Care Home: Albany House

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What the care home does well The home responds to recommendations and requirements made by us and also knows how it would like to improve and has plans in place for this. There is a well established staff team with a good knowledge and understanding of the needs of people who live here. This ensures stability and continuity of care. People who live here say they are happy and they get on well with staff. One service user `staff are very nice` and `I am well looked after and have everything I need`. Another said `staff are very kind` and another said `they are magnificent, they seem to understand me`. There was a relaxed and natural rapport between staff and service users. Staff responded to people in a friendly and respectful manner. Albany House DS0000014348.V377653.R01.S.doc Version 5.3 Staff are well trained and supervised which ensures staff are confident and competent at their job. What has improved since the last inspection? The assessment process has improved to ensure only people whose needs can be met are admitted to the home. The manager has overhauled the care plans and risk assessments; the new and improved format gives more information to ensure that care needs are met consistently. An adjoining door between two bedrooms has now been blocked off to ensure the safety and privacy of the people using those rooms. Recruitment procedures have improved and two references are now taken up for all prospective employees. The main lounge has been redecorated offering more pleasant and comfortable surroundings. A deputy manager has been employed and is supporting the manager with the ongoing improvements in the home. What the care home could do better: The manager has agreed to carry out a risk assessment for the practice of locking the kitchen door to show it is in the best interests of all service users. The manager has also agreed to improve the recording and checking of the monies held on behalf of service users to ensure they are accurate and people are protected by the home`s procedures.Albany HouseDS0000014348.V377653.R01.S.docVersion 5.3 Key inspection report CARE HOME ADULTS 18-65 Albany House 13 Stocker Road Bognor Regis West Sussex PO21 2QH Lead Inspector Liz Palmer Key Unannounced Inspection 9th September 2009 09:00 Albany House DS0000014348.V377653.R01.S.doc Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought 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. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Albany House DS0000014348.V377653.R01.S.doc Version 5.3 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Albany House DS0000014348.V377653.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service Albany House Address 13 Stocker Road Bognor Regis West Sussex PO21 2QH 01243 822533 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) Mrs Philippa Dawn Solan Mrs Philippa Dawn Solan Care Home 17 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0) of places Albany House DS0000014348.V377653.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Mental disorder, excluding learning disability or dementia (MD) The maximum number of service users to be accommodated is 17. Date of last inspection 9th September 2008 Brief Description of the Service: Albany House is a care home providing accommodation and personal care for seventeen people with a diagnosis of mental disorder. The Registered Provider/Manager is Mrs. Philippa Dawn Solan. The property is situated close to the sea front and a short walk from Bognor Regis town centre with its shops, train station and other amenities. Albany House consists of two large three-storey houses, which have been linked to form one establishment. The accommodation is provided in seventeen single rooms and there are two lounges and a separate dining room. There is a large garden to the rear of the building which is accessible to service users. Albany House DS0000014348.V377653.R01.S.doc Version 5.3 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The inspection took place over five and a half hours, starting at 9.00hours. Mrs Phillippa Solan is the registered provider and registered manager of the home. She has been referred to as the manager throughout this report. The manager of the home was present during the inspection. Three residents were met and spoken to about living in the home; others were seen in passing during the course of the day. Two members of staff were spoken to in private. Others were observed interacting with service users. During the inspection we looked at a sample of care plans, daily records, staff files, policies and medication records. We also used the homes Annual Quality Assurance Assessment (AQAA) and their last inspection report to help make our judgements about the home. The AQAA is a document we require the home to complete and return to us with a given timescale, on an annual basis. The home completed theirs within the given timescale and gave us all the information we asked for. What the service does well: The home responds to recommendations and requirements made by us and also knows how it would like to improve and has plans in place for this. There is a well established staff team with a good knowledge and understanding of the needs of people who live here. This ensures stability and continuity of care. People who live here say they are happy and they get on well with staff. One service user ‘staff are very nice’ and ‘I am well looked after and have everything I need’. Another said ‘staff are very kind’ and another said ‘they are magnificent, they seem to understand me’. There was a relaxed and natural rapport between staff and service users. Staff responded to people in a friendly and respectful manner. Albany House DS0000014348.V377653.R01.S.doc Version 5.3 Page 6 Staff are well trained and supervised which ensures staff are confident and competent at their job. What has improved since the last inspection? What they could do better: The manager has agreed to carry out a risk assessment for the practice of locking the kitchen door to show it is in the best interests of all service users. The manager has also agreed to improve the recording and checking of the monies held on behalf of service users to ensure they are accurate and people are protected by the home’s procedures. Albany House DS0000014348.V377653.R01.S.doc Version 5.3 Page 7 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 on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Albany House DS0000014348.V377653.R01.S.doc Version 5.3 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Albany House DS0000014348.V377653.R01.S.doc Version 5.3 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 2. