Inspection on 25/07/06 for Aberry House

This inspection was carried out on 25th July 2006.

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

Aberry House 22/04/08

Aberry House 04/12/07

Aberry House 20/06/07

Aberry House 19/09/05

Aberry House 07/06/05

Aberry House 17/02/05

Aberry House 23/08/04

Similar services:

Applegarth

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

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

CARE HOMES FOR OLDER PEOPLE Aberry House 6 Monsell Drive Leicester Leicestershire LE2 8PN Lead Inspector Mrs Diane Butler Unannounced Inspection 25th July 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 Aberry House DS0000006356.V304700.R01.S.doc Version 5.2 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.V304700.R01.S.doc Version 5.2 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 0116 2915603 Mrs Margaret Madden Mrs Debra Ann Robinson 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.V304700.R01.S.doc Version 5.2 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. To be able to admit the named person under the age of 65 years named in the variation application number V25761. Named Person To be able to admit a named person under the age of 65 years named in variation V30998 dated 28 March 2006 19th September 2005 2. 3. 4. 5. 6. Date of last inspection Brief Description of the Service: Aberry House is a care home for older persons, providing accommodation and personal care for up to thirty five residents. The home can also care for up to eighteen older people with dementia and/or a mental disorder, up to four older people with a sensory impairment and up to six older people with a physical disability. The home is situated on a quiet street off the main Lutterworth road in the city of Leicester. Accommodation is on two floors with the upper floor accessed by lift or stairs. There are three lounges and a dining room on the ground floor. The home offers thirty three single bedrooms and one shared bedroom, all but one of these rooms offer ensuite facilities. A well-maintained enclosed garden is situated to the rear of the home. Current charges range from £320.00 per week to £475.00 per week. Additional charges are in place for hairdressing, chiropody treatment and transport to appointments. Details of all charges can be found in the homes Statement of Purpose document which is given to all prospective and current residents. Aberry House DS0000006356.V304700.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit, which took place over a six and three quarter hour period on Tuesday 25th July 2006. When undertaking key inspections the Commission for Social Care Inspection (CSCI) focuses on the outcomes for residents living in a home. In order to do this, the inspector ‘case tracked’ four residents. This means the inspector checked their care records and met with them. Where communication was difficult, observation was used to evidence whether care needs were being met. The inspector talked with staff on duty at the time of the visit and observed them going about their daily work. The inspector also had the opportunity to talk with four other residents, five visitors to the home, the registered manager and the registered owner. Correspondence received since the last inspection and the last inspection report have also been taken into account when producing this report. What the service does well: What has improved since the last inspection? Aberry House DS0000006356.V304700.R01.S.doc Version 5.2 Page 6 The registered owner has commenced upgrading the homes ensuite toilets. A quarterly newsletter has been developed which is available to all residents, relatives and staff. A support group has been set up for the relatives of residents living in the home. This group takes place on the first Wednesday of each month and all relatives are made welcome. 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. Aberry House DS0000006356.V304700.R01.S.doc Version 5.2 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.V304700.R01.S.doc Version 5.2 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 Quality in this area is good. This judgement has been made using available evidence including a visit to this service. The needs of prospective residents are assessed before moving into the home. EVIDENCE: The registered manager explained that all prospective residents are visited and assessed before they move into the home. On checking the paperwork/files belonging to the four residents case tracked, three of the four were found to include an assessment of need completed by either the residents social worker or the registered owner. There was no evidence of a needs assessment being carried out by either the manager or the owner for two of the residents. The inspector was informed that close communication had taken place with the resident’s social workers to ensure that they had all the relevant information. On checking the paperwork belonging to a resident due to move into the home that day it was evident that the owner had visited them to assess their needs. Aberry House DS0000006356.V304700.R01.S.doc Version 5.2 Page 9 Three relatives visiting at the time of the inspection confirmed that someone from the home had visited their relative before they moved in and four relatives confirmed that a member of the family had had the opportunity to look around the home to decide if it was the right place for their relative to live. All residents and/or their families receive a copy of the homes Statement of Purpose document, which includes details of the Terms and Conditions of residency. Information includes details of the homes charges, what services the home provides and how the resident and or their relatives can make a complaint if they are not happy with something. On speaking with a relative of a privately funded resident it was noted that they have yet to receive a terms and conditions/contract document. Intermediate care is not provided at the home. Aberry House DS0000006356.V304700.R01.S.doc Version 5.2 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 Quality in this area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s health care needs are currently met, however, lack of risk assessment documentation and care plan documentation could potentially put service users at risk. EVIDENCE: On checking the files of the resident’s case tracked only two of the four had care plans in place. Although the two residents without care plans were the most recent to arrive at the home one had been living there since May 06 and therefore should have had a care plan in place. Another resident who moved into the home in December 05 didn’t have a care plan drawn up until February 06. The manager acknowledged this and the inspector was informed that this would be dealt with. Aberry House DS0000006356.V304700.R01.S.doc Version 5.2 Page 11 The home currently uses a document entitled ‘needs