Latest Inspection
This is the latest available inspection report for this service, carried out on 26th May 2010. CQC found this care home to be providing an Adequate service.
The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.
For extracts, read the latest CQC inspection for Albany House.
What the care home does well People who use the service and members of staff benefit from the appointment of a competent, qualified and experienced manager. The manager has a clear view of how the home is to be developed. She is working through her action plan for improvements and implementing more person centred care planning. New people benefit from being involved in detailed assessment of their needs before they move in, to see whether the home is suitable and can meet their needs. Safe systems are in place for managing people`s medicines. A robust recruitment process means that people are protected from anyone who is unsuitable to work with people who may be vulnerable. Members of staff are respectful and sensitive to the needs of people who use the service and they have developed good relationships. The providers make sure that the environment is well maintained for people`s comfort. What the care home could do better: Handwritten entries in the medicine administration record should be witnessed by another member of staff who should sign to agree that the record is accurate. Random inspection report
Care homes for older people
Name: Address: Albany House The Square Tisbury Salisbury Wiltshire SP3 6JP one star adequate service 04/08/2009 The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Sally Walker Date: 2 6 0 5 2 0 1 0 Information about the care home
Name of care home: Address: Albany House The Square Tisbury Salisbury Wiltshire SP3 6JP 01747870313 F/P01747870313 albanyhouse@bmcare.plus.com www.bmcare.plus.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Susan Mary Waugh Type of registration: Number of places registered: Conditions of registration: Category(ies) : BM Care Limited care home 21 Number of places (if applicable): Under 65 Over 65 1 21 dementia old age, not falling within any other category Conditions of registration: 0 0 Albany House can accommodate one named service user with Dementia however, the registered person must notify CSCI if the service user is no longer accommodated. This condition will then be removed. Date of last inspection Brief description of the care home Albany House is an older detached building, which is situated in the village of Tisbury, Wiltshire. The home benefits from a good location within the centre of the village, within walking distance of the local amenities. A main line station from Waterloo to the
Care Homes for Older People Page 2 of 11 1 9 0 1 2 0 1 0 Brief description of the care home west country is also located in Tisbury and again within walking distance of Albany House. Accommodation is provided on 2 floors of the home with the majority of the bedrooms provided being single. The home provides two communal areas and a large conservatory, which leads to a patio area and garden. Albany House is registered to provide personal care for 21 older people. The home was purchased by BM Care Limited in Jan 2006. Mrs Susan Waugh was appointed as manager in March 2010 and is awaiting approval of her application to register as manager. Care Homes for Older People Page 3 of 11 What we found:
This Random unannounced inspection took place on 26th May 2010 between 9.20am and 2.00pm. The new manager, Mrs Susan Waugh, was present during the inspection. Mrs Waugh was awaiting confirmation from our Registration department that her application to register as manager was approved, following a recent fit person interview. Mrs Waugh started managing the home in March 2010. We met with the last two people who moved into the home and looked at their care plans and medicines. We met with one of the last members of staff to be appointed. We looked at the staffing files of the last two people to be appointed, one of which was Mrs Waugh. We made a brief tour of the premises. We looked at the notifications that the home is required to send us. We looked at the accident book. We asked the home to complete an Annual Quality Assurance Assessment (known as the AQAA). This was their own assessment of how they were performing. It told us about what has happened during the last year and about their plans for the future. As part of the inspection process we sent survey forms to the home for people who use the service, staff, relatives and healthcare professionals to tell us about the service. Comments are included in this report. The last Key inspection was on 4th August 2009. Our pharmacist inspector made a Random inspection on 19th January 2010 to look at the homes progress in meeting the requirements about the safe handling of peoples medicines. All of the requirements relating to safe management of peoples medicines were met. Three of the outstanding requirements we made at the Key inspection were met and the others were in good progress. Mrs Waugh had identified priorities and was making improvements to different systems. These included the recording of care plans, risk management action plans, the staffing rota, supervision and staff development and the arrangements for peoples medicines. She had changed the staffing rota to make sure that members of staff were available at key times of the day. A shift leader had been identified each day, they were responsible for completing the shift planning form. This meant that the shifts were better organised and the shift leader was taking responsibility for making sure that members of staff knew the work plan for the day. Mrs Waugh had introduced a staff communication book so that information could be passed on and issues addressed. Mrs Waugh had used her new pre-assessment documentation with one person who had recently moved in. Care management assessments had been obtained from funding authorities. Both people who had recently moved in told us that the move had been a positive one for them. Mrs Waugh had met with members of the senior team to discuss and train them in care planning and review. She had prepared a new care planning format which related to each area of need, with guidance on how each need was to be met and monitored. This format was more person centred and was being introduced to senior staff, who would write and review the care plans, following the training. The system would include a section where
Care Homes for Older People Page 4 of 11 people decided what they would like to happen each day. Mrs Waugh told us she planned to introduce more activities, including more trips out. One person was identified in their care management assessment as having a history of developing pressure sores. They had pressure relieving equipment in place. Mrs Waugh told us that the new care planning documentation had a section on pressure sores and treatment. The format also took into consideration peoples nutritional status. We saw that recording had improved with less judgemental statements. We said that further improvement would be made if unclear statements such as no problems and all care given were avoided. These statements were only being used by the same few staff. Mrs Waugh told us she was addressing record writing and language in supervision with some staff. We saw that other members of staff made clear and detailed recordings. This included conversations with the person, observations and interventions. Risk assessments had been carried out with one person who had recently moved in. One person told us they could go out in the village on their own and this was identified in their care plan. Accidents and incidents were recorded in the accident book and in peoples daily records. Body maps were being used to show more detail about wounds or marks. Two people told us that members of staff gave them their medicines when they needed them. A new system for administration of peoples medicines was about to be introduced. Mrs Waugh told us that she had met with the supplying pharmacist who will provide a better pre-printed recording system and an improved monitored dosage system. The pharmacist planned to give training sessions on medicines. The GP had reviewed peoples medicines. Handwritten entries in the medicine administration record were not being witnessed by another member of staff to show that details were accurately recorded. Mrs Waugh told us that this would be addressed with the new medicine administration record. Currently some medicines were not always pre-printed on the sheet and had to be handwritten. We asked people about making complaints and telling management if there was anything they were not happy with. One person told us they had been given information about the homes complaints procedure when they moved in. Both the people we spoke with told us they would tell members of staff or Mrs Waugh if they were not happy with anything. We asked a member of staff to tell us about the local safeguarding procedure. They were quick to tell us that they would report any allegations or observations of abuse to the manager or providers. They told us that the contact details of the local safeguarding unit were in the office. They said they would have no hesitation in referring any incidents themselves directly to the unit, if they felt it was not being dealt with. In the AQAA the providers told us that they planned to provide more individual time to staff to express their concerns. Mrs Waugh showed us the arrangements for safekeeping small amounts of peoples money. Records were kept of all transactions and regular audits took place. Only Mrs Waugh and the deputy manager had access to the money. Mrs Waugh told us that she intended to further safeguard the arrangements, with numbered receipts attached to each individual persons balance sheet.
