Inspection on 18/07/05 for Aarondale Residential Home

This inspection was carried out on 18th July 2005.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Aarondale Residential Home 30/10/07

Aarondale Residential Home 21/03/07

Aarondale Residential Home 21/03/06

Aarondale Residential Home 12/10/04

Aarondale Residential Home 05/05/04

Similar services:

Chirnside House

Sunny Bank (P.R.S.) Ltd

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Ashwood Court Unit 1

Langrigg House

Parkside

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

CARE HOMES FOR OLDER PEOPLE Aarondale Residential Home Sunny Brow Off Chapel Lane Coppull, Chorley, Lancashire PR7 4PF Lead Inspector Sue Hale Announced 18 July 2005 08:30 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 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. Aarondale Residential Home F57 F08 S5948 Aarondale V231094 180705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Aarondale Residential Home Address Sunny Brow Off Chapel Lane Coppull Chorley Lancashire, PR7 4PF 01257 471571 01257 470220 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Southern Cross Care Homes Limited Mrs Ann Margaret Sheward Care Home 48 Category(ies) of DE(E) - Dementia - over 65 (20) registration, with number MD - Mental Disorder (1) of places OP - Old age (28) Aarondale Residential Home F57 F08 S5948 Aarondale V231094 180705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 48 service users to include: 2. Up to 20 service users in the category of DE(E) (Dementia over 65 years of age). 3. Up to 28 service users in the category of OP (Old Age not falling into any other category). 4. 1 named female service user in the category MD (Mental Disorder, excluding Learning Disability and Dementia) may be accommodated within the overall number of registered places. 5. Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidelines which may be issued through the Commission for Social Care Inspection regarding staffing levels in care homes. 6. The service should, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Date of last inspection 12 October 2004 Brief Description of the Service: Aarondale is a purpose built care home, situated in a residential area. It is registered to provide care for 43 older people, 23 of whom require residential care, and 20 who have a mental illness or cognitive impairment. The accommodation comprises of 5 communal areas, 24 en suite single bedrooms and 20 single bedrooms.There is an open side garden to the premises and a large rear garden, which is landscaped and enclosed.The home is close to local shops, post office, public house and local churches, all of which may be accessed by service users with assistance from staff if required. Aarondale Residential Home F57 F08 S5948 Aarondale V231094 180705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and took place over the course of one day in August 2005. The inspector spoke to people living and working at the home. Selected resident and staff files were checked as were other documents related to the running of the home. A tour of the building was undertaken. The ownership of the home had recently changed and the documentation was in the process of being reviewed and updated to reflect this. Three comment cards were received from relatives/visitors and two comment cards from people living at the home. What the service does well: What has improved since the last inspection? The home now produces a regular newsletter, which is circulated to residents, relatives and visitors. Special editions had been published, to celebrate a residents 103rd birthday and the recent summer fair. Several areas of the home have been refurbished and redecorated including the entrance hall and the first floor. The refurbished rooms provided a clean, homely and safe environment for people living at the home. Staff files were well maintained and contained evidence that all the information required to ensure staff were suitable to work with vulnerable people. Aarondale Residential Home F57 F08 S5948 Aarondale V231094 180705 Stage 4.doc Version 1.40 Page 6 Good progress had been made in the number of staff registering to undertake training courses to improve their skills and experience and improve the quality of care offered at the home. Good progress had been made to reducing the number of outstanding requirements and recommendations that had been identified in the last inspection report. 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. Aarondale Residential Home F57 F08 S5948 Aarondale V231094 180705 Stage 4.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection Aarondale Residential Home F57 F08 S5948 Aarondale V231094 180705 Stage 4.doc Version 1.40 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3 The statement of purpose and service user guide gave some information to prospective residents, relatives and other interested parties details about the services the home provided. All residents had been given a copy of their contract with the home. Prospective residents care needs were assessed prior to admission to ensure that the home could provide the level of care they needed. EVIDENCE: The home produced a statement of purpose and service user guide to give prospective residents, relatives and other interested parties information about the services that the home provided. The statement of purpose had been reviewed and included all the information required in the national minimum standards. The service user guide should be amended to include all the information required in the national minimum standards. Both documents are due to be revised and updated to reflect the new ownership of the home by Southern Cross Healthcare. All residents files checked, contained a copy of their terms and conditions of residency at the home. Aarondale Residential Home F57 F08 S5948 Aarondale V231094 180705 Stage 4.doc Version 1.40 Page 9 An assessment of prospective residents needs health, social and care needs had been undertaken before people moved into the home. Consideration should be given to widening the range of the assessment to ensure that all aspects of residents care needs have been addressed. Aarondale Residential Home F57 F08 S5948 Aarondale V231094 180705 Stage 4.doc Version 1.40 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,10 All residents had a care plan but they did not cover all aspects of residents’ health, social and care needs. Residents’ privacy and dignity was not always maintained to a satisfactory standard. EVIDENCE: All residents’ files checked