Care Home: Albion Park House

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What the care home does well Albion House has a homely/family type environment. There are a variety of communal rooms that enable residents` a choice of relaxing in a quiet lounge or engaging in social interaction with others. Residents are enabled choices in their daily living with efforts being made to ensure their health and personal care is not compromised. A relative told us` the personal care is very good` and when asked is there any thing they could do better told us `no, not at all`. The standard of medicines administrating and recording are good. Assessments are detailed and there is a focus on good nutrition with nutritional assessment undertaken on admission and close monitoring of food and fluid intake. Fresh fruit is provided in bowls and offered to residents between meals. A relative told us `I am very pleased with the care and my x `likes the food`. A range of stimulating and varied activities is provided throughout the day and regular physical exercise is provided to help residents with general mobility. Outings are provided on occasions and resident encouraged to take part. The standard of cleaning and practices to minimise the risk of infection are in the main good. Many of the residents` rooms are personalised with their own photographs and personal items. There is an emphasis on meeting residents` spiritual needs with representatives of various faiths attending the home and some residents as able attending church. Staff retention is good and care staff work well as a team. The number of staff trained to NVQ level 2 exceeds the recommended standard. What has improved since the last inspection? The manager has been registered and a deputy manager employed to provide support. Recruitment checks are undertaken as required. Regular documented supervision is undertaken and there is a regular training programme available to them. Care plans are been developed and include more detail and appropriate risk assessments. Consultation with relatives regarding healthcare needs has improved. Efforts have been made to ensure residents` privacy and dignity is upheld. Some progress has been made in quality assurance in consulting with residents and their relatives. The registered provider undertakes regular visits that are reported as required. The kitchen has been refitted and refurbished and additional storage provided. Some decoration has taken place and carpets replaced. What the care home could do better: The level of detail included in the AQAA was brief and did not provide sufficient information on how well the home was achieving its stated aims and objectives. The quality assurance programme needs further development to consult with other stakeholders (GPs, district nurses, chiropodists etc) and produce an annual plan. This would provide evidence that appropriate action is being taken to improve the service following consultation with residents, their relatives and others. Staff and others are accessing the kitchen for refreshments and toilet facilities. This will need to be resolved on completion of the extension to ensure the risk of infection is minimised.The laundry room is too small and the hopper sluice currently housed within it and in use compromises infection control recommendations. The recently updated Essex safeguarding procedures were not available. Storage of hoist slings and linen is not appropriate (for example some linen stored on the floor in cupboards). The complaints procedure did not include details of the local authority responsible for placing residents to advise residents and their representatives who to complain to if they were dissatisfied with the registered providers response. The temperature storage of medication is above recommended maximum levels to ensure the safety of medicines and the medication trolley is not secured to the wall. CARE HOMES FOR OLDER PEOPLE Albion Park House 7 Albion Hill Loughton Essex IG10 4RA Lead Inspector Diana Green Unannounced Inspection 27th June 2008 09:30 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 Albion Park House DS0000017746.V367269.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. Albion Park House DS0000017746.V367269.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Albion Park House Address 7 Albion Hill Loughton Essex IG10 4RA 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) 020 8508 4172 020 8508 4172 Mr Mark Bowman Elizabeth Veronica Mary London Care Home 19 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (19) of places Albion Park House DS0000017746.V367269.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Persons of either sex, aged 65 years and over, who require care by reason of old age (not to exceed 19 persons) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 10 persons) The total number of service users accommodated must not exceed 19 persons No more than three persons may attend the home on a daily basis in addition to those 19 accommodated The registered provider must consult with the existing service users and staff every three month on the daily attendance at the home of non-resident persons. The registered provider must respond according to the wishes and feelings of service users in respect of nonresident persons attending the home daily. Copies of the minutes of these meetings must be forwarded to the Commission 28th June 2007 Date of last inspection Brief Description of the Service: Albion Park House is a detached, two story, older style property, situated in a