Care Homes for Older People Page 5 of 11 Mrs Waugh told us that she was involving people who use the service in the recruitment process. One person had asked one prospective member of staff about what they would offer to the home. All the documents and information required by regulation were obtained as part of the recruitment process. A system had been set up to ensure that each member of staff received regular supervision. The agenda now included areas of staff development and support and future training needs. Mrs Waugh showed us the training matrix she had developed which indicated when updated training was needed. Each member of staff had an individual record of completed training as well as accompanying certificates. One member of staff told us they had started the National Vocational Qualification (NVQ) Level 3. In the AQAA the providers told us most of our staff have completed at least NVQ 2 standard. Staff members had recently undertaken training in health and safety. One member of staff told us they had asked that moving and handling training was more practical and this was being addressed. Staff meetings were regularly held with minutes kept. People made positive comments about the care and support they received from members of staff. One person said they are very caring, very pleasant. They always want to know if they can do something for me. Another person told us the staff are very nice people. We can have a bit of a laugh. In a survey a member of staff told us staff rota could be better organised. In a survey one person told us There is a very good atmosphere of kindness and caring and the carers are mostly marvellous dealing with unpleasant happenings. Another person told us The staff are happy and helpful but they always are short staffed. They try to do their best. [Do better] Spare more time for the residents, lack of leadership. This survey was received before Mrs Waughs appointment. The call alarm system was now being turned off at the call point rather than on the panel in the dining room. This meant that members of staff went directly to the person making the call reducing the risk of people not being attended to. New carpets had been fitted to the sitting room and dining room. There were new curtains in the sitting room. Mrs Waugh told us that the providers planned to have broadband installed for better internet access and email. Quotes had been obtained to install a wet room with shower. There were plans to replace the heating boiler and hall carpets. One of the bedrooms was being re-decorated and re-carpeted. In the AQAA the providers told of their plans to keep the internal and external environment well maintained. Mrs Waugh told us she had recently trained in the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. She said she intended to cascade the training to the staff team. Mrs Waugh had management meetings with the providers when they visited every two weeks. A member of staff told us that Mrs Waugh had made a big and positive difference since coming to the home. They told us they felt well supported and could discuss anything
Care Homes for Older People Page 6 of 11 with Mrs Waugh. In a survey one of the relatives told us Albany House is a very friendly, relaxed home. All the staff are very pleasant and always make visitors very welcome. Activities are organised on a Tuesday and Penny is excellent at getting everyone to join in. My mum really enjoys these activities. [Do better] Perhaps more activities for the residents. Sometimes I think they could do with some more stimulation. My mum gets bored. Handling of the laundry: every time I visit I find other residents clothes in my mums wardrobe. She has also clothing which was never found. On the whole my family are very happy with the quality of care our mother receives, she is very happy. In a survey a member of staff told us We now have a new manager so this will make the home a better working environment as the manager will be able to communicate with staff on a regular basis rather than often. Another member of staff told us the home has been without a full time manager for the last 2 years which at times has put a lot of pressure on senior staff and other staff members, but thankfully we now have a new manager starting which will help to boost staff moral and be able to address and resolve any issues that arise at the home, hopefully. What the care home does well: What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 7 of 11 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action 1 7 13 Bathing risk assessments 30/09/2009 must identify whether people need staff with them in the bathroom or not. To reduce the risk of drowning or scalding. 2 7 15 Care plans must identify guidance to staff on how peoples care and support needs are to be met and monitored. So that peoples current care and support needs are met. 30/09/2009 3 7 13 The home must record size and colour of any wounds, together with details of whether the skin is broken. For peoples safety 30/09/2009 4 7 17 The home must keep their own notes and not rely on those kept by the district nursing service. So that records are kept of monitoring and healing. 30/09/2009 5 7 13 Risk assessment outcomes must be clearly identified in peoples care plans. There must be information about how any identified risks are 30/09/2009 Care Homes for Older People Page 8 of 11 Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action managed and monitored. For peoples safety Care Homes for Older People Page 9 of 11 Requirements and recommendations from this inspection:
Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours.
No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No Refer to Standard Good Practice Recommendations 1 9 All handwritten entries in the medicine administration record should be checked by a second member of staff. Care Homes for Older People Page 10 of 11 Reader Information
Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for noncommercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. Care Homes for Older People Page 11 of 11 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