had a care plan, which detailed some aspects in detail of the care each resident needed. Consideration should be given to increasing the range of needs covered so that all aspects of residents’ health, social and care needs are addressed. Care plans were not reviewed monthly or updated as necessary. Entries were not made daily in the care record. There was little evidence that residents and their relatives were involved in the care planning process. A visiting health care professional commented that the standard of care varied, and in their opinion, could be improved in some instances, particularly for residents who had some ability to look after themselves but didnt appear to receive the level of support from staff to ensure their personal appearance and hygiene standards were maintained. Staff were observed to be polite and helpful towards residents throughout the inspection. Policies and procedures were in place to give instruction to staff on how to ensure that residents previously and dignity was maintained. However, Aarondale Residential Home F57 F08 S5948 Aarondale V231094 180705 Stage 4.doc Version 1.40 Page 11 comments from residents varied and one resident spoken to was unhappy having a male member of staff undertaking personal care. One resident said that staff were ‘rough and shouted at me’ and this was confirmed by another resident who had overheard this on more that one occasion. Care records checked included details of residents preferred name, and their family and social contacts. Medical and health care treatment was carried out in the privacy of residents’ own rooms. Aarondale Residential Home F57 F08 S5948 Aarondale V231094 180705 Stage 4.doc Version 1.40 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 14,15 Residents were encouraged and supported to maintain as much control over their lives as possible. The meals served in the home offered choice and variety and were of a satisfactory standard. EVIDENCE: The home provided information about local services that offered independent advice and support to older people in the service user guide and by displaying leaflets in the entrance hall. The policies and procedures of the home encouraged residents to manage their own finances, with support from their family and /or representatives. Residents spoken to confirmed that they were able to bring small items of furniture and personal possessions into the home and their private rooms had been personalised. All residents had been given a service user guide, which gave them information on their rights to look at any information held about them by the home. The majority of residents spoken to were very satisfied with the food and the meals were described as varied and suitable, and offering a choice. A cooked meal was available at lunchtime and lighter snacks teatime with alternatives to the menu always available on request. Special diets were catered for as necessary to ensure all residents received appropriate food in the right way. Residents’ birthdays and other special occasions were celebrated with a cake and a buffet style tea. Aarondale Residential Home F57 F08 S5948 Aarondale V231094 180705 Stage 4.doc Version 1.40 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 The home had a satisfactory complaints policy and procedure, which ensured that all complaints would be acknowledged and investigated. However, residents were generally unfamiliar with how to complain or raise concerns. EVIDENCE: There was a complaints policy, and procedure in place in the home and available for all to see in the entrance hall and on the unit notice boards. The home had received three complaints since the last inspection, two of which had been investigated and resolved, one of which was still under investigation by the home. Four residents spoken to did not know what the complaints procedure was or how to complain, one resident said that they had ‘no idea how to complain’. Some other residents said that they would go to the manager if they had any problems and appeared confident that any problems would be sorted out. The home should ensure that all residents are regularly reminded about how to complaint or raise concerns and whom they should speak to about this. The whistle blowing policy had been revised to ensure that staff were aware of how to raise concerns about care practices. The adult protection policy could not be found by the manager on the day of the inspection and could not be assessed. Aarondale Residential Home F57 F08 S5948 Aarondale V231094 180705 Stage 4.doc Version 1.40 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20 The home provided those living there with a safe, comfortable and homely environment with a refurbishment programme underway. Areas designated for use by people who smoke impacted on others, who chose not to smoke. EVIDENCE: A refurbishment and redecoration programme had been taking place, and the first floor and entrance hall had been redecorated and new furniture and fittings put in place, improving the standard of the environment for residents. The carpet in the ground floor dining room and residents smoking lounge, required replacement due to their poor condition. The area designated for smoking for residents and their visitors was poorly ventilated and consideration should be given to resolving this matter. This room is in close proximity to a lounge, used by residents who choose not to smoke. The lounge did not have a door fitted and smelt of smoke, serious consideration should be given to fitting a door to the lounge for the comfort of residents who do not smoke. Aarondale Residential Home F57 F08 S5948 Aarondale V231094 180705 Stage 4.doc Version 1.40 Page 15 Bedrooms were well furnished, nicely decorated and comfortable. Residents spoken to were satisfied with their rooms and one resident described living at the home as ‘very comfortable’. Aarondale Residential Home F57 F08 S5948 Aarondale V231094 180705 Stage 4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 The policies and procedures for the recruitment of staff were robust and provided safeguards for the protection of residents. The home was staffed to the minimum level required. The policy on smoking for staff impacted on the people living and working at the home who chose not to smoke. EVIDENCE: On the day the inspection there was a rota, which showed who was on duty and in what capacity. A member of staff, qualified in first aid was available on every shift. The home was staffed to the minimum level required by the previous regulatory body. Three comment cards