residential area near to Loughton town centre in Essex. The home is registered to provide residential care for 19 Older People (over the age of 65, 10 beds for residents with dementia), the home does not provide nursing care. There are seventeen single bedrooms and one shared room (currently used as single). The communal rooms include two dining areas, and two lounge areas. The grounds around the property have been developed to provide additional access and facilities for service users, with wheelchair access at the rear via the extension. However due to the location of the house: on a steep hill, only the front garden is accessible for service users to use at present, and only with staff support to negotiate several steps. The home provides 24-hour personal care and support to service users with varying levels of need. Albion Park House DS0000017746.V367269.R01.S.doc Version 5.2 Page 5 The fees range from £434.61 -£577.00 weekly. Additional costs apply for chiropody, toiletries, sundries, hairdressing and newspapers. This information was provided to the CSCI on 27/06/08. CSCI inspection reports are available from the home and the CSCI internet website Albion Park House DS0000017746.V367269.R01.S.doc Version 5.2 Page 6 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 report has been written using accumulated evidence gathered prior to and during the site visit, including the homes (AQAA) Annual Quality Self Assessment and surveys distributed to residents, relatives, staff, and health and social care professionals. This was an unannounced key inspection lasting 6.5 hours. The inspection process included: discussions with the registered manager, the proprietor, four residents, four care staff, one relative and feedback from health and social work professionals; a tour of the premises including a sample of residents’ rooms, bathrooms, communal areas, the kitchen, the laundry/sluice-room; an inspection of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). Twentysix standards were inspected and two requirements and three recommendations were made. The registered manager, proprietor and staff were welcoming and helpful throughout the inspection. The home was being extended to upgrade the accommodation to provide additional communal space, a new bathroom, 2 single en-suite rooms, a new lift, undercover parking and additional security. What the service does well: Albion House has a homely/family type environment. There are a variety of communal rooms that enable residents’ a choice of relaxing in a quiet lounge or engaging in social interaction with others. Residents are enabled choices in their daily living with efforts being made to ensure their health and personal care is not compromised. A relative told us’ the personal care is very good’ and when asked is there any thing they could do better told us ‘no, not at all’. The standard of medicines administrating and recording are good. Assessments are detailed and there is a focus on good nutrition with nutritional assessment undertaken on admission and close monitoring of food and fluid intake. Fresh fruit is provided in bowls and offered to residents between meals. A relative told us ‘I am very pleased with the care and my x ’likes the food’. A range of stimulating and varied activities is provided throughout the day and regular physical exercise is provided to help residents with general mobility. Outings are provided on occasions and resident encouraged to take part. Albion Park House DS0000017746.V367269.R01.S.doc Version 5.2 Page 7 The standard of cleaning and practices to minimise the risk of infection are in the main good. Many of the residents’ rooms are personalised with their own photographs and personal items. There is an emphasis on meeting residents’ spiritual needs with representatives of various faiths attending the home and some residents as able attending church. Staff retention is good and care staff work well as a team. The number of staff trained to NVQ level 2 exceeds the recommended standard. What has improved since the last inspection? What they could do better: The level of detail included in the AQAA was brief and did not provide sufficient information on how well the home was achieving its stated aims and objectives. The quality assurance programme needs further development to consult with other stakeholders (GPs, district nurses, chiropodists etc) and produce an annual plan. This would provide evidence that appropriate action is being taken to improve the service following consultation with residents, their relatives and others. Staff and others are accessing the kitchen for refreshments and toilet facilities. This will need to be resolved on completion of the extension to ensure the risk of infection is minimised. Albion Park House DS0000017746.V367269.R01.S.doc Version 5.2 Page 8 The laundry room is too small and the hopper sluice currently housed within it and in use compromises infection control recommendations. The recently updated Essex safeguarding procedures were not available. Storage of hoist slings and linen is not appropriate (for example some linen stored on the floor in cupboards). The complaints procedure did not include details of the local authority responsible for placing residents to advise residents and their representatives who to complain to if they were dissatisfied with the registered providers response. The temperature storage of medication is above recommended maximum levels to ensure the safety of medicines and the medication trolley is not secured to the wall. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Albion Park House DS0000017746.V367269.R01.S.doc Version 5.2 Page 9 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 Albion Park House DS0000017746.V367269.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon sampled inspected standards 3, 5 & 6. Residents were well informed, and had their needs fully assessed prior to moving in to the home to ensure they could be appropriately met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The admission procedures were discussed with the manager during the site visit. The manager stated that she undertook pre-admission assessments either at home or hospital where possible to ensure needs could be met at the home. Care management assessments were obtained where relevant and seen on the care records viewed. A sample pre-admission assessment form was seen, and included all elements of need as indicated under this standard. A relative spoken with during the site visit confirmed that they had seen a copy of the statement of purpose and service user guide prior to admission. Albion Park House DS0000017746.V367269.R01.S.doc Version 5.2 Page 11 The manager stated that prospective residents and their relatives are able to visit the home prior to making a decision. A relative spoken with told us that this had been offered to them but they chose not to visit. The home does not provide intermediate care. Albion Park House DS0000017746.V367269.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon sampled standards 7, 8, 9, 10. The health and personal care needs of residents are met through care planning that is closely monitored and regularly reviewed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four residents’ care files were viewed. All files contained a pre-admission assessment form developed by the home that had been completed prior to admission and used to develop care plans. Additional individual assessments had been completed in regard to specific needs (e.g. risk of falls, moving and handling, continence, nutrition, skin condition, etc.) and regularly reviewed. The records included evidence that nutritional intake was recorded and weight monitoring undertaken two weekly with appropriate action taken to provide supplements as needed. A range of care plans were present on the care files Albion Park House DS0000017746.V367269.R01.S.doc Version 5.2 Page 13 viewed, and these contained a good level of detail of the action required by staff to help the person meet their needs. The records confirmed evidence of good monitoring of health care needs with prompt referral to GPs and health care professionals and appropriate follow up action being taken. The AQAA stated that the home was supported by 3 GP practices and they found visits from the district nurses very helpful. The records confirmed that residents were enabled access to GPs, practice nurses, district nurses, community psychiatric nurses, chiropodists, dentist, and opticians. One resident told us ‘I like it here. I have people to talk to and they look after me and help me to get washed and dressed’; and another resident said ’they do everything for you. I like it very much’. A relative told us they were very pleased with the care provided at Albion Park House: ‘the personal care is very good and x sees the GP and the staff let me know if x is not well. ‘ The systems for administration of medicines were discussed during the site visit with the registered manager. The home had a medication policy and procedures that were available for staff guidance and had been provided by the local Primary Care Trust (PCT). These had been developed for use by care homes and were comprehensive. However they were still in draft form and the manager was advised to request a copy of the final guidance and to enure that procedures were developed that were localised to Albion Park House. Care staff administered all medication at the home and the records confirmed that all had undertaken medication training. A current list of staff names, signatures and initials was available to identify those staff who were authorised to administer medication. Medication was supplied through a local pharmacy in dosset boxes and individual containers and appropriate ordering and disposal procedures were in place. Supplies were stored in a locked trolley in the corridor of the ground floor but this was not secured to the wall as required for additional security. Further storage was provided in a separate cupboards. A Controlled Drugs (CD) cupboard was alsdo available that was located in the manager’s office on the ground floor but was not in use for CD drug storage. The drug fridge was stored in the dining room and regular monitoring and recording of room and refrigerator temperatures were undertaken ensuring medication was stored within safe recommended levels. The medication administration records and supplies for four residents were inspected. All medication was available as prescribed and the medication administration records (MAR) were well recorded with no omissions evident. During the site visit, staff were observed to be friendly towards residents and to treat them with respect. A relative told us’ the staff are lovely; they are very nice to residents’ and another said ’the manager and the staff fondly care for the residents’. Albion Park House DS0000017746.V367269.