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service can be assured that their individual needs would be assessed prior to moving to the home. EVIDENCE: At the last inspection we made a requirement stating that the home must carry out assessments of need for people referred for possible admission to ensure that only those whose needs can be met are admitted. In their AQAA the home told us they had a new assessment process which would ensure all relevant information was gathered before people are offered a place in the home. We looked at an example of the new assessment format completed for someone recently admitted to the home. The assessment was detailed and covered all the relevant aspects of a person’s care needs. For example, their daily living skills, their mental health, physical health and communication needs. Also included were their social needs, religious and cultural needs and details of family and friends. There was evidence that a social worker and other professionals were involved in the process. Records of their assessments were kept. Records also showed us that the person had visited once, briefly, Albany House DS0000014348.V377653.R01.S.doc Version 5.3 Page 10 before moving in. The manager explained this was due to the service user’s personal circumstances at the time and that more visits, including staying for meals are on offer. This person was not available to give us their views on the assessment and moving in process during the inspection. Albany House DS0000014348.V377653.R01.S.doc Version 5.3 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements to the care planning process means that people who use the service have individual care plans and risk assessments that are more detailed and clear further development will benefit individuals. EVIDENCE: At the last inspection we found that care plans were lacking in detail and that risk assessments were not always in place when needed. The detail lacking was mainly in the area of social, educational and leisure needs. A requirement was made for this to be included in future and for evidence that people are Albany House DS0000014348.V377653.R01.S.doc Version 5.3 Page 12 involved in their care plans. The home’s AQAA states that new and improved care plans are now in place. Three care plans were looked at during the inspection. They all included details such as mental health needs, physical health needs, personal care needs, communication needs, religious and cultural needs and some detail about social and educational needs. The manager stated meeting people’s social and educational needs was still an area for development within the home; however the requirement regarding this is met. The three care plans seen had been signed by service users and when asked about their care plans they said they are regularly consulted on whether they are happy with them and the care they receive. There was written evidence that care plans are reviewed on a monthly basis and changes are noted as they occur. Service users spoken to said they could make choices and felt in control of their daily lives. They said they could choose how to spend their time, when to get up and go to bed and that staff were supportive and understanding of their needs. One of the care plans did not include some information that later became apparent to the inspector, whilst talking to a service user. This was discussed with the manager who agreed to immediately update the care plan. There was no imminent risk to the person involved however it was agreed that anyone supporting this person should be in receipt of the information. Marked improvements to the care plans were noted, however, the manager acknowledged that there was still room for improvement and it was an area for development for the home. Risk assessments were seen to be in place, this is an improvement since the last inspection. These assessments were designed to meet the individual needs of people and covered areas such as smoking, self administration of medication, community access and health related issues. These risk assessments were seen to be reviewed monthly and kept up to date. Albany House DS0000014348.V377653.R01.S.doc Version 5.3 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 12, 13, 15, 16 and 17. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service say they have enough to do, they would benefit from support to access a wider range of educational, social and community activities. Healthy and varied meals are provided with the preferences of people who use the service taken into account. EVIDENCE: People living in the home told us they had enough to do and were happy with the arrangements for leisure activities and access to the community. People said they can choose how to spend their time and enjoyed playing cards and boards games with staff in the afternoons. One service user said they enjoyed Albany House DS0000014348.V377653.R01.S.doc Version 5.3 Page 14 gardening and another said she liked going into town and having visitors to the home. At the last inspection we said there was room for improvement in the amount of detail written in care plans about social, leisure and educational needs. More detail was seen on this visit, and a record of activities