CARE HOMES FOR OLDER PEOPLE
Aberford Hall Oakwood Green Leeds Yorkshire LS8 2QU Lead Inspector
Kathleen Firth Unannounced Inspection 27th February 2006 11:45 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 Aberford Hall DS0000001316.V277868.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. Aberford Hall DS0000001316.V277868.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Aberford Hall Address Oakwood Green Leeds Yorkshire LS8 2QU 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) 0113 2323225 0113 2736550 Southern Cross Healthcare Services Limited Mrs Jacqueline Wisdom Care Home 42 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (42) of places Aberford Hall DS0000001316.V277868.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 31st October 2005 Brief Description of the Service: Aberford Hall is a privately owned care home providing nursing and personal care for up to forty-two people over the age of sixty. The home is purpose built and accommodation is provided over two floors in forty single and one double room with en suite facilities. The first floor is accessed by a passenger lift. There are well-maintained gardens that can be accessed by the residents and people enjoy sitting out in the good weather. Local amenities are available within a reasonable distance including shops and a pub. Aberford Hall DS0000001316.V277868.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over 3.75 hours by one inspector on Monday 27th February 2006. The inspector looked around the building; examined residents’ care plans, staff files, financial records and the home’s brochure. Staff and residents were helpful throughout the inspection and joined in the process. Four residents, three staff members were spoken to and the manager was present throughout the inspection. What the service does well: What has improved since the last inspection?
Residents and relatives are signing the care plans.
Aberford Hall DS0000001316.V277868.R01.S.doc Version 5.1 Page 6 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. Aberford Hall DS0000001316.V277868.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 Aberford Hall DS0000001316.V277868.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): 1, 3, 4 and 6 People are able to make an informed choice about the home from the written information they receive and what they see when looking round the home. Prospective residents can be sure their needs can be met at the home once an admission is agreed. EVIDENCE: Prospective residents are given a brochure when they show interest in coming to live at the home. This contains a copy of the Service User Guide; information about the company who own the home plus specific information about Aberford Hall and a copy of the latest CSCI Inspection report is made available. The manager visits all prospective residents and carries out an assessment of need. She will not agree to admit a resident unless she is sure that the home is suitable for them and their needs will be met. The manager discusses the level of need with her senior staff before a decision is made. Therefore residents and their families can be sure that their needs will be met once an admission has been agreed. Intermediate Care is not provided at this home.
Aberford Hall DS0000001316.V277868.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, 10 and 11 There is good communication amongst the staff team and they show a good awareness of the needs of the residents. Staff treat residents and their families with respect at all times. EVIDENCE: The pre-admission assessments are very good and contain excellent information about the residents including a past medical history. Each resident has a comprehensive care plan in place detailing their needs and how these will be met. Specific instructions are given where required including how to deal with someone who has speech difficulties e.g. ask closed questions where only one word answers can be given. The plans seen were clear, concise, and easy to understand and contained physical, social and spiritual needs. Risk assessments are in place as required including ones concerned with movement and handling, nutrition, pressure care, continence and falls. Residents and their families are involved in drawing up the care plans where possible and evidence was seen that the plans are reviewed and updated on a regular basis. Staff record people’s food and drink preferences, where people wish to eat their meals, family and friend relationships and hobbies. Residents can choose their preferred magazines and newspapers.
Aberford Hall DS0000001316.V277868.R01.S.doc Version 5.1 Page 10 Residents are registered with eight different GP practices and receive good support from these. One practice has introduced a Nurse Practitioner who works with them and staff have found this very helpful. Any GP visits plus the outcomes and any required actions are clearly recorded in the residents’ files. Staff are able to access any specialist services that residents may need including Tissue Viability and Diabetic Nurses. Evidence was seen that a Chiropodist visits the home to treat residents every six weeks and Opticians and Dentists visits are arranged as required. People can stay at the home until they die if that is their choice and their needs can continue to be met. The manager will discuss this with the GP, family and any specialist services that may be required before making the decision. Relatives can stay with the residents if this is their choice and their wishes regarding being contacted during the night are recorded. Staff were seen to treat people in a polite manner and help with personal care was offered in a discreet way. Aberford Hall DS0000001316.V277868.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): 13, 14 and 15 Residents are supported and encouraged to maintain contact with family and friends. Staff help residents to make choices about their lives. EVIDENCE: Visitors are welcome at the home and some are quite involved. Residents can go out with them if this has been agreed in their care plan. Regular residents meetings are held but no one attended the last one. The manager holds a weekly surgery for family and friends but people do not tend to come to these. Family and friends tend to speak with the manager and staff if there is anything that they are unhappy about. Residents are able to choose the times they go to bed and get up and these times are recorded. One lady was exercising her choice of going outside for a cigarette even though the weather was cold. Activities are arranged for the residents and they are able to choose if they wish to join in with these. The home provides a good, varied and nutritious diet that takes into account individual choices. Residents say that they enjoy their meals and that choices are always offered. Particular attention is paid to helping the residents to eat and making sure that they have sufficient nourishment. Weight checks are done as often as is felt necessary on individual residents.