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon sampled inspected standards 12, 13, 14 and 15. People living at Albion Park House can expect to mantain contact with their family and friends and to have a lifestyle that satisfies their cultural expectations and needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There was a board displayed in the dining room with the week’s activities. Activities were organised by a designated care assistant. The manager explained that activities included board games, craft sessions; sing a long session, ball games and bingo. Reminiscence therapy was also provided by an external provider every two months and entertainment monthly. During the site visit , residents were seen watching television, listening to music, or reading newspapers. One resident was observed painting a picture and care staff were seen taking part in an ‘Old Thyme Music’ sing a long session with residents during the morning. During the afternoon some residents were Albion Park House DS0000017746.V367269.R01.S.doc Version 5.2 Page 15 watching a Wimbledon tennis match whist others in another lounge room were listening to music and talking to care staff. A resident told us ‘they play games and keep us interested’. Another resident told us they ‘went on a trip recently in a limousine and went to see all the animals and we had a singsong’. Care staff confirmed that they encouraged residents to go on the two mystery trips that were organised locally during the year. A visiting therapist was observed providing a seated exercise session during the morning. From the comments made and the mood displayed, residents were clearly enjoying the activity and feeling the benefit of the exercise. A relative who completed a survey told us ‘she comes in once a week’ to help with the exercise. The home’s statement of purpose included the policy on visiting. A relative spoken with said that they were able to visit at any time. Several visitors were seen to come and go throughout the inspection. The home’s statement of purpose and service user guide detailed the arrangements made for residents to maintain their faith by representatives of different faiths attending the home as they had requested. The manager told us that during the Christmas celebrations they invited local choirs to come into the home to entertain residents. Residents were observed to have some choice about their daily life in the home, especially in regard to where they spent their day, ate their meals etc. The manager explained that one resident had chosen to stay in bed during the morning, as they had not slept well the previous night and arrangements had been made for their meal and medication to be provided once they got up. This was confirmed later when the resident was observed having their lunch and being given their medication. From discussion with the manager it was evident that staff would ensure medication was given at appropriate times for the remainder of the day. Many of the rooms seen were well personalised, showing that people could bring their own possessions into the home with them. The menus viewed provided a varied range of meals with alternatives available and with seasonal variations and based on mainly homely type food. Residents were observed enjoying the lunchtime meal that comprised fish and chips with mushy peas, followed by rice pudding and cream. The tables were nicely laid with tablecloths and condiments and drinks provided. Several residents were observed eating from trays in their chairs. We were told that some had chosen to do so but that there was not enough space for them all to sit at the table. However with the ongoing improvements to the accommodation it was expected this would be rectified. Several residents were spoken with during the site visit and all said they had enjoyed lunch. When asked if they enjoyed the meals at the home, a resident who completed a survey, responded ‘always’. A relative also told us that ‘they especially look after x gastronomic needs’ and ‘the staff cook from scratch, ensuring fresh food, healthy food for our x’. Albion Park House DS0000017746.V367269.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon sampled inspected standards 16 & 18. People living at Albion Park House can expect to have their complaints listened to and acted upon and to be protected from abuse by policies, procedures, staff training and practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a complaints procedure that included the timescales within which complainants can expect a response. The procedure advised complainants’ of their right to refer to CSCI but did not provide details of the placing authority who have a legal responsibility for safeguarding residents placed under their arrangements. The procedure was included in the statement of purpose and displayed in the entrance of the home. No complaints had been received since the previous inspection. When asked ‘has the care service responded appropriately if you or the person using the service has raised concerns about their care? We received the following comment from relatives ‘we cannot see this ever being necessary’. A relative spoken with told us they knew how to complain but had not had a reason to make a complaint. A resident also told us that if they had any issues: ’I just go to Liz (the manager) and she sorts it out’. Albion Park House DS0000017746.V367269.R01.S.doc Version 5.2 Page 17 The home had comprehensive policy and procedures for safeguarding vulnerable adults that were kept under review. Local Essex procedures were available for staff guidance but the recent updated procedures had not been received and the manager agreed to follow this up. The records confirmed that all staff had received relevant training. There had been no incidents or allegations of abuse since the previous inspection. From discussion with the manager it was evident that she was knowledgeable on safeguarding adults and aware of the procedures to be followed in the event of any allegations being made. Albion Park House DS0000017746.V367269.