Inspection on 10/01/06 for Aaron Park Care Home

This inspection was carried out on 10th January 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Aaron Park Care Home 30/11/06

Aaron Park Care Home 14/07/05

Aaron Park Care Home 11/03/05

Aaron Park Care Home 01/07/04

Aaron Park Care Home 10/02/04

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

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

CARE HOME ADULTS 18-65 Aaron Park Care Home 115 Poplar Road Cleethorpes North East Lincs DN35 8BD Lead Inspector Eileen Engelmann Unannounced Inspection 10th January 2006 09:30 Aaron Park Care Home DS0000002818.V263890.R01.S.doc Version 5.1 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 Aaron Park Care Home DS0000002818.V263890.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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. Aaron Park Care Home DS0000002818.V263890.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Aaron Park Care Home Address 115 Poplar Road Cleethorpes North East Lincs DN35 8BD 01472 605685 01472 605685 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) Prime Life Limited Ms Debra Jayne Mogg Care Home 21 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (21) of places Aaron Park Care Home DS0000002818.V263890.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user, CM, who is over the age of 65 with a mental health problem to be accommodated in the home until discharge or in the event of death. 14th July 2005 Date of last inspection Brief Description of the Service: Aaron Park is a 21 bedded home for younger adults who experience mental health problems. The home is a converted two-storey property situated in the seaside town of Cleethorpes. The home is not registered to provide nursing care, however the home has developed good working relationships with local health care professionals and agencies. The home has 14 single rooms and 3 double rooms, privacy screens are provided. In addition the home has a range of communal facilities, which residents and visitors can access. The home has a good-sized courtyard garden complete with barbeque, flowerbed and a grassed area. The home maintains its staffing levels in accordance with levels set as at the 31.3.02. Aaron Park Care Home DS0000002818.V263890.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out with the manager, staff and residents of Aaron Park. The inspection took 2.5 hours and included a tour of the premises, examination of resident and staff files, and records relating to the service. One member of staff was spoken to and their comments have been included in this report. All key standards have been inspected over the past year and information on these and the outcomes can be found in this report and the one for 14th July 2005. The manager and staff have worked hard to meet the requirements of the previous report and those remaining require action by the provider to implement change in company policies and documents. What the service does well: What has improved since the last inspection? 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. Aaron Park Care Home DS0000002818.V263890.R01.S.doc Version 5.1 Page 6 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 Aaron Park Care Home DS0000002818.V263890.R01.S.doc Version 5.1 Page 7 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5. The home’s statement of terms and conditions for funded individuals is inadequate and does not offer prospective residents the same depth of information as that provided for self-funding individuals. This could prevent funded residents from being able to make an informed decision about admission to the home. EVIDENCE: The manager told the inspector that no changes to standard 5 have taken place since the last inspection. The home has produced a statement of terms and conditions for private paying residents, which meets the required standard, but this document has not been given to funded individuals. Previous discussion with Louise Hayward from Prime Life Limited indicated that the company is currently working on the development of a suitable format that can be given to all residents on admission. This is an outstanding requirement from previous reports and must be given priority in the home’s action plan for this inspection report. Aaron Park Care Home DS0000002818.V263890.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 10. There is a clear and consistent care planning system in place to provide staff with the information they need to satisfactorily meet the needs of the residents. EVIDENCE: Individual care plans are in place for all residents and clearly set out the health, personal and social care needs identified for each person. One plan looked at was for a new resident and information within it was completed in full and was based on the initial needs assessment completed before admission. All the plans looked at have been evaluated on a monthly basis and any changes to the care being given are documented and monitored by the staff. Staff have implemented the recommendation from the last report and are completing the resident’s hygiene charts on a daily basis. The residents sign their own care plan and have input to the reviews of their care. Concerns were raised by the inspector over the confidentiality of complaints and accidents given that these are recorded in bound books, and do not have removable pages. See comments in standard 22 and 42. Aaron Park Care Home DS0000002818.V263890.