Inspection on 20/02/06 for St Albans House

This inspection was carried out on 20th February 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Albans House 16/01/08

St Albans House 12/09/06

St Albans House 05/01/05

St Albans House 15/07/04

St Albans House 31/03/04

St Albans House 07/01/04

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE St Albans House 59-61 St Albans Avenue Queens Park Bournemouth Dorset BH8 9EG Lead Inspector Catherine Churches Unannounced Inspection 11:15 20 February 2006 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000003982.V284467.R01.S.doc Version 5.1 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. DS0000003982.V284467.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Albans House Address 59-61 St Albans Avenue Queens Park Bournemouth Dorset BH8 9EG 01202 397817 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) Mr Timothy Martin Culley Mrs Sally Eileen Culley Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places DS0000003982.V284467.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st October 2005 Brief Description of the Service: St Albans house is located in a quiet residential area of Bournemouth between Queens Park and Charminster. Most local amenities are available in Charminster, approximately ¼ mile level walk from the home. The home is registered for 28 residents in the category of older people (OP) and is run by the owner/managers Mr and Mrs Culley. The care home comprises two houses linked together at ground and first floor levels. Accommodation is provided on the ground and first floor as follows: Ground floor 9 bedrooms, 6 with full ensuite, 3 with toilet and wash hand basins. First floor 17 bedrooms, 10 with full ensuite facilities, 5 with wash hand basins, 1 with toilet and wash hand basin. Residents have access to a variety of communal areas. The home has a large lounge area linking to a dining room. Along the length of the home to the rear of the property is a large conservatory overlooking the garden. The large grounds are well maintained and contain an oriental sunken garden area in addition to the large lawn area. Seating is provided outside in the summer months. Upstairs the two properties are linked via a covered sun terrace providing further communal seating. All communal areas are tastefully decorated and plants and flowers add to the domestic character of these rooms. All food is cooked on the premises and the menus offer a range of choices. St Albans offers a wide variety of activities on a regular basis including physical exercise, musical evenings, card and board games, reminiscence therapy and regular interdenominational church services. DS0000003982.V284467.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place during the morning of 20th February 2006. The inspection took place as part of the regular, programmed inspection schedule for the home. This report should be read in conjunction with that from the inspection in October 2005 as all key inspection standards are reported on in these two reports. The purpose of this visit was to check that the home continues to run in a satisfactory manner and that the people who are living in the home are properly cared for. What the service does well: What has improved since the last inspection? Eleven requirements and one recommendation were made as a result of the last inspection. Six of the requirements have been fully actioned leading to improved record keeping, staff training (and therefore competencies), and health and safety practices which ensures greater protection for residents, staff and visitors. DS0000003982.V284467.R01.S.doc Version 5.1 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. DS0000003982.V284467.R01.S.doc Version 5.1 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 DS0000003982.V284467.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Prior to admission, the needs of each prospective resident are assessed to ensure that the home will be able to properly meet them. Whilst the assessment is comprehensive, the documentation and methodology used to support this process unwieldy. Improved systems would make processes simpler and therefore provide better evidence that the standard is complied with. EVIDENCE: Pre admission documentation for the newest resident admitted to the home was examined. After careful analysis and discussion, it was found that the required information was available although the methodology and documentation used by the home was at times hard to follow. It was noted that some but not all new admissions receive a letter confirming that, following assessment, the home can meet their needs and evidence was not always available that the Statement of Purpose, Service Users Guide etc had been given to the resident. DS0000003982.V284467.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Systems for care planning and resident consultation are in place but could be reviewed and improved to provide more effective information and therefore further enhance evidence that the home meets the needs of residents. The home ensures that resident’s healthcare needs are met through seeking appropriate input from GP’s and other healthcare professionals. Residents’ medication at this home is well managing, therefore promoting good health. The ethos in the home is one of respect for the residents living there. This means that the residents feel settled and at home and their privacy is respected. EVIDENCE: Care Plans and related documentation regarding care for 3 residents were examined. After careful analysis and discussion, it was found that the required information was available although the methodology and documentation used by the home was at times hard to follow. DS0000003982.V284467.R01.S.doc Version 5.1 Page 10 Evidence was available on file and through discussion that GP’s, district nurses, specialist nurses and other health professionals are called upon whenever the need arises. Medicines in the medication cupboard were examined together with administration records. These were found to be satisfactory. Most staff have undertaken required training. Mrs Culley confirmed that a course is booked for the few staff that still require training. The home has a policy for the promotion of privacy and dignity. During the previous inspection residents confirmed (where they were able to) that they were happy with the care they received and that either they or their representatives are involved in reviews. Recently completed survey cards also confirmed that residents feel respected by staff and are able to maintain their privacy when receiving personal care or visits from professionals such as GP’s and solicitors, family and friends. It was observed that staff knock on doors before entering and that residents preferred form of address is recorded and used. DS0000003982.V284467.