offered and who participated is now kept. Examples of the sorts of activities taking place included; a trip to Arundel, pitch and putt, bingo, scrabble, pat the dog, quizzes and board games. Staff and service users told us that there is an activity most afternoons. Minutes of meetings for service users showed that suggestions from them for trips and activities are noted. In their AQAA they told us that they are now offering monthly trips out and more in-house activities. They also say that they plan to continue with this and improve upon the needs led activities for individuals. Some service users attend a day centre where they have the opportunity to learn independent living skills and educational courses. Service users said their visitors are made welcome and records showed that people are supported to maintain contact with their family and friends by telephone and assisting with transport. The AQAA states that healthy and varied meals are provided and people said they enjoyed the meals and some liked helping in the kitchen. Details of specific dietary needs are recorded in care plans as well as individual needs and preferences. Meals and meal times are regular with an amount of flexibility built in so that a meal can be kept for someone who is out at the meal and requests for food can be made in between meal times. Service users said they get regular drinks and some people have drink making facilities in their rooms. Albany House DS0000014348.V377653.R01.S.doc Version 5.3 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements to care plans and risk assessments means that staff are better informed about how to support people and ensure their needs are met. EVIDENCE: People spoken to said they felt their needs were met and that staff were kind, caring and respectful towards them. Three of the four people spoken to said they felt staff understood their mental health needs, one said ‘not always’. This was discussed with the manager and from looking at the care plan and talking to staff we were satisfied that this person was being supported in a consistent manner and that staff had a good understanding of their needs. Care plans included details of peoples’ emotional needs and staff were observed meeting these needs during the inspection. Albany House DS0000014348.V377653.R01.S.doc Version 5.3 Page 16 People using the service told us they could get medical assistance when they needed it and records showed that all medical concerns or requests are followed up and that people are well supported to keep doctors’ and out patients’ appointments and that good relations are maintained with health care professionals. For example, general practitioners, district nurses and clinical psychologists. Medication was seen to be safely stored, for example, insulin is stored in a locked box within the fridge. A lockable cupboard is provided for other medication. Procedures and records for this were sampled and found to be secure and accurate. The home supports people to be independent as far as possible and where appropriate individual risk assessments are in place. Since the last inspection the home has installed a controlled drugs cabinet for the safe and legal storage of controlled drugs. Records were checked for this and found to be in order. The home uses a monitored dosage system from a national pharmacy; they audit the home’s storage and procedures every six months. Albany House DS0000014348.V377653.R01.S.doc Version 5.3 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are able to voice their concerns and expect to have their complaints listened to. They are protected by the policy and procedures relating to safeguarding. EVIDENCE: There is a complaints procedure in the home which is given to service users and included in the service users’ guide. People spoken to said they know how to complain and would feel comfortable talking to the manager or any of the staff if they were unhappy about something. They said they felt listened to and were confident action would be taken on their behalf. People said they felt safe in the home. Records showed that staff are trained in procedures for safeguarding adults and those spoken to show a good understanding of their responsibilities. The home has a copy of the West Sussex County Council Safeguarding procedures and the policy within the home is in line with this. The manager said she is aware of the Deprivation of Liberty Safeguards but currently has not made any requests under this legislation. Albany House DS0000014348.V377653.R01.S.doc Version 5.3 Page 18 Albany House DS0000014348.V377653.R01.S.doc Version 5.3 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service have a clean, homely and safe environment to live in. EVIDENCE: During the inspection the kitchen, two lounges, dining room, office, two bedrooms and two bathrooms were seen. All these areas were clean and suitably decorated. Doors marked as needing to be locked were locked and fire doors were clear from obstruction. There is an ongoing maintenance programme which includes the redecoration of communal areas and bedrooms. One of the staff in the home is also responsible for the day to day maintenance. Jobs were being done around the home during the inspection. Bedrooms have been personalized according to the individual tastes of service Albany House DS0000014348.V377653.R01.S.doc Version 5.3 Page 20 users with pictures, stereos, televisions and other personal items. At the last inspection we made a requirement that the home must look into ways that the door, which opens between the two residents’ rooms can be locked for privacy and security. The Fire and Rescue service were consulted on this and the access has now been permanently blocked. We saw that a wardrobe has been placed in front of the blocked doorway to ensure the privacy and safety of both service users. The garden was well maintained with plenty of tables and seating for people to use. Several service users were in the garden during the inspection. One