were received from relatives, and all stated that they did not feel there was always sufficient numbers of staff on duty. One visitor commented that they felt that the home ‘needed more staff’. There were references on the notice board, and on the nameplate of residents’ private rooms to ‘named nurses’. The home does not provide nursing care, and using the term nurse could be misleading to residents, their relatives and visitors and should be removed. The home did not provide facilities for staff to take a break in a smoke-free environment. A member of staff commented that it was ‘not pleasant for nonsmokers’ and that it would be ‘better if there was an alternative room available’. It was also apparent that smoke seeped into the first floor, where residents lived. A comment made by a visitor to the home was that they were ‘unhappy about staff smoking on the premises and that they felt it was dangerous and shouldnt be allowed’. Aarondale Residential Home F57 F08 S5948 Aarondale V231094 180705 Stage 4.doc Version 1.40 Page 17 The recruitment and selection procedure had been followed for three new members of staff to ensure the protection of residents. All staff had started, or had completed an induction programme, and all had completed training in moving and handling. The training matrix identified that 33 of staff were qualified to NVQ level 2 or above, and that a further ten were working towards the qualification so that the staff team were qualified to provide a good level of care. Aarondale Residential Home F57 F08 S5948 Aarondale V231094 180705 Stage 4.doc Version 1.40 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 30,34,35.37 Records were well maintained and kept securely. All new staff had been given the initial training to enable them to provide the care residents needed. EVIDENCE: All new staff had been on external induction course and completed the homes own induction programme to give them the knowledge and skills needed to work at the home. The manager made sure that this was all completed within six weeks of staff starting work at the home, records of staff training confirmed this. The home kept records of residents’ personal allowance and these were regularly checked by the manager to ensure that financial procedures were followed. Records were kept of valuables handing over the safekeeping and residents had been given a receipt. Appropriate insurance cover was in place and the certificate displayed. All business and financial records are kept by the company at the regional office. Aarondale Residential Home F57 F08 S5948 Aarondale V231094 180705 Stage 4.doc Version 1.40 Page 19 The records required for the protection of service users and efficient running of the business were well maintained, up-to-date and accurate. The statement of purpose and service user guide, clearly explained to residents and their families their rights to have access to their records and information held about them by the home. There was little evidence that residents had been involved in compiling or checking their personal file. Aarondale Residential Home F57 F08 S5948 Aarondale V231094 180705 Stage 4.doc Version 1.40 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 2 2 x x x x x x STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 x x x 3 3 x 2 x Aarondale Residential Home F57 F08 S5948 Aarondale V231094 180705 Stage 4.doc Version 1.40 Page 21 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 OP1 Regulation 5 (1), (2), (3) (6) Requirement Timescale for action 31.10.05 2. OP7OP37 15 (1) (2) 3. OP7 12(4)(a) (b) 13(6) 4. OP18 The service user guide must be revised to include all the information required in standard 1.2. (Timescale of 31.12.04 not met) The registered person must 31.10.05 ensure that residents, their families/representatives of involved in the care planning and review process. (Timescale of 30.11.04 not met The registered person must 30.9.05 make suitable arrangements to ensure that residents, privacy and dignity is respected. The registerd person must 30.9.05 ensure that there is an adult protection policy in place in home and available to all staff. 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. Refer to Standard OP3 Good Practice Recommendations The registered person should ensure that all topics detailed in standard 3.3 are covered in the pre admission F57 F08 S5948 Aarondale V231094 180705 Stage 4.doc Version 1.40 Page 22 Aarondale Residential Home 2. OP7 3. 4. OP7 OP7 5. 6. OP7 OP7 7. 8. 9. OP16 OP20 OP 20 10. 11. 12. OP27 OP28 OP27 assessment. The registered person should ensure that care plans cover all the topics detailed in standard 3.3 to ensure that residents needs are identified and met. The plan should include clear instructions to staff on how such needs will be met. All care plans should be reviewed monthly. It is strongly recommended that the manager, discusses with each resident. Their preferences as to the gender of staff undertaking personal care, including bathing. Residents preferences should be recorded on their care plan. It is strongly recommended that entries are made daily in the care record, giving detail of the care given and any significant events. It is strongly recommended that systems are set up to support residents to retain independent living skills, with support and oversight from staff to ensure their personal appearance and personal hygiene is maintained to an acceptable standard. The manager should consider how to keep residents informed about the complaints procedure, and who to speak to if they have a problem. The registered person should give serious consideration to installing an extractor fan in the smoking lounge on the ground floor The registered person should give serious consideration to fitting a door on the smoke-free lounge on the ground floor for the comfort of those service users who choose not to smoke. The registered person should give urgent consideration to stop staff smoking in the treatment room. The registered person should ensure that 50 of staff are qualified to NVQ level 2 or above by 2005. All references to staff being nurses on name plates and notice boards should be removed . Aarondale Residential Home F57 F08 S5948 Aarondale V231094 180705 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Levens House Ackhurst Business Park Foxhole Road Chorley, Lancashire, PR7 1NW 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 Aarondale Residential Home F57 F08 S5948 Aarondale V231094 180705 Stage 4.doc Version 1.40 Page 24 - 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!