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 and 14 Residents have the opportunity to choose their own lifestyle within the home and this means that their individual preferences and routines are respected. Open visiting arrangements are in place enabling residents to retain contact with families and friends. EVIDENCE: The visitor’s book showed that there is a constant stream of visitors to the home and discussions with Mr and Mrs Culley confirmed this as well as the fact that many residents are taken out by visitors. Examination of records evidenced that residents are assisted appropriately to exercise choice and control over their lives. It was noted from documentation and observation of rooms that residents are encouraged to bring their own personal items of furniture and to personalise rooms etc. Choices are also promoted with encouragement to make decisions regarding food, clothing, social activities etc. DS0000003982.V284467.R01.S.doc Version 5.1 Page 12 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 and 18 The home has a satisfactory system for making complaints. This means that residents and others involved in the home that may wish to make a complaint should feel confident that they would be taken seriously and that matters of concern will be acted upon. Arrangements for protecting service users from abuse were satisfactory. This means that St Albans is a safe environment that will protect residents from abuse. EVIDENCE: The complaints procedure was displayed in the main hallway of the home and included in the Service Users Guide that is given to all residents/ representatives. No complaints have been made either to the home or to CSCI. Staff have received detailed in-house training in the protection of vulnerable adults and the home has clear policies and procedures both regarding abuse and whistleblowing. It was noted that neither of these policies contained contact details for local CSCI offices. DS0000003982.V284467.R01.S.doc Version 5.1 Page 13 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): Neither of the key standards were assessed on this occasion as both were assessed at the last inspection and found to be met. EVIDENCE: DS0000003982.V284467.R01.S.doc Version 5.1 Page 14 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 and 28 The home was well staffed ensuring that residents receive the care and attention they need in an unrushed manner. The staff team remains stable; this provides a good level of consistency and continuity for residents. Staff have not yet received the required NVQ training but do have extensive experience. Residents should feel assured that they are in safe hands; training will provide further support and knowledge for staff. EVIDENCE: Examination of the staff rota and observation throughout the inspection demonstrated there was a sufficient number and skill mix of staff to meet the needs of residents. Responses from comment cards confirmed that sufficient numbers of staff are on duty and provide a good standard of care. Mrs Culley reported that the staff employed in the home have been in post for many years and therefore have a great deal of experience. They are all unwilling to undertake NVQ training so the home is unable to meet this standard. They are willing to undertake various short courses and Mrs Culley is therefore developing a detailed training programme of short courses to try to go some way to ensuring that staff receive up-to-date training. DS0000003982.V284467.R01.S.doc Version 5.1 Page 15 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): 33,35 and 38 The management arrangements for the home support good care practice for the residents. Quality monitoring systems need to be better defined and coordinated in order to demonstrate that the home is run in the best interests of the residents. Sound practices and procedures are in place regarding residents’ finances. The health, safety and welfare of residents and staff is protected by the systems that the home has in place for staff training, maintenance and risk assessment. EVIDENCE: The home has a brief policy regarding quality assurance. This lacked in detail, self-monitoring surveys were out of date and there was no analysis of previous responses or annual development plan. DS0000003982.V284467.R01.S.doc Version 5.1 Page 16 Mrs Culley confirmed that residents are encouraged to retain control of their own finances for as long as possible. Where they state that they no longer wish to or they lack the capacity to do so then the home ensures that either family or other representatives such as solicitors take on this role. No cash or valuables are held in the home for residents. Fire records, staff training records and accident books were examined and found to be up to date and detailed. DS0000003982.V284467.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X X 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 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 X X X X X X X X STAFFING Standard No Score 27 3 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 3 DS0000003982.V284467.R01.S.doc Version 5.1 Page 18 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. Standard Regulation Requirement The registered person must confirm in writing to the resident that having regard to the assessment the care home is suitable for the purpose of meeting the residents needs in respect of his/her health and welfare. The registered person must operate a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. Evidence of a new employees identification must be held on file, 2 written references and a Criminal Records Bureau/POVA check must be obtained prior to an employee commencing duties or being confirmed in post. This is the fourth time this requirement has been made. Failure to comply may result in further action being taken. This requirement is therefore carried over to the next inspection as no new staff have been employed. Timescale for action 1. OP3 14 30/04/06 2. OP29 19 30/08/04 DS0000003982.V284467.R01.S.doc Version 5.1 Page 19 3. OP30 12 & 18 4. OP36 18 & 19 It is a requirement that All staff must receive induction and foundation training to NTO specification within the required timescales. This requirement is therefore carried over to the next inspection as no new staff have been employed. It is a requirement that Care staff must receive formal supervision which covers all aspects of practice, philosophy of care in the home and career development needs, at least six times a year. Further advice regarding this matter was given. This requirement is carried over to the next inspection 30/08/06 30/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard OP7 Good Practice Recommendations It is recommended that systems for care planning and resident consultation are reviewed and amended so as to provide greater compliance with the National Minimum Standards. It is recommended that Adult Protection and Whistle blowing policies are amended to include contact details of the local CSCI offices. A plan must be developed and implemented to ensure that 50 of care staff are trained to a minimum of NVQ level 2 in care Further work must be undertaken with regard to quality assurance systems in the home, by means of surveys, analysis and annual development plans, in order to demonstrate that the home is meeting its aims and objectives and statement of purpose 1. 2. 3. OP18 OP28 4. OP33 DS0000003982.V284467.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 DS0000003982.V284467.R01.S.doc Version 5.1 Page 21 - 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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