CARE HOMES FOR OLDER PEOPLE
Aberry House 6 Monsell Drive Leicester Leicestershire LE2 8PN Lead Inspector
Helen Abel Unannounced Inspection 19/09/05 13:00 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 Aberry House DS0000006356.V249884.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. Aberry House DS0000006356.V249884.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Aberry House Address 6 Monsell Drive Leicester Leicestershire LE2 8PN 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) 0116 2915602 Mrs Margaret Madden Mrs Margaret Madden Care Home 35 Category(ies) of Dementia - over 65 years of age (18), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (18), Old age, not falling within any other category (35), Physical disability over 65 years of age (6), Sensory Impairment over 65 years of age (4) Aberry House DS0000006356.V249884.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service user numbers. No person falling within category SI(E) may be admitted to the home when 4 persons who fall within category SI(E) are already accommodated within the home. Service user numbers. No person falling in category MD(E) or DE(E) may be admitted to the home when 18 persons who fall within category/combined categories MD(E) or DE(E) are already accommodated within the home. Service user numbers. No person falling within category PD(E) may be admitted to the home when 6 persons who fall within category PD(E) are already accommodated within the home. Service user numbers. Persons who fall within registration category PD(E) can only be accommodated in rooms numbered (at the time of registration) 7-20 and 22. 7th June 2005 2. 3. 4. Date of last inspection Brief Description of the Service: Aberry House is registered to accommodate older people. The additional registration allows the home to accommodate up to 19 elderly people with dementia, up to 18 elderly people with mental disorder, up to 6 elderly people with physical disability and up to 4 elderly people with sensory impairment. The home is a large, comfortable Victorian building with purpose built bedrooms in the extension to the home. All the bedrooms have en-suite facilities. The home operates, a No Smoking Policy. The home is situated in a quiet street off a main road. The home is near a local bus route approximately 15 minute bus ride from the city centre and there are local community facilities and shops, nearby. The home is clean, safe and comfortable with a bright, cheerful, décor. Aberry House DS0000006356.V249884.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 during a weekday morning over a 4-hour period. A part tour of the building took place with care records, policies and procedures inspected. There was the opportunity to talk with three residents, a visitor and staff. The Registered Provider and Acting Manager assisted throughout the inspection visit. What the service does well: What has improved since the last inspection? What they could do better:
Staff to follow the home’s policies and procedures for dealing with medicines ensuring residents are supported and protected. Obtain adult protection training and review policies and procedures in line with good practice. Review recording systems around residents care ensuring residents needs are fully met. Aberry House DS0000006356.V249884.R01.S.doc Version 5.0 Page 6 Provide first aid training for staff so as they are able to perform their jobs properly and take charge in an emergency situation. To undertake maintenance checks, and repairs to individual accommodation, bathrooms, and corridors. This will ensure a safe and comfortable environment for people living in the home. 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. Aberry House DS0000006356.V249884.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 Aberry House DS0000006356.V249884.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 to 5 Residents benefit from an admission process, which works well and ensures that the placement is right for the individual. EVIDENCE: The Registered Provider and Acting Manager undertake a needs assessment prior to the new resident entering the home. Trial visits are flexibly arranged with residents and relatives. Written information is given to the resident including the statement of terms and conditions, and a brief description of the accommodation and services provided. Aberry House DS0000006356.V249884.R01.S.doc Version 5.0 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 to 11. The residents personal and social care needs are generally met and set out in an individual plan of care. Some shortfall around medication policies and procedures, which have the potential to place residents at risk. EVIDENCE: Care plans are well documented, regularly reviewed with risk assessments in place. A communication book is used for staff to highlight any changes in residents care. The Registered Provider and Acting Manager agreed to review the information recorded. Surplus medication was found in the medicine area that could not be accounted for. The Acting Manager will be investigating this incident and agreed to undertake regular monitoring of the medicine administration systems. Photographs of residents are held on medicine sheets to aid staff when administering medication. Staff have received accredited medication training. It was agreed with the Registered Provider confirmation would be sought from the Pharmacist that the storage of controlled drugs is satisfactory. Managers confirmed arrangements for recording residents’ wishes around death and dying are sensitively dealt with.