assessment’ as their care plan document. The two care plans seen were comprehensive in content and a care plan summary was also available. This summary gives the reader a good snapshot of the overall needs of the resident. Two of the four files checked did not include a risk assessment. One of the residents without a risk assessment had been identified as at risk of falls and the other was for a resident who has been diagnosed as suffering with diabetes. A risk assessment had also not been completed for a resident who smokes. Details of visits carried out by health care professionals were seen. These included the residents GP, Community Nurses and the chiropodist. The Procedures for the administration of medication were in order with all paperwork completed appropriately. All staff responsible for the administration of medication have received relevant medication training. All staff are well aware of the individual care needs of the residents in their care and all residents and relatives spoken with stated that individual care needs were currently being met. Comments received included: “They are very good, they treat me well” “I’m alright, do I look alright? Them I’m alright” “Its great, there friendly, that’s all you need” “I feel she’s safe here, she’s getting on fine” Throughout the inspection the inspector observed staff interacting with residents in a positive and dignified manner. Aberry House DS0000006356.V304700.R01.S.doc Version 5.2 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): 12,13,14,15 Quality in this area is good. This judgement has been made using available evidence including a visit to this service. Visiting is encouraged enabling residents to maintain contact with family and friends. EVIDENCE: Family and friends are encouraged to visit the residents. Comments received included: “I’m always made very welcome” “They always make me welcome, I would recommend it to anyone” “They offer me a cup of tea” An activities programme is in place and activities are provided on a daily basis. Activities offered during the inspection included dominoes, board games and a quiz. Other activities provided include craft sessions, mobility sessions, sing a longs and aromatherapy sessions. Aberry House DS0000006356.V304700.R01.S.doc Version 5.2 Page 13 Residents are offered choices on a daily basis. Choices include when to get up or go to bed, what to wear, what to have for meals and where to eat them and whether to join in any activities provided. One resident stated: “I have my own room, I can go to my room at any time and I can go out in the garden whenever I want”. A relative explained: She likes to have a nap on her bed which they let her have”. The meals in the home are good offering both choice and variety. All residents spoken with stated that they really enjoyed the food. Comments received included: “The foods good, and for me its enough”. “You get a choice of two”. “I like the food, I have no complaints”. “The foods alright, you get plenty”. “They do all there own cooking”. Aberry House DS0000006356.V304700.R01.S.doc Version 5.2 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): 16,18 Quality in this area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives are confident that any concerns will be listened to, taken seriously and acted upon. EVIDENCE: A complaints procedure is in place and all residents and relatives spoken with were aware of who to go to should they have a concern of any kind. One resident stated: “I would go to Debbie” [the manager] A relative spoken with stated: “I would talk to Debbie, she would sort anything out”. The registered manager explained that eleven complaints had been received since the last inspection in September last year. This statement was supported on checking the complaints book. These complaints, which included the behaviour of a resident and the receipt of an invoice from the home, were taken seriously, appropriately looked into and suitable action was taken. One relative spoken with stated: “Debbie [the manager] is the one that keeps it going, any problems tell her and she will sort it. Aberry House DS0000006356.V304700.R01.S.doc Version 5.2 Page 15 Care workers spoken with were aware of what to do should they suspect any act of abuse and the registered manager is aware of her responsibility with regard to adult protection. Aberry House DS0000006356.V304700.R01.S.doc Version 5.2 Page 16 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): 19,20,23,24,25,26 Quality in this area is good. This judgement has been made using available evidence including a visit to this service. The standard of the accommodation within this home is good, providing residents with an attractive and homely place to live. EVIDENCE: The home is well maintained and suited to the residents needs. Decoration in the home is of a good standard and furnishings in the communal areas are domestic in character and in good condition. The rooms belonging to the residents whose care plans were checked were seen. These were clean, appropriately furnished and included the residents personal belongings. One relative spoken with stated: “Her room is perfect, they keep them very clean”. Aberry House DS0000006356.V304700.R01.S.doc Version 5.2 Page 17 It was noted that one of the lounge carpets was rather stained. The owner explained that she was aware of this and it was due to be cleaned in the very near future. Other areas of the home seen on this occasion were clean and fresh. During a walk around the home it was noted that one of the two assisted baths was out of action, leaving just one bath and one shower available to the residents. On speaking with the care workers on duty it was found that this didn’t currently pose any problems and residents were still able to have there baths/showers as and when they required. The owner explained that it was her intention to refurbish this bathroom by the autumn. The gardens to the rear of the building are very well maintained and offer circular walkways for the residents. Seating is also available for the residents and their relatives to use. Aberry House DS0000006356.V304700.R01.S.doc Version 5.2 Page 18 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 Quality in this area is adequate. This judgement has been made using available evidence including a visit to this service. Sufficient numbers of staff are currently employed to meet the individual needs of the residents living in the home, however, current recruitment practices could potentially put the residents at risk. EVIDENCE: There were sufficient numbers of staff on duty on the day of the inspection to meet the current needs of the residents and all care workers spoken with stated that staffing levels were sufficient to enable them to care properly for the residents without feeling rushed. On checking a number of staff files it was evident that not all of the required checks had been carried