Inspection on 13/11/07 for Atholl House

This is the latest available inspection report for this service, carried out on 13th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

CARE HOMES FOR OLDER PEOPLE Atholl House 98-100 Richmond Road Compton Wolverhampton WV3 9JJ Lead Inspector Joy Hoelzel Unannounced Inspection 13th November 2007 10:00 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 Atholl House DS0000070032.V354708.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. Atholl House DS0000070032.V354708.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Atholl House Address 98-100 Richmond Road Compton Wolverhampton WV3 9JJ 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) 01902 429342 01902 713838 Caram (AH) Ltd Mrs Heather Jean Murray Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40), Physical disability (40) of places Atholl House DS0000070032.V354708.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide accommodation and personal care (with nursing) for service users of both sexes whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category (OP) 40 Physical Disability (PD) 40 The maximum number of service users to be accommodated is 40. 2. Date of last inspection New Service Brief Description of the Service: Atholl House is a care home providing accommodation, personal and nursing care to forty people. There was a change of ownership of the home in June 2007 with the registered provider now being Caram (AH) Ltd. Atholl House is situated in a residential area of Compton, Wolverhampton and consists of an Edwardian building, which has been extended over the years set in substantial and well maintained grounds. The accommodation comprises of single occupancy bedrooms, with communal lounge and dining areas. Information of the home and the provision of the service are available in the statement of purpose and service user guide, both documents have recently been revised and are readily available. The service user guide does not include information on the current level of fees for the service. The reader may wish to obtain more up to date information from the care service. Commission for Social Care Inspection reports for this service are available from the provider or can be obtained from www.csci.org.uk Atholl House DS0000070032.V354708.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over four hours on Tuesday 13th November 2007 and is the first inspection following the change of provider in June 2007. It was conducted by one Commission for Social Care Inspection regulation inspector. Twenty three of the thirty eight National Minimum Standards for Care Homes for Older People were inspected as they are viewed as key standards for services. Thirty one people are currently living at the home and during the inspection were observed to be accessing all areas of the home. The registered manager was on the premises supported by two registered nurses, seven care staff, and ancillary personnel. The care provided for three people were examined in detail, relevant documents were inspected, discussions were held with people living at the home, visitors, members of staff and the manager. Observation was made of the various daily activities and a tour of the premises was conducted. Prior to this inspection an Annual Quality Assurance Assessment (AQAA) document was posted to the home for completion. The AQAA is a selfassessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service and is an opportunity for providers to share with the CSCI areas that they believe they are doing well. It is a legal requirement that the AQAA is completed and returned to the commission within a given timescale. The acting manager completed this document and returned it the commission. Comments from the AQAA are included within this inspection report. A thematic inspection was carried out 17th September 2007; this is a short, focused inspection that looks in detail at a specific theme. This inspection looked at the quality of care people with dementia experience when living in care homes, focussing on ‘dignity’ as an important part of people’s quality of life. The outcome of this inspection is that people living at this home are supported by staff that respect their privacy and dignity and promote their independence where possible. A separate report is available upon request. Atholl House DS0000070032.V354708.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The home was registered with new providers in June 2007; no changes have been made to the registered manager, Mrs Murray remains in day-to-day charge of the service. The requirements and recommendations made following the inspection in August 2006 have been satisfactorily complied with. Atholl House DS0000070032.V354708.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Atholl House DS0000070032.V354708.R01.S.doc Version 5.2 Page 8 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 Atholl House DS0000070032.V354708.R01.S.doc Version 5.2 Page 9 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): OP 1, 3, 6 Quality in this outcome area is excellent. The assessment process focuses on achieving positive outcomes for people and this includes ensuring that the facilities, staffing and specialist services provided by the home meet the ethnicity and diversity needs of the individual. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Details of the service provision are available in the statement of purpose and service user guide; both documents have been reviewed in June 2007, and are available on request. Atholl House DS0000070032.V354708.R01.S.doc Version 5.2 Page 10 Three case files of people living at the home were selected for inspection and indicated that pre admission assessments and personal details had been sought prior to offering a placement at the home. One person who hasn’t been at the home for very long expressed an general satisfaction with the service and stated they were ‘ Very happy to be at the home’. They went on to say how their relative had visited the home on their behalf with the decision to move in being based on the relative’s opinion. The manager of the home visited the person in their place of residence before offering a placement this ensuring that the persons care needs could be fully met. The home does not offer an intermediate care service. Atholl House DS0000070032.V354708.R01.S.doc Version 5.2 Page 11 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): OP 7,8,9,10 Quality in this outcome area is excellent. Staff ensures that care is person led, personal support is flexible, consistent, and is able to meet the changing needs of the residents. Resident’s individual plans clearly record their personal and healthcare needs and detail how they will be delivered. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All people living at the home have a plan of care that is generated at the point of admission and reviewed at regular intervals. Wherever possible the person and/ or their representative are involved in the process, however it is acknowledged there are occasions when the person may not wish to or be able to fully participate. Atholl House DS0000070032.V354708.R01.S.doc Version 5.2 Page 12 The care plans cover areas of healthcare including mobility, pressure area care, maintaining a safe environment, continence, nutrition and specialist interventions. Specific details of a person’s individual need are recorded to ensure that staff have sufficient information to deliver the required care. Risk assessments and monitoring tools are used to further ensure that a persons care needs are being fully met. Evaluations and review of the plan of care is carried out at regular monthly intervals or when a change in need has been identified. Observations of staff working practice evidenced that interventions for assisting with personal care were undertaken in private, in an appropriate manner and points to the care needs of people are being satisfactorily met. Inspection of medicine storage and administration records, demonstrated the home’s practices meet the guidelines of the Royal Pharmaceutical Society. The registered nurses demonstrated a good knowledge and competence of medication procedures. Two trolleys are used to store medications that are in use for the monthly prescribing cycle, both trolleys appeared somewhat crowded for the amount of medication within them. Staff commented of the difficulties with this, to reduce the potential risk of a medication error it is recommended that consideration be given to replacement. Atholl House DS0000070032.V354708.R01.S.doc Version 5.2 Page 13 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): OP 12,13,14,15 Quality in this outcome area is excellent. The service has very strong and highly effective methods, which focus on involving residents in all areas of their life, and actively promotes the rights of individuals to make informed choices, providing links to specialist support when needed. This includes developing and maintaining family and personal relationships. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The in-house recreational and leisure activities continue to be organised each month with opportunities for group or individual participation. Religious ministers visit at regular intervals and offer a short service and Holy Communion to those people who wish to partake. Atholl House DS0000070032.V354708.R01.S.doc Version 5.2 Page 14 A musician/ entertainer is organised each month and staff organise group and individual activities on a regular basis. During the morning people were in a variety of activity, watching television, listening to music, sleeping and talking with staff, family and friends. One person stated that they preferred to stay in their own room and did not wish to participate in the arranged activities and was – ‘Quite happy with my own company, I have my television and books and look forward to seeing my family each week ’. The Annual Quality Assurance Assessment completed by the manager outlines the plan for improvement during the next 12 months – • • • To introduce aromatherapy/reflexology if the budget permits To have a reading hour and include current affairs To explore activities available to service users with cognitive impairment The home has an open visiting policy with people able to visit at times suitable to the resident. Tea and coffee making facilities are readily available for visitors. Three visitors completed the ‘Have your say about’ survey and were all generally satisfied with the care provided and made additional comments of ‘The staff are all very caring’ ‘The standard is very high’. During the tour of the premises many bedrooms contained personal possessions, pictures, photographs and ornaments etc. One person commented that having ones ‘things’ around helps with the settling in process. People are encouraged and supported to use the dining room for meals but can have their meals where they prefer, some people were in the lounge others in their own rooms. The daily menu is displayed in the dining room and offers a choice of main and dessert courses, staff explained that alternative dishes are offered if the menu is not to a person’s preference. People generally expressed a satisfaction with the meals. Staff were observed to be assisting some people with their meal at the dining table in a satisfactory manner. Many relatives visit at lunchtime to help their relative with the meal, most stated that they enjoyed this opportunity to spend quality time with their relative and to ‘feel useful’. Atholl House DS0000070032.V354708.R01.S.doc Version 5.2 Page 15 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): OP 16,18 Quality in this outcome area is good. The home has an open culture that allows residents to express their views, and concerns in a safe and understanding environment. Residents and others involved with the service say that they are happy with the service provision, feel safe and well supported by an organisation that has their protection and safety as a priority. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The statement of purpose and service user guide detail the complaints procedures, a copy of the procedure is given to all new residents, and a copy is displayed at the entrance of the home and is available upon request. People spoken with said they didn’t have any complaints but would feel very comfortable to speak with the manager or staff at any time. The manager discussed a recent referral to the safeguarding adults team, the information of the incident and referral had been comprehensively recorded with a satisfactory outcome being achieved following the investigation. Atholl House DS0000070032.V354708.R01.S.doc Version 5.2 Page 16 Staff have received training in the protection of vulnerable adults this year. The home offers a facility for residents to deposit personal monies for safekeeping; records relating to this are maintained and fully receipted. Atholl House DS0000070032.V354708.R01.S.doc Version 5.2 Page 17 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): OP 19,26 Quality in this outcome area is good. The home is a very pleasant, safe place to live the bedrooms and communal rooms meet the national minimum standards and are suitable to meet the needs of the people who use the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The private and communal rooms are furnished to a high standard, people living in the home state they are very comfortable and satisfied with the environment. Atholl House DS0000070032.V354708.R01.S.doc Version 5.2 Page 18 Daily routine maintenance of the premises continues. The manager explained that currently there is no formal programme for the redecoration and replacement of the fabric and fittings, but work is carried out on an as needed basis. The fire safety officer visited the premises in October 2007 and was satisfied with the arrangements in place. The Environmental Health Officer inspected the premises in June 2007; some recommendations were issued following the visit. The manager confirmed that they are working through the recommendations. Staff demonstrated a good knowledge of infection control procedures. Hand wash facilities have been provided in all communal areas and at the point of the delivery of care. All areas of the home were spotlessly clean; the staff responsible for the household cleaning must be commended on maintaining such high standards. Atholl House DS0000070032.V354708.R01.S.doc Version 5.2 Page 19 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): OP 27,28,29,30 Quality in this outcome area is excellent. The service has plentiful staff available at all times to support the needs, activities and aspirations of the people using the service in an individualised and person centred way. This judgement has been made using available evidence including a visit to this service. EVIDENCE: General observations and discussion with staff confirmed that staffing numbers and skill mix make possible a service provision, which meets the care needs of the people living at the home. Staff were observed to carry out their duties in an enthusiastic and professional manner. All service users looked well groomed and it was obvious that the staff assisted people with maintaining high standards of personal care. Staff personnel files and records relating to recruitment were examined and showed they contained all the necessary information, which demonstrates Atholl House DS0000070032.V354708.R01.S.doc Version 5.2 Page 20 potential staff are well screened before they are deemed suitable to start work at the home. Staff training continues in the core and specialist topic areas for all staff. A recommendation was made following the thematic inspection in September 2007 that training in dementia awareness would be beneficial for staff to gain a greater awareness in caring for people with cognitive impairments and dementia related conditions. Staff demonstrated a good knowledge of caring for people with dementia but confirmed that they had received no formal training. The Annual Quality Assurance Assessment completed by the manager indicates that out of 29 permanent staff, 27 have gained accreditation at National Vocational Qualification level 2 or above. Atholl House DS0000070032.V354708.R01.S.doc Version 5.2 Page 21 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): OP 31,33,35,38, Quality in this outcome area is excellent. The manager communicates a clear sense of direction, is able to evidence a sound understanding and application of ‘best practice’ operational systems, particularly in relation to continuous improvement, customer satisfaction, and quality assurance. This judgement has been made using available evidence including a visit to this service. Atholl House DS0000070032.V354708.R01.S.doc Version 5.2 Page 22 EVIDENCE: Mrs Heather Murray is the registered manager of the home and has been in this position for a considerable period of time. Mrs Murray demonstrated a sound knowledge and understanding of the client group and the difficulties and dilemmas associated with ageing and end of life care. There are very clear lines of accountability within the management structure with staff commenting that the managers are approachable and accessible. Quality assurance continues through out the year with different areas of the service being audited, reports are produced and the findings actioned. Service users and relatives satisfaction questionnaires are circulated periodically and comments and any suggestions for improving the service are actioned. Small amounts of cash are held on behalf of service users for safekeeping. Records are maintained and audited on a regular basis to ensure accuracy. Weekly, monthly and annual testing of the equipment and premises are conducted with records kept. The fire risk assessment was last reviewed in October 2007. Atholl House DS0000070032.V354708.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 4 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 4 STAFFING Standard No Score 27 4 28 4 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 4 X X 3 Atholl House DS0000070032.V354708.R01.S.doc Version 5.2 Page 24 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. 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. 1 2 Refer to Standard OP9 OP30 Good Practice Recommendations Consideration should be given to replacing the medication trolleys to ensure that there is sufficient space to safely store people’s medication. Staff should receive training in dementia care and awareness to further enhance their skills and knowledge and to fully meet a persons needs. 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