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon sampled inspected standards 19, 22 and 26. People living at Albion Park House can expect to live in a clean, homely and well-maintained environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A partial inspection of the premises was made that included communal areas, several bathrooms, a number of residents’ rooms, the kitchen and the laundry. The home was being extended to provide additional accommodation and improved communal space for residents and from observation and discussion with residents; this did not appear to have caused undue disruption for people living at the home. The records confirmed that action had been taken to address maintenance issues as they arose. The home was clean and decorated Albion Park House DS0000017746.V367269.R01.S.doc Version 5.2 Page 19 and comfortably furnished in accordance with the client group. The front garden of the home was laid to lawn. A patio area with seating provided a place for residents to sit out. Records provided evidence that the building complied with the requirements of the local fire and environmental health department. The home had a passenger lift to enable access throughout the premises. There were grab rails, and aids in bathrooms, toilets and communal rooms to meet the needs of residents. Assisted baths and toilets were provided and the home was fully accessible to wheelchairs. Call systems were provided throughout all individual and communal rooms. Pressure relief equipment (cushions and mattresses) was observed on residents’ chairs and beds to meet their needs. The records confirmed that all equipment including hoists was serviced as per manufacturers recommendations. There were policies and procedures for infection control available for staff guidance and the sampled staff records viewed confirmed that infection control training had been provided since the previous key inspection. The home was cleaned to a satisfactory standard throughout. There was no designated laundry assistant and laundry was therefore the responsibility of care staff. The laundry room was very small with no space to organise resident’s personal laundry or for ironing. Despite this, residents’ personal clothing seen was well laundered and had been put tidily in drawers and wardrobes (key workers’ responsibility). There were two washing machines and one drier that were in use. A hopper sluice was located in the laundry room (confirmed to be used by staff) that is contrary to infection control guidance. Systems were in place to minimise the risk of infection via the use of red bags for any laundry soiled by body fluids, placed directly in the washing machines and washing machines had the capacity to carry out sluice wash cycles. The laundry arrangements were discussed with the provider (in relation to lack of space and the hopper sluice) who proposed this being addressed during the building programme. Hand washing facilities (liquid soap and paper towels) were provided in bathrooms and toilets but not in all areas where personal care is provided. Bins used for disposal were open, rather than foot operated, however the provider took immediate action to ensure the appropriate bins were supplied throughout as required. Access through the kitchen for staff and others must be discouraged to minimise the risk of infection (although it is acknowledged this has been compounded by the current building works). Albion Park House DS0000017746.V367269.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon sampled inspected standards 27, 28, 29 and 30. People living at Albion Park House can expect to have their needs met by caring staff that have been robustly recruited and received appropriate training. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were seventeen residents at the home. Staffing levels comprised three care staff (including the deputy manager). The registered manager and one domestic assistant were on duty and the proprietor was also present during most of the site visit. The manager explained that the maintenance person attends on request and a gardener attends one day per week. There was evidence from the staff rota that staffing levels were well maintained and from observation these seemed to meet residents’ needs. Information received in the AQAA stated that the home had 18 care staff of which 14 had NVQ level 2 qualifications or above which is 80 and therefore exceeds the recommended 50 needed to meet the standard. A further 4 staff were working towards NVQ level 2 training. Albion Park House DS0000017746.V367269.R01.S.doc Version 5.2 Page 21 We were told that staff retention was good with a number having been employed at the home for some years. The recruitment files of two recently employed staff were inspected. Both had evidence that the required checks had been obtained (two satisfactory references, CRB/POVA checks) and evidence of identification and photographs obtained before the individuals commenced employment at the home. Both had received a statement of terms and conditions of employment. The manager reported that all staff received induction to Skills for Care Standards and this was also confirmed from the records viewed. The home had an established training programme. The training records were viewed for two members of staff. One had completed training since appointment on fire safety, protection of vulnerable adults, infection control, moving and handling, dementia awareness and the second had also received training on food hygiene, first aid and drug and alcohol awareness. When asked ‘Do the care staff have the right skills and experience to look after people properly? Two relative told us ‘always’ and another said ’they do everything well’ and a resident also told us ‘I’m looked after well’. Albion Park House DS0000017746.V367269.