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15. The arrangements for contact between residents and family/friends are good, and staff demonstrated a clear understanding of their role in supporting individuals to maintain these relationships. EVIDENCE: Contact arrangements between residents and friends/family are clearly documented in the individual care plans and have been made using a risk assessment process that looks at vulnerability and risk of harm. The residents, and the people they wish to visit, make decisions around the contact process with some input from the home or other healthcare professionals were needed. Some individuals see their families on a regular basis, whilst others choose to visit less often or not at all. The staff receive training around maintenance of relationships and this is also supported by further discussions during staff meetings or supervision. The manager said that the home enables residents to see their families when they are living out of the immediate area, by taking individuals (to visit) in the home’s transport or arranging public transport tickets. These trips are arranged weekly, fortnightly or monthly depending on the wishes of the individual resident. Aaron Park Care Home DS0000002818.V263890.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20. The systems for administration of medication are good with clear and comprehensive arrangements in place to ensure the residents’ medication needs are met. EVIDENCE: The medication policy for the home says that individuals can self-medicate if they want to and after a risk assessment has been completed and agreed. Checks of the medication records and the system used showed that these are up to date, accurate and well managed. The medication trolley was broken at the time of this visit and the manager assured the inspector that a new wheel has been ordered and would be fitted shortly. Adequate arrangements for the administration of medication have been put into place until this repair is carried out. No progress has been made towards providing staff with a room to take their breaks in or somewhere for staff to keep their valuables. At the moment the staff are using the medication cupboard or office, which are both very small areas and not suitable for this use. It is recommended that the provider look at different ways in which staff could be offered suitable facilities. Aaron Park Care Home DS0000002818.V263890.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22. Improvements to the recording aspect of the complaint system must be made to ensure issues raised by individuals are kept confidential; however, residents are satisfied that their views are listened to and acted on. EVIDENCE: No changes to the way in which complaints are recorded have been made since the last inspection. This is not acceptable practice and the company must look at how it can change the type of documents it is supplying to the home for complaint record keeping, to ensure individuals can be assured that their right to confidentiality is upheld. The manager said that no complaints have been received since the last inspection. The home has a complaints procedure that residents and staff are aware of and are confident of using if needed. Complaints are currently recorded in a book, but this does not offer individuals confidentiality because the format means that anyone writing in the book can see previous complaints that have been made by different people. Discussion with the staff indicated that the book is accessible to all employees, and is kept in the manager’s office. The inspector recommended that a separate complaints form should be developed that can be filled in by the complainant and filed away by the manager once an issue has been investigated and resolved. Aaron Park Care Home DS0000002818.V263890.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24. The standard of the environment within this home is good providing residents with a comfortable and homely place to live. EVIDENCE: There is an ongoing programme of refurbishment and renewal at the home. Since the last inspection there has been a new floor covering fitted to bedroom 18, which the resident is please with as it is more appropriate to his needs. A new cooker has been purchased for the kitchen and the exterior of the building has been painted and looks smart and welcoming. All areas seen during this visit were clean, bright and warm, well maintained and comfortable. The last visit by the Environmental Health Officer (EHO) was after the July 2005 inspection. The manager said that this visit coincided with a fund raising day at the home and this event had some impact on the kitchen. The EHO report made a number of requirements/recommendations from the home including the development of the kitchen paperwork systems for HACCP, and to review its Food Hygiene Policies. The manager said that all issues raised in the report have been addressed except the fitting of a fly screen door to the kitchen. The inspector, in the last report, raised this as a recommendation, and the provider must make it a priority in his action plan for this report. Aaron Park Care Home DS0000002818.V263890.