician and forward a copy of test certificates to CSCI. It is required that the manager ensures POVA1st checks are sought prior to staff start dates whilst waiting for CRB clearance. It is required that the manager completes an environmental risk assessment to include freestanding wardrobes, uncovered radiators and unrestricted window openings. It is required that all staff members receive up-to-date mandatory training. Timescale for action 01/12/06 2. OP29 19 01/12/06 3. OP38 13 4(a) 01/12/06 4. OP9 13.2 01/12/06 Alvony House DS0000008137.V312454.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP16 Good Practice Recommendations It is recommended that the Commission’s contact details are updated to provide consistency on the following paperwork: Service User’s Contract, Service User’s Guide, Complaint procedure, and Statement of Purpose. It is recommended that one care plan’s falls risk assessment be updated in order to reflect the current situation. Carried forward from the last inspection. It is recommended that photographs of service users are placed in all care plans. (Schedule 3) It is recommended that the Medication Administration Record file has photographs of all service users. Also variable dosage should be recorded as good practice. It is recommended that staff are provided with at least six formal 1:1 supervisions a year. It is recommended that the manager arrange for an external contractor to provide Legionella checks at least once a year. It is recommended that water temperatures from hot water outlets are recorded weekly to ensure it is not above 43 degrees Celsius. This was a recommendation from the last inspection. It is recommended that a service user’s assessment be made within 48 hours of an emergency admission. This should enable the home to confirm that the service user’s needs can be met. 2. OP38 3. 4. 5. 6. 7. OP7 OP9 OP36 OP38 OP38 8. OP3 Alvony House DS0000008137.V312454.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Alvony House DS0000008137.V312454.R01.S.doc Version 5.2 Page 27 - 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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