Inspection on 27/01/06 for Abercarn Residential Home

This inspection was carried out on 27th 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Abercarn Residential Home 21/10/09

Abercarn Residential Home 29/07/09

Abercarn Residential Home 04/11/08

Abercarn Residential Home 15/11/07

Abercarn Residential Home 19/01/07

Abercarn Residential Home 11/11/05

Abercarn Residential Home 11/03/05

Abercarn Residential Home 06/07/04

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Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Abercarn Residential Home 56 High Street Pensnett Dudley West Midlands DY5 3AW Lead Inspector Mr Jon Potts Unannounced Inspection 27th January 2006 9:30 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 Abercarn Residential Home DS0000024968.V281636.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 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. Abercarn Residential Home DS0000024968.V281636.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Abercarn Residential Home Address 56 High Street Pensnett Dudley West Midlands DY5 3AW 01384 480059 01384 480059 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) Cotdean Nursing Homes Ltd Miss Sarah Phillips Care Home 32 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (1), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (3), Old age, not falling within any other category (20), Physical disability (1), Physical disability over 65 years of age (7) Abercarn Residential Home DS0000024968.V281636.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11/11/05 Brief Description of the Service: Abercarn is a double fronted detached house located in the heart of Pensnett on a main route between Kingswinford and Dudley, this served by a bus route. It provides accommodation for 32 service users on two floors. The home has two assisted bathrooms, one on the ground floor and one on the first. There is a lift, which provides access to all parts of the communal areas. On the ground floor, the home has a large through lounge and dining room, the Manager ’s office located to the corner of the dining room. There are a number of bedrooms on the ground and first floor, and number of these shared. The home boasts a large garden area at the rear of the property. There are car parking spaces to the front and side of the property. The home is managed by an acting manager who supervises a number of seniors and care assistants. There is also a number of ancillary staff including domestics, laundry workers and cook. Abercarn Residential Home DS0000024968.V281636.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out between 9.30am and 3.25pm by one inspector. Evidence was gathered through case tracking three residents care, this including discussion with the residents themselves. Further evidence was gained from sight of such as staffing files, policies and procedures, health and safety documentation, medication records and menus. There was some inspection of some areas of the building. The acting manager and a senior manager were also involved in the inspection as well as some of the staff team. All those involved in the inspection are to be thanked for their forbearance and assistance. What the service does well: What has improved since the last inspection? What they could do better: There are a number of areas where improvement is required this including better documentation within care plans as to the residents individual preferences and information that is always consistent with risk assessments (suggesting a lack of update). There also needs to be consistent evidence of resident’s involvement within the care planning process. Residents access to dentists and opticians must also be better documented to evidence this is in Abercarn Residential Home DS0000024968.V281636.R01.S.doc Version 5.1 Page 6 accordance with individual choices. Medication when self administered by the resident must be risk assessed and any eye drops used dated when opened. Residents choices in respect of individual preferences could be better documented and activities offered in accordance with these, and the choices of the residents as a whole. The premises require redecoration in areas and this needs to be reflected in a timed programme that shows forward planning. Clarification is still to be sought in respect of the servicing of the parker bath and cleanliness in the laundry area could be better. The homes quality assurance system still needs to be developed, this so that findings from consultation exercises are appropriately actioned and the home can better demonstrate its methods for self-assessment. 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. Abercarn Residential Home DS0000024968.V281636.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Abercarn Residential Home DS0000024968.V281636.R01.S.doc Version 5.1 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 the following standard(s): 3,5 Resident’s needs are assessed prior to their admission to the home, and the home confirms its ability to meet their needs. Prospective residents and their relatives have opportunity to visit and assess the suitability of the home prior to making any decision as to whether or not to move in. EVIDENCE: From sight of case files it was clear that the home was in receipt of assessments carried out by social workers prior to admission, these in part forming the basis for the homes care plans. These assessments were complimented by the homes own assessments and there was evidence of the home confirming it was able to meet the needs of residents prior to admission. Discussion with a resident that had recently moved into the home evidenced that he was able to visit the home prior to admission, view the room that was available to him and sample the service prior to making any decision to move in. It was stated that the resident’s relatives accompanied them on the visit to the home. Abercarn Residential Home DS0000024968.V281636.R01.S.doc Version 5.1 Page 9 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 the following standard(s): 7,8,9 The resident’s health, personal and social needs are detailed in care plans that are not consistently up to date or agreed by residents/representatives. Resident’s health care needs, with the exception of access to dentists at appropriate intervals, are met. Residents are able to self-administer medication but the homes procedures for assessment of risk does not currently protect residents. EVIDENCE: Care plans were found to be in place in respect of all the resident’s files that were case tracked, these generally clear, subject to monthly review and covering areas in respect of physical, social and emotional care. There is still scope for continued development so as to ensure the plans are up to date and accurate. The following examples illustrate areas where such improvement is to be targeted: - One risk assessment in respect of a resident