Aberford Hall DS0000001316.V277868.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): Not assessed at this inspection. EVIDENCE: Aberford Hall DS0000001316.V277868.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): 20, 23, 24, 25 and 26 The home offers a safe and comfortable environment to the residents and they are able to access all areas of the home. EVIDENCE: There are handrails throughout the home that allow residents to walk around safely. The corridors are wide enough for people to be safe when walking with a mobility aid. There is a pleasant garden area at the rear of the building that the residents can make use of in good weather and access to this is via a ramped area. Some residents sit out side to have a cigarette and they are able to do this as there is level access. Communal areas within the home offer a safe comfortable space for the residents to follow their own interests. Specialist equipment can be provided if required to keep people independent for as long as possible. One person is able to move about in bed by using a monkey pole. Cot sides are used to make sure that people are safe in bed once a risk assessment has been carried out to assess the suitability of these.
Aberford Hall DS0000001316.V277868.R01.S.doc Version 5.1 Page 14 The bedrooms are of a good size that offers people sufficient space to follow their lifestyle. Residents have personalised their rooms by having their own possessions around them. There are some people who choose to spend most of the time in their own room. Staff try to encourage them to mix with other residents but ultimately the choice is theirs. The home is clean and tidy throughout with no offensive odours present. Protective clothing is available for staff where required and the home has a control of infection policy in place. The laundry is well organised and a specific person takes care of this area. Aberford Hall DS0000001316.V277868.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): 28 and 29 Residents are protected by the robust recruitment procedure that the home has in place. EVIDENCE: There is a mix of qualified nurses and care staff on duty on each shift to make sure that the residents are well cared for. The company place a high priority on training and provide opportunities both in house and outside the home. Induction training is affiliated to TOPSS and everyone undergoes this before starting work at the home. Training is looked at in staff appraisals and an audit has just been completed. The home has a comprehensive recruitment procedure in place that takes into account equal opportunities. Two written references, Criminal Records Bureau (CRB), Protection of Vulnerable Adults (POVA), Visa and work permits checks are all obtained before anyone is allowed to work at the home. Notes from a formal interview were seen during the inspection. Aberford Hall DS0000001316.V277868.R01.S.doc Version 5.1 Page 16 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): 32, 34, 35, 37 and 38 The home is well managed, the interests of the residents are seen as important to the manager and staff and are safeguarded at all times. EVIDENCE: The manager is a qualified nurse with many years experience working with this client group. She holds a Certificate of Management in Health and Social Care and is looking to parts of this fulfilling some modules in the Registered Managers award. Staff say that she offers good support to them and the residents. She holds regular staff and residents meetings and is available to speak to families at a weekly surgery. Records concerned with two residents’ financial affairs were correctly maintained. The home has all the required policies and procedures in place to safeguard the interests of the residents. All record keeping in the home is
Aberford Hall DS0000001316.V277868.R01.S.doc Version 5.1 Page 17 done to a high standard and all information stored correctly. Confidentiality in the home takes a high priority. The company operating the home has its own Health and Safety department and send regular bulletins to the home. Health and Safety training is included in the Mandatory training rolling programme. Fire bells are tested weekly and all other safety checks done as required. The qualified nurse on duty on each shift acts as the first aider. Aberford Hall DS0000001316.V277868.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X 3 X X 3 3 3 3 STAFFING Standard No Score 27 X 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X 3 3 X 3 3 Aberford Hall DS0000001316.V277868.R01.S.doc Version 5.1 Page 19 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. Refer to Standard Good Practice Recommendations Aberford Hall DS0000001316.V277868.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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