out, particularly with two new care workers. One had no evidence of any checks being carried out at all, whilst the other had no evidence of references being collected or a CRB (Criminal Records Bureau) or POVA first check (Protection of Vulnerable Adults). Aberry House DS0000006356.V304700.R01.S.doc Version 5.2 Page 19 Care workers spoken with during the visit confirmed that they had received induction training on commencement of their employment. On checking the induction programme it was noted that this is currently an in house induction covering areas such as an introduction to the home, rotas, personal hygiene, use of wheel chairs and assisting residents out of bed. Through observation and discussion it was evident that the staff were aware of the care needs of the residents case tracked. All care workers spoken with on the day of the visit had completed a National Vocational Qualification level 2. Evidence of ongoing training was seen including training in moving and handling, food hygiene and first aid. A number of care workers are also under taking training in dementia awareness. On speaking with one care worker the inspector was informed that this training was most worthwhile. The care worker stated: “I’m glad I did my dementia training, it’s the little things like, xxxx couldn’t find her room, we knew she liked flowers so we put a picture of flowers on her door and now she can find her room”. Aberry House DS0000006356.V304700.R01.S.doc Version 5.2 Page 20 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): 31,33,35,36,38 Quality in this area is adequate. This judgement has been made using available evidence including a visit to this service. The home is appropriately managed, however, current practices within the moving and handling of residents could potentially put their health and safety at risk. EVIDENCE: The manager has been in post for five years and was registered with the Commission for Social Care Inspection in November 2005. She is a trained moving and handling trainer and is currently completing her Registered Managers Award. Aberry House DS0000006356.V304700.R01.S.doc Version 5.2 Page 21 Staff spoken with stated that they were well supported and positive relationships between management, staff, residents and their relatives were evident throughout the visit. Comments received included: “The office door is always open if you need anything” “They are always there if I need to talk about something” “I feel supported, the office is always open and they are there if you need anything”. Care workers spoken with confirmed that staff meetings and appraisal sessions take place and a quarterly newsletter has been developed which is made available to all staff, residents and their relatives. A support group has been set up for the relatives of residents living in the home. This group takes place on the first Wednesday of each month and all relatives are made welcome. A representative of the Alzheimer’s Society attended the first session. This is seen as good practice. Fire records were not available at the time of the visit. The manager explained that checks had recently slipped but were due to recommence shortly. A new recording book has been obtained and a fire training pack has been purchased. The manager explained that fire training was to be delivered to all staff in the near future and a fire drill was arranged for the day after the inspection. It was noted whilst walking round the home that fire doors had chains on them to make them secure. The registered owner explained that this had been discussed with, and agreed as acceptable, by the fire officer. It was also noted during the inspection that a large number of bedroom doors were wedged open. The register provider must satisfy herself that this is an acceptable practice. The manager stated that there was no facility for looking after resident’s money. It was noted through speaking with the care workers on duty during the visit that training in health and safety and infection control have yet to be provided. The manager explained that all staff had received training in moving and handling, however during the inspection two care workers were seen handling residents inappropriately and one resident was transported in a wheelchair without the use of foot plates. The owner and manager stated that this would be addressed immediately. Aberry House DS0000006356.V304700.R01.S.doc Version 5.2 Page 22 Aberry House DS0000006356.V304700.R01.S.doc Version 5.2 Page 23 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 1 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 1 Aberry House DS0000006356.V304700.R01.S.doc Version 5.2 Page 24 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. 1 Standard OP38 Regulation 13 Timescale for action The registered person shall make 02/08/06 suitable arrangements to provide a safe system for moving and handling service users. The registered person must ensure that staff move and handle residents in an appropriate and safe manner. The registered person shall after consultation with the service user, or a representative of his, prepare a written plan as to how the service users needs in respect of his health and welfare are to be met. The registered person must ensure a care plan is developed for each resident living at the home. The registered person shall ensure that: Unnecessary risks to the health and safety of service users are identified and so far as possible eliminated. Requirement 2 OP7 15 02/08/06 3 OP7 13 02/08/06 Aberry House DS0000006356.V304700.R01.S.doc Version 5.2 Page 25 4 OP29 19 The registered person must ensure risk assessments are completed for all residents living at the home. The registered person shall not employ a person to work at the care home unless: He has obtained in respect of that person the information and documents specified in paragraphs 1 to 7 in Schedule 2. The registered person must ensure that all required checks are carried out on staff employed at the home. 02/08/06 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 OP38 OP3 Good Practice Recommendations It is strongly recommended that the registered person contact the fire officer with regard to the use of door wedges. It is strongly recommended that the registered person carry out their own needs assessment as well as receiving the social workers assessment so that she can satisfy herself that the home can meet the residents needs. It is strongly recommended that training is arranged in Health and Safety and Infection Control for all staff working in the home. It is recommended that privately funded residents receive a terms and conditions/contract document. 3 4 OP38 OP2 Aberry House DS0000006356.V304700.R01.S.doc Version 5.2 Page 26 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.V304700.R01.S.doc Version 5.2 Page 27 - 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. 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