Aberry House DS0000006356.V249884.R01.S.doc Version 5.0 Page 10 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): 14,15 Residents exercise choice and control over their lives and receive a wholesome and appealing diet in pleasant surroundings. EVIDENCE: Residents spoken with said: “Excellent meals here with everything well served up”. “The food is good here”. There are three dining areas all set out attractively with some seating areas overlooking the garden. One new resident had requested a window near the garden so as time maybe taken to eat and enjoy the surroundings. One resident spoke of wanting to go out more for short trips, and another resident wanted to play dominoes with staff and residents. The Registered Provider and Acting Manager promptly agreed to include dominoes on the activity list and make arrangements for more short trips out. Aberry House DS0000006356.V249884.R01.S.doc Version 5.0 Page 11 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 The complaints procedure meets the required standard. There is a shortfall around vulnerable adults procedures, which do not ensure that people living in the home are protected from abuse. EVIDENCE: A complaints procedure is held in the Statement of Purpose and is current. A formal complaints book is held in the office for the recording of any complaints. A visitor made a complaint on the day of inspection. The Registered Provider verbally responded and recorded the incident in the complaints book. Managers were given a contact point for information around the revised “No Secrets” Multi Agency Policy and Procedure for the Protection of Vulnerable Adults; and the identification of suitable adult protection training for the staff group. Following on a robust review of the home’s adult protection policies and procedures. This will further safe guard residents. Aberry House DS0000006356.V249884.R01.S.doc Version 5.0 Page 12 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): 19,20,23,24,25, The premises are not consistently well maintained however they are clean, hygienic and comfortable throughout. EVIDENCE: Parts of the home were inspected and found to be fresh, clean and comfortable. Bedrooms were generally well maintained and personalised with resident’s possessions. The following areas require attention: • Fire doors were wedged open along a main corridor and a settee in the main corridor blocked off a fire exit and fire extinguisher. • Two identified bedroom carpets require replacing. One en-suite floor was found to be sticky and presents as a hazard to residents. Residents and visitors use the rear garden area for short walks and were attractively presented with trees, border plants, and benches. Aberry House DS0000006356.V249884.R01.S.doc Version 5.0 Page 13 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): 27,28,29,30 The staff group are effective and able to meet the individual needs of residents. Residents are supported by the home’s recruitment policy and procedures. EVIDENCE: Staff and the Acting Manager undertake a range of training and development opportunities including National Vocational Qualifications in care and management. The Acting Manager reported delegating daily worksheets to guide staff and ensuring individual residents needs are met. Recruitment files were sampled and contained all the required information ensuring residents are protected. The Registered Provider confirmed they are in the process of reviewing all job descriptions including the Acting Managers, and the staffing structure within the home. Aberry House DS0000006356.V249884.R01.S.doc Version 5.0 Page 14 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): 34 to 38 Residents finances are safe guarded but there are shortfalls with promoting the health, safety and welfare of people using the service. EVIDENCE: The Acting Manager confirmed a formal staff supervision programme is due to start up again. Currently staff are informally supervised on a daily basis. Staff have received training in food hygiene, infection control, and moving and handling, Managers confirmed some staff had not received training in first aid and recognised this was now a priority. Trained first aiders should be available on each shift to safe guard resident’s safety and wellbeing. Training around advanced food hygiene and food hazard analysis was also discussed with managers for domestic staff. Aberry House DS0000006356.V249884.R01.S.doc Version 5.0 Page 15 The handy person is responsible for checking the hot water valves and that hot water is provided close to 43.c. It is recommended regular hot water tests continue with records held. This is to reduce the risk of residents being scalding by hot water. Portable appliance testing and fixed electrical systems are due to be tested. Risk assessments must be in place for asbestos and the risk of Legionella. Managers confirmed these would be done. All other safe working practice topics were in order. Aberry House DS0000006356.V249884.R01.S.doc Version 5.0 Page 16 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 x x 3 3 3 x STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x 3 3 3 3 2 Aberry House DS0000006356.V249884.R01.S.doc Version 5.0 Page 17 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 2001and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13 Requirement The Registered Provider shall make arrangements for the recording, handling, and safekeeping of medicines. Training to be provided around physical and verbal aggression by residents. This should be followed through with a robust review of the homes written policies and procedures. Outstanding from the last inspection 7th June 2005. The Registered Person shall ensure that the premises are kept in good state of repair. The following areas require attention: • Fire doors were wedged open along a main corridor and a settee in the main corridor blocked off a fire exit and fire extinguisher. • Two identified bedroom carpets require replacing. One en-suite floor was found to be sticky and presents as a hazard to
DS0000006356.V249884.R01.S.doc Timescale for action 19/09/05 2 OP18 18 31/10/05 3 OP19 23 31/03/06 Aberry House Version 5.0 Page 18 4 OP38 13 5 OP38 13 the resident. The Registered Person must ensure staff at the home receive training appropriate to the work they are to perform. The Registered Person shall ensure all parts of the home to which residents have access are so far as possible free from hazards to their safety: • Portable appliance testing and fixed electrical systems to be tested. • Risk assessments must be in place for asbestos and the risk of Legionella. 31/10/05 19/10/05 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 OP7 Good Practice Recommendations A formal family tree format to be provided at the point of admission for new residents. This maybe a short document that outlines the resident’s lifestyle, previous work/vocation and position within their family. Outstanding from the last inspection 7th June 2005. Review the use of the communication book in line with confidentiality and disclosure of information policies and procedures. Obtain the revised “No Secrets” Multi Agency Policy and Procedure for the Protection of Vulnerable Adults. Carry out regular checks for the hot water valves on all water outlets accessible to residents, with written records held. 2 3 4 OP2 OP18 OP38 Aberry House DS0000006356.V249884.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Aberry House DS0000006356.V249884.R01.S.doc Version 5.0 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