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon sampled inspected standards 31, 33, 35, 36, 37 and 38. Albion Park House is well managed and run in the best interests of residents. The health and safety of residents and staff is safeguarded by the policies, procedures and practices at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager had worked as an acting manager for some time and as a senior care assistant for several years. She is contracted for 20hours management time, working the remaining time in care. There was no administrator or secretary to provide support. However recommendations in Albion Park House DS0000017746.V367269.R01.S.doc Version 5.2 Page 23 the previous key inspection to appoint a deputy manager to provide support to the manager had recently been actioned. We were informed that the manager was in the process of undertaking the Registered Managers award (RMA) and was due to complete this in September 2008. The home had a quality assurance programme that included consultation with residents, their relatives, staff and health professionals. The process was discussed with the manager. She explained that questionnaires had been distributed to stakeholders and the responses acted upon. However this had not been formalised by producing a report on the outcome and no annual plan had been produced and therefore needs to be further developed. Registered Provider visits were undertaken and confirmed from the reports (required under Regulation 26) that were seen. Neither the manager nor staff were appointee for any resident at the home. All residents had a representative/advocate to manage their finances on their behalf. Monies were held for some residents in zipped pouches that were held in lockable facilities for safekeeping. Records of income and expenditure were maintained. Three residents monies were inspected: receipts were held and all cash was confirmed as accurate. From discussion with the manager and the staff records viewed it was evident that regular handover sessions were in place to ensure any changes in residents’ needs were communicated. Staff supervision was provided to Skills for Care standards and we were informed that efforts were being made to ensure this was provided every two months to meet the standard. Records held on behalf of residents were kept up to date and stored safely in secure facilities in the office in accordance with the Data Protection Act 1998. Records viewed at this inspection included the statement of purpose, the service user guide, medication records, care plans, staff recruitment and training files, fire safety records, maintenance records and accidents records. The home had health and safety policies and procedures that were regularly reviewed. The training records viewed confirmed that two recently appointed staff had attended health and safety training since appointment. Evidence of a sample of records viewed showed that there were systems in place to ensure the servicing of equipment and utilities and there was evidence of appropriate weekly and monthly internal checks being carried out (e.g. checks on fire equipment fire alarms and emergency lighting etc.). All accidents, injuries and incidents were well-recorded and appropriate action taken. Albion Park House DS0000017746.V367269.R01.S.doc Version 5.2 Page 24 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 3 x 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 X X X 2 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 x 3 3 3 3 Albion Park House DS0000017746.V367269.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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 OP9 Regulation 13(2) Requirement To ensure the safe storage of medicines: 1. Room temperature of medication storage facilities must remain within safe maximum recommended levels of 25°Centigrade. 2. Medication trolleys must be secured to the wall. To minimise the risk of infection the laundry arrangements must be reviewed and remove the hopper sluice and extend the facilities. Timescale for action 31/07/08 2. OP26 13(3) 30/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP16 OP33 Good Practice Recommendations To ensure residents and their representatives are fully informed the complaints procedure should be reviewed to include details of the Local Authority. To ensure residents, their representatives and other DS0000017746.V367269.R01.S.doc Version 5.2 Page 26 Albion Park House 3. OP38 stakeholders viewed are listened to and acted on, the home should ensure an annual plan is developed for the home. To minimise health and safety risks to residents and staff COSHH policy and procedures should be reviewed. Albion Park House DS0000017746.V367269.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Albion Park House DS0000017746.V367269.R01.S.doc Version 5.2 Page 28 - 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. 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