said they enjoyed doing the gardening. People use the garden as a smoking area. The home has plans to build a smoking shelter before the winter. At the last inspection there was a discussion about the homes’ practice of locking the kitchen door therefore restricting access to the people living in the home. During the inspection the door was open and service users were seen approaching the door and making requests to staff. The manager stated this is usual and that some residents will access the kitchen to help or to talk to staff and make requests. The manager stated that the purpose of locking the door was for the safety of all service users and was recommended by an environmental health officer. This was discussed again with the manager who has agreed to draw up a risk assessment, considering the individual needs of each service to be drawn up. Albany House DS0000014348.V377653.R01.S.doc Version 5.3 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A trained and competent and staff team ensures the smooth running of the service. EVIDENCE: In their AQAA the home tells us they have a well established staff team and that training is ongoing and up to date. They have recently employed a deputy with National Vocation Qualification (NVQ) level 3 and a carer is also qualified to this level. The home has plans to continue to train staff to at least NVQ level 2. The manager ensures that all staff receive mandatory training, such as, health and safety, manual handling, fire safety, food hygiene and first aid. New staff receive a Skills for Care standard induction programme. Staff have all recently been trained in mental health awareness and safeguarding adults procedures. Certificates were seen for training and staff confirmed they had attended the relevant courses. Two members of staff were spoken to privately during the inspection. They said they enjoyed their work and showed sound Albany House DS0000014348.V377653.R01.S.doc Version 5.3 Page 22 knowledge of the individual needs of people who use the service. They spoke about people in a sensitive and positive manner. People who use the service said they liked the staff and got on well with them. One new staff have been employed at the home since the last inspection and their file was seen to contain all the required documentation, including, an application form, two written references and a Criminal Record Bureau check. This is an improvement since the last inspection where only one reference had been taken up for new staff. Records seen showed that regular supervision and appraisal takes place and this was confirmed by the members of staff spoken to. They said they were well supported and could always ask the manager or any of the staff for help. Albany House DS0000014348.V377653.R01.S.doc Version 5.3 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service can be assured the home is run in their best interests. EVIDENCE: Mrs Phillippa Solan is the registered provider and registered manager of the home. She has been referred to as the manager throughout this report. She has completed the City and Guilds 3250/03 Advanced Management for Care qualification as well as the NVQ Level 4 Registered Manager’s Award level 4 and has over 20 years experience. Albany House DS0000014348.V377653.R01.S.doc Version 5.3 Page 24 In their AQAA they tell us that there is an open management style in the home. Staff and service users say the manager is approachable, open to ideas and listens to the views of others. They say they have confidence in her and feel the home is well run. The manager has shown us she is open to change and has complied with the requirements we made at the last inspection as well as implementing suggested changes and improvements. In their AQAA they have told us about future improvements they would like to make and have a clear idea of how they will achieve this. The home has their own quality assurance system in place where they consult with people living in the home, their relatives and other professionals who are involved in their care. At the last inspection we made a requirement that risk assessments should be completed for the use of storage heaters. These storage heaters have now been replaced by covered radiators to reduce the risk of burns. In their AQAA the home tell us they employed the services of a health and safety expert and are implementing all the recommendations that came out of that assessment. They tell us they carry out regular health and safety checks including fire safety drills for example. Service users told us there were regular fire drills; the records relating to this were not looked at on this occasion. The home holds monies on behalf of service users. These are stored securely and individually and receipts and records are kept. The balances of three service users’ monies were checked. Two had slight discrepancies and the amounts recorded on these did not match what had been signed for as correct by staff members. One had more money than was recorded; one was less by a few pence and the third was accurate. The manager said that discrepancies may have occurred where a service user has brought back small change and this has not been recorded. Any large sums of money changing hands were accounted for and receipts were seen for these. The manager has agreed to ensure that staff are checking the amounts and only recording what is actually there. Albany House DS0000014348.V377653.R01.S.doc Version 5.3 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Version 5.3 Page 26 Albany House DS0000014348.V377653.R01.S.doc No 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. Standard Regulation Requirement Timescale for action 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 Good Practice Recommendations Albany House DS0000014348.V377653.R01.S.doc Version 5.3 Page 27 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: 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. 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