Inspection on 31/10/05 for Aberford Hall

This inspection was carried out on 31st October 2005.

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

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

Other inspections for this house

Aberford Hall 29/10/08

Aberford Hall 07/03/07

Aberford Hall 27/02/06

Aberford Hall 28/01/05

Aberford Hall 10/06/04

Aberford Hall 21/04/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Aberford Hall Oakwood Green Leeds Yorkshire LS8 2QU Lead Inspector Kathleen Firth Unannounced Inspection 11:00a 31 October 2005 st 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.V259132.R01.S.doc Version 5.0 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.V259132.R01.S.doc Version 5.0 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 Old age, not falling within any other category registration, with number (42) of places Aberford Hall DS0000001316.V259132.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th January 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.V259132.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over five hours by one inspector on Monday October 31st 2005. The inspector looked around the building, examined residents’ records including care plans, menus, staff rosters and the Service User Guide. Staff and residents were very helpful throughout the inspection and joined in the process. Eight residents, four staff members, the manager and a visitor were all spoken to. What the service does well: What has improved since the last inspection? The TOPSS based induction programme has been implemented. More care staff have been enrolled on NVQ training. Aberford Hall DS0000001316.V259132.R01.S.doc Version 5.0 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.V259132.R01.S.doc Version 5.0 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.V259132.R01.S.doc Version 5.0 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, 2, 3, 5, 6 People are able to make an informed decision about the home from the written information they receive and from what they and their families see when visiting the home. EVIDENCE: A copy of the Service User Guide given to prospective residents was seen. This contained information about the company and the home. The information about the home is excellent and even contained meal times. There is sufficient information to enable people to make an informed choice about the home. Each individual has a contract that contains the terms and conditions of the home. It details what residents can expect from the home and what is expected from them. The manager or her deputy visits everyone to carry out an assessment of need. A discussion is then held with the nursing staff at the home to make sure that the person’s needs can be met at the home. It would be at this stage that a person would be refused admission. Aberford Hall DS0000001316.V259132.R01.S.doc Version 5.0 Page 9 Everyone is invited to visit the home before admission and meet with staff and other residents. If they are unable to visit, their families or representatives do so. The manager advises people to look at other homes before making a decision about admission. Several people were visiting the home during the inspection to decide if it was suitable for them. Intermediate care is not provided at this home. Aberford Hall DS0000001316.V259132.R01.S.doc Version 5.0 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 the following standard(s): 7, 8, 9, 10 Staff are aware of the residents’ needs and there is good communication amongst the staff group. Residents are treated with dignity and their privacy maintained at all times. EVIDENCE: The pre admission draft care plans are very good and contain excellent information about the resident including past medical history. Care plans looked at were clear, concise, easily understood and contained physical, social and spiritual needs. Baseline observations are recorded on admission. Staff record food and drink preferences, where people want to eat their meals, family and friend relationships, magazine and newspaper choices and hobbies and interests. Risk assessments were in place as required including ones concerning movement and handling, nutrition, pressure care, continence and falls. There was evidence of regular care plan reviews and updates. Some evidence was seen that residents and relatives are involved in writing the care plans but they were not all signed. Residents are registered with eight different GP practices and they receive very good support from them. One practice has a Nurse Practitioner who deals with Aberford Hall DS0000001316.V259132.R01.S.doc Version 5.0 Page 11 smaller things and this is working very well. GP visits; outcomes and any actions required were clearly recorded. The staff can access any specialist services they require such as Tissue Viability and Diabetic nurses. One resident was admitted with a pressure sore and the Tissue Viability nurse recommended a special mattress that has been provided by the home. Arrangements are in place for chiropody and opticians visits. People are able to receive dentist treatment if they require it. Only one resident is able to manage medication and the home has a policy and procedure in place to do this for everyone else. Blister packs are in use that are stored in a locked trolley and only nurses administer these. The home receives excellent support from the pharmacist who has set up a contract to deal with returns. All records were correctly maintained, residents’ photographs in place and any allergies clearly recorded in the medication file. Staff were seen to treat people in a polite way and those spoken to confirmed that they are treated with respect and their privacy maintained. Help with personal care was offered in a discreet way and staff observed knocking on bedroom doors before entering. Aberford Hall DS0000001316.V259132.R01.S.doc Version 5.0 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 the following standard(s): 12, 15 Residents are encouraged to be part of the decision making process and make choices about their lifestyle. A good, varied and nutritious diet taking into account individual choices is provided at the home. EVIDENCE: The home employs an activities organiser who arranges a broad range of things for the residents. Entertainers come into the home on a regular basis; one to one time is spent with residents as well as activities done in small groups. A typical week’s activities are included in the Service User Guide. Residents spoken to thought they had enough to do and enjoy the activities arranged. The Activities organiser has recently carried out a sponsored walk to raise funds for the home and the company then double this amount. The manager holds a surgery one evening per week to meet with family and friends. Not many people attend this and when the last residents meeting was arranged they said that they would rather speak with the manager or staff than attend. Residents spoken to said that they enjoy the meals served at the home and that they always had a choice. Menus seen confirmed that a good, varied and nutritious diet is served at the home. Peoples’ food and drink preferences are Aberford Hall DS0000001316.V259132.R01.S.doc Version 5.0 Page 13 recorded on admission so staff are aware of individual’s likes and dislikes. The dining areas offer sufficient space