that was assessed as not weight bearing indicated that a hoist may not be necessary and the assessment by the Occupational Therapist was not followed through into the homes assessment/care plan. Abercarn Residential Home DS0000024968.V281636.R01.S.doc Version 5.1 Page 10 - The care plan for one resident stated that the risk of falls for the resident was high where as the risk assessment stated it was medium. - Some but not all of the case files contained a sheet signed by the resident or the representative, sometimes stating that they did not wish to have involvement in the care planning process. Wherever possible residents or their representatives should be encouraged to have this involvement. Residents were assisted to access their G.Ps as needed although there is a need to ensure that there is at least annual access to dentists and opticians or some record as to the resident’s preferences in respect of access to these services, although there was some evidence of improvement in this area. All case files were seen to contain appropriate risk assessments in respect of falls, tissue viability and moving and handling, these updated on a regular basis (see prior comments though). Two types of nutritional risk assessments were present, these in places contradictory. The acting manager was advised to rationalise these assessments, removing the one from use. Weights were now seen to be recorded on a regular basis. The requirements placed on the home in respect of practices related to medication administration were seen to have been met although there were some further issues identified namely: - Where a resident was found to be self-administering medication there was no documented risk assessment in place identifying whether staff has considered potential dangers and necessary control measures. - Eye drops were found not to have been dated at the point they were opened, this necessary as they have a limited lifespan. Abercarn Residential Home DS0000024968.V281636.R01.S.doc Version 5.1 Page 11 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 the following standard(s): 14 Residents are helped to exercise choice and control over their lives. EVIDENCE: Discussion with 2 out of 3 residents indicated that they are involved in decision making in respect of their lives at the home. The third resident did however give some examples of how the staff allowed them to make various day-to-day choices. Examples of choices cited was in respect of meals, when they wish to stay in their room, and to be able to bring items of furniture into the home (evidence of this seen). The home only handles small amounts of money for the residents, with financial affairs managed by social services or relatives. There was some evidence of residents having access to their records (some but not all of the care plans carried signatures from the resident or relative) although discussion of this right with residents indicated awareness but lack of interest in access. Information on advocacy was seen to be on display within the home and information in case files showed that there was at least annual contact (if not more regular) with social workers. The way the home documents activities was seen to be improving but this area was not fully assessed at this inspection. Abercarn Residential Home DS0000024968.V281636.R01.S.doc Version 5.1 Page 12 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 the following standard(s): . These outcomes were not fully assessed at the time of this inspection. EVIDENCE: These standards were not fully assessed at the time of this inspection although it was noted that staff have now received training in adult protection issues. Applications for enhanced disclosures have been submitted to the CRB for all staff, although these are yet to be returned. Abercarn Residential Home DS0000024968.V281636.R01.S.doc Version 5.1 Page 13 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 the following standard(s): 19,20,23,26 Residents live in a safe environment that could be better maintained in some areas. EVIDENCE: Overall the home offers a comfortable living environment although there are some key areas that needs attention, this including the following: The dining area was undergoing redecoration at the time of the visit, and it was stated that new flooring and double glazed window units in the compromised patio door were to follow. The flooring in many toilets and bathrooms needed replacing, it was stated that an appropriate workman was due to visit the home to estimate on the work in the near future. Abercarn Residential Home DS0000024968.V281636.R01.S.doc Version 5.1 Page 14 Corridors needed redecoration although it was stated that this would follow the redecoration of bedrooms, which was on going (evidence was seen of this). The provider has produced a programme of works, this only identifying those works that have been carried out since the last inspection, not a forward plan of those areas that need attention. This plan did show that a number of bedrooms have been redecorated since the last inspection. On a positive note, following a fire prevention officer’s visit, where areas of serious concern were raised, the provider has worked with the fire officer to address these matters. The provider stated that work has now been completed to address all the outstanding areas identified in the last environmental health officer’s report. The bedrooms seen were those of the resident’s case tracked and all the residents indicated that they were satisfied with their bedrooms in respect of size and furnishings, with evidence of bedroom door locks made available to residents on request. The home was generally clean and tidy and toilets and bathrooms were seen to be provided with liquid soap dispensers and paper towels. The homes laundry is sited in a separate building to the side of the home and sight of this raised concerns as to its general cleanliness. The paint on the floor was also seen to be peeling in areas and needs repainting. The washing machines fitted were able to satisfy the expected disinfection standards however. Abercarn Residential Home DS0000024968.V281636.