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34. The standard of vetting and recruitment of staff has improved since the last inspection with the appropriate checks being carried out, ensuring residents are supported and protected by the homes policy and practices. EVIDENCE: The manager said that improvements to the recruitment of staff have taken place and that POVA First checks are now being completed and received back for all employees before they start work. The home has a recruitment policy and procedure that the manager understands and uses when taking on new members of staff. Checks of two new members of staff files showed that police/CRB checks, written references, health checks and past work history are all obtained and satisfactory before the person starts work. Aaron Park Care Home DS0000002818.V263890.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 and 43. The management of the home is satisfactory overall, but the lack of an electrical wiring certificate could potentially place residents at risk. EVIDENCE: Discussion with the manager and deputy manager indicated that they both have achieved their Registered Managers Award and also have an NVQ 4 in care as qualifications. No progress has been made since the last inspection to produce an Annual Development Plan as part of the Quality Assurance system for the home. Time was spent with the manager discussing how this could be achieved. Resident meetings are held on a regular basis and minutes are circulated to people living in the home. Staff have meetings with the manager and everyone is encouraged to join in with discussions and voice their opinions. Residents and staff agreed that they are able to express ideas; criticisms and concerns without prejudice and the management team will take action where necessary to bring about positive change. Aaron Park Care Home DS0000002818.V263890.R01.S.doc Version 5.1 Page 15 The home has a Prime Life Limited Quality Assurance system in place and audits of the service are carried out on a regular basis, but no annual development plan has been created from the results of these audits. Policies and procedures are up dated and reviewed as an ongoing practice and action is being taken to ensure the requirements of the inspection reports are met. Discussion with the manager indicated that staff and residents are able to discuss the home’s policies and procedures through attending meetings, and as part of the supervision process for staff. No progress has been made since the last inspection to have the electrical wiring checked at the home. The provider has been asked by the Commission to provide written evidence that his insurance company are aware that the home does not have an electrical wiring certificate, and that this does not affect the insurance cover for the home. Checks of the accident books found that incidents are accurately recorded, but the books do not promote confidentiality, as they do not have removable pages so information about different people is available to anyone using the book. Staff spoken to confirmed that all employees have access to the book within the manager’s office. The inspector recommended that the manager ask the company for the new ‘data protection’ type book where the pages detach from the book and can be filed away in the resident’s personal file or for access by the manager only. Aaron Park Care Home DS0000002818.V263890.R01.S.doc Version 5.1 Page 16 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 X 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 X ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X X 2 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X 3 X 2 X X 2 X Aaron Park Care Home DS0000002818.V263890.R01.S.doc Version 5.1 Page 17 Yes. 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. 1. Standard YA5 Regulation 5 Requirement Timescale for action 10/04/06 2. YA10 17 3. YA24 16 4. YA39 24 The registered manager must develop and agree with each prospective resident a written and costed contract/statement of terms and conditions between the home and resident (given timescales of 31/7/04, 31/5/05 and 01/11/05 were not met). Staff must ensure that 10/04/06 information (complaints and accidents) about the residents is kept confidential. The premises must have a fly 10/04/06 screen door fitted to the kitchen as highlighted in the latest Environmental Health Department report for the home. There must be an annual 10/04/06 development plan for the home, based on a systematic cycle of planning, action and review; reflecting the aims and outcomes for residents (given timescale of 01/11/05 was not met). Aaron Park Care Home DS0000002818.V263890.R01.S.doc Version 5.1 Page 18 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 YA20 YA22 Good Practice Recommendations Staff should be provided with suitable facilities for storing valuables, as the current arrangement of using the medication cupboard is not acceptable. A separate complaints form should be developed that can be filled in by the complainant and filed away by the manager once an issue has been investigated and resolved. The provider should provide the Commission with written evidence that the home’s insurers are aware that the home does not have an electrical wiring certificate and that this does not affect the insurance status of the home. The home should introduce an accident book in line with ‘data protection’ guidance, with detachable pages so information about individual residents can be filed into their own personal files or kept where only the manager has access. 3. YA42 3. YA42 Aaron Park Care Home DS0000002818.V263890.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Aaron Park Care Home DS0000002818.V263890.R01.S.doc Version 5.1 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!