for people to be able to sit and enjoy their meals and help to do so is given as required. Aberford Hall DS0000001316.V259132.R01.S.doc Version 5.0 Page 14 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): 16, 17, 18 Residents and their relatives have their views listened to, taken seriously and action is taken to resolve issues. Residents have their rights protected and are protected from abuse. EVIDENCE: The appropriate policies and procedures were seen to be in place and the manager confirmed that other than new people staff have had Adult Protection training. Staff are aware of the signs to look for and how to deal with any suspicion of Abuse. The manager said that staff are aware of how to deal with abuse from one resident against another, as there has been an incidence of this at the home that was dealt with appropriately. A copy of the complaints procedure is included in the Service Use Guide so everyone is aware of this. The manager feels that residents and relatives will approach her or the staff if they have any concerns or worries. All of the residents have been registered to vote although not many of them choose to do so. They can use the postal system or go to the polling station if they prefer. Help is offered to complete a vote either way. Residents and their families or representatives are made aware that they can have access to their records. Aberford Hall DS0000001316.V259132.R01.S.doc Version 5.0 Page 15 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, 21, 22, 24, 26 The home offers a safe, well-maintained environment for the residents and provides appropriate bathing and toilet facilities. EVIDENCE: The home is decorated and furnished to a good standard throughout and evidence was seen of regular maintenance. There is a maintenance man in post and staff, relatives and residents are able to write any jobs required in his book. The home offers a safe environment both inside and out with the garden area being enclosed. Residents spoken to said that they have enjoyed sitting outside in the good weather. There is a call system throughout the home. There are sufficient toilets close to the communal rooms and all bedrooms have en suite facilities. Soap and towels were available in the communal toilets and they are big enough for people to be able to go in using a mobility aid. Assisted bathing facilities are available throughout the home. Aberford Hall DS0000001316.V259132.R01.S.doc Version 5.0 Page 16 The bedrooms are of a good size to allow people to follow their own lifestyle. Residents have personalised their rooms by bringing their own possessions with them. Some residents choose to spend much of the day in their own rooms although staff do encourage them to mix with the others at meal times or some other time during the day. Specialist equipment can be provided to make sure that people are able to be as independent as possible. One resident has a monkey pole above the bed to allow her to be able to move herself rather than having to call for help. The home was clean and tidy throughout with nothing seen that could cause a hazard to staff, residents or visitors. One small area however smelled of urine and the manager explained that the resident in that room does not allow staff to clean his room to their usual standard. There is a control of infection policy in place with protective clothing available for staff. Laundry is done at the home and although it is only small the room is well organised and washing is done at the correct temperatures. Aberford Hall DS0000001316.V259132.R01.S.doc Version 5.0 Page 17 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 Staffing numbers and skill mix make sure that residents’ needs can be met. Training takes a high priority at the home. EVIDENCE: Staff numbers and skill mix were appropriate at the time of the inspection and staff and residents were able to confirm that this is the normal way of working. The staff rosters viewed for a period of weeks confirmed the numbers and grades of staff on duty. The manager is able to access extra staff if they are required as the home has its own bank of casual workers. Agency staff can be used if necessary and the staff at the home are also willing to work extra hours. There is a good team spirit amongst the staff and they all said that they receive good support from the manager. Staff said it is a nice sized home to work in and that the company is a good one to work for. Training is very important at the home and staff confirmed that they have easy access to relevant courses. All staff have induction and mandatory training that includes movement and handling, fire safety, Adult protection, food hygiene and COSHH. Evidence was seen of the monthly training programme in place. Qualified staff have time and opportunity to complete their Post Registration Education Programme. Care staff are involved in National Vocational Qualifications and the home will have more than 50 trained when the present people working on the awards have completed them. Aberford Hall DS0000001316.V259132.R01.S.doc Version 5.0 Page 18 Regular staff meetings are in place with an agenda available for people to contribute to. Minutes are made available to all staff whether they attended or not. Aberford Hall DS0000001316.V259132.R01.S.doc Version 5.0 Page 19 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, 36, 38 The home is well managed, the interests of the residents are seen as very important to the manager and staff and are safeguarded at all times. EVIDENCE: The manager has many years experience working in the caring profession. She is a Registered Nurse and is working on the Registered manager’s award that she hopes to complete early next year. The manager operates an open door policy and good interaction was seen between her, staff and residents during the inspection. Residents and staff confirmed that she offers good support and is always ready to listen to them. Formal supervision sessions are in place for all staff with written records being maintained. General staff meetings are held every two months plus the manager holds departmental meetings as and when required. Aberford Hall DS0000001316.V259132.R01.S.doc Version 5.0 Page 20 The manager has overall responsibility for health and safety although all staff receive training in this area. There is a health and safety committee at the home that meets every two to three months or more regularly if needed. The head of departments attend these meetings or send their representative. Minutes are made of the meetings and made available to the appropriate people. Fire bells are tested weekly with drills being held on a regular basis. Night staff have recently completed their fire drills and training. Aberford Hall DS0000001316.V259132.R01.S.doc Version 5.0 Page 21 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 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X 3 3 X 3 X 3 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 3 X 3 X X 3 X 3 Aberford Hall DS0000001316.V259132.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP 28 Good Practice Recommendations The manager should make sure that the target of 50 of care staff complete the NVQ level2. Aberford Hall DS0000001316.V259132.R01.S.doc Version 5.0 Page 23 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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