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 30 There is sufficient allocated care staff to meet the needs of the residents accommodated at the time of the inspection. Staff are generally well trained and there is on-going training in place that will ensure staff are sufficiently trained to be competent to do their jobs, and that residents are in safe hands at all times. EVIDENCE: Based on the calculation of staffing levels with use of the residential forum staffing tool the home has sufficient care staff available for the number and dependency of the residents at the time of the inspection, this translating into four carers during the morning period, four in the afternoon and three waking night staff. In addition to care staff there are also ancillary staff available (cooks, domestics etc). Whilst there were shortcomings in the homes recruitment practice at the time of the last inspection, no new staff have been employed since but in discussion the management were aware of the shortcomings at the previous inspection, with evidence to show that all the existing staff enhanced disclosures had been applied for. The home was seen to have a training planner that clearly identified what training staff held, and what was needed. It was of note that the provider has invested in a number of training courses for staff over the last year, this Abercarn Residential Home DS0000024968.V281636.R01.S.doc Version 5.1 Page 16 including recent adult abuse training. There is less than 50 of staff with NVQ 2 at this time (7 out of 16 staff hold the qualification) although six staff are currently undertaking this training with expected completion in April 2006. There was clear evidence of recently employed staff commencing the Skills for care (formerly TOPSS) induction programme although the provider should be aware that expectations in respect of the induction and foundation training have recently been revised. Abercarn Residential Home DS0000024968.V281636.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 Management arrangements need to be kept under review. The home needs to better demonstrate how it is run in the best interests of the residents. EVIDENCE: The home currently has an acting manager that is closely supervised by an experienced manager from another home. Due to circumstances the company is not in a position to put forward an application for a manager’s registration for the home at this time, although is keeping the CSCI informed of matters in respect of this issue, which is to be kept under regular review by the CSCI. The home does not have a professionally recognised quality assurance tool but there is evidence that service user and relative views about the standard of care are formally sought. This should now be extended to include other Abercarn Residential Home DS0000024968.V281636.R01.S.doc Version 5.1 Page 18 stakeholders. Resident’s written comments were largely complimentary about the service. The opinions collated are not being published or made available to interested parties and the home needs to make use of feedback and evidence how this influences practice. There is not a development plan in place to ensure that such improvements are made. There is continued concern that some of the resident’s inventory forms were still found not to have been completed. Abercarn Residential Home DS0000024968.V281636.R01.S.doc Version 5.1 Page 19 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 X X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 2 X X 3 X X 2 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X X X X Abercarn Residential Home DS0000024968.V281636.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? YES 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 OP7 Regulation 13(4) Requirement Where cotsides are in use there must be a risk assessment in place, this identifying measures put in place to reduce risk and to assess whether the individuals choice as to the use of this device outweighs the risks presented. This is a repeated requirement that was to have been met by the 31.12.05. 2. OP7 15 To ensure that residents or their chosen representative’s involvement is consistently evidenced by signature within the case file. To ensure that information in individual risk assessments does not contradict the information recorded in their care plans, and that when a risk assessment is updated the care plan is as well. This is a repeated requirement that was to have been met by the 31.12.05. Abercarn Residential Home DS0000024968.V281636.R01.S.doc Version 5.1 Page 21 Timescale for action 28/02/06 31/01/06 3. OP7 13 & 15 28/02/06 4. OP8 13(1)b To ensure that all residents are offered access to a dentist and optician at least annually, or their choices in respect of not accessing these services to be documented and agreed with them. This is a repeated requirement that was partly met but was to have been fully met by the 31.12.05. To remove all duplicated nutritional risk assessments so as to reduce on what is conflicting information. Where a resident selfadministers medication a robust risk assessment must be carried out. All eye drops must be marked with the date they are first opened. To ensure there is better and more precise information in care plans as to resident’s individual choices in respect of religion, bathing, food preferences, dayto-day routines and activities. An activities programme must be produced that contains activities that are based on the resident’s preferences as identified within residents meetings and individual assessments. This is a repeated requirement that should have been fully meet by the 1.4.05. To develop a programme of maintenance and renewal for the premises that identifies timescales for work to be completed. This to include: - Dining area - replacement of the flooring and replacement of the compromised window panel in the double glazed patio door. DS0000024968.V281636.R01.S.doc 31/01/06 5. OP8 14,17 28/02/06 6. OP9 13 28/02/06 7. 8. OP9 OP12 13 12 & 15 28/02/06 28/02/06 9. OP12 16(2)m 31/01/06 10. OP19 16 & 23 31/03/06 Abercarn Residential Home Version 5.1 Page 22 - Redecoration of the exterior of the home. - Replacement of vinyl flooring in bathrooms and toilets where needed. - Redecoration of corridors as needed. This is a repeated requirement that was to have been met by the 31.12.05. 11. OP26 13, 23 To ensure that the walls and floor in the laundry are kept clean and that the surfaces are maintained in such a condition as to allow effective cleaning. To implement a quality assurance and monitoring system. This is a repeated requirement that is partly met. See comments in the body of the report. 13. OP35 13 & 17(2) Inventories of resident’s property 31/03/06 must be consistently completed on admission and then reviewed on a regular basis. This is a repeated requirement that was to have been met by the 31.11.05. The manager must clarify with environmental services as to the expected servicing schedule for the Parker bath. This is a repeated requirement that was to have been met by the 15.3.05. 15/03/06 12. OP33 35 31/03/06 14. OP38 23 28/02/06 Abercarn Residential Home DS0000024968.V281636.R01.S.doc Version 5.1 Page 23 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 OP28 OP36 Good Practice Recommendations To continue with the training of staff in NVQ level 2 so as to allow the home to have 50 or more staff so qualified. To continue with staff supervision sessions so that all staff have one at least every two months. Abercarn Residential Home DS0000024968.V281636.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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. 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