CARE HOMES FOR OLDER PEOPLE
Aberry House 6 Monsell Drive Leicester Leicestershire LE2 8PN Lead Inspector
Helen Abel Unannounced 7 June 2005, 10:00am
th 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 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 C51 S6356 Aberry House V228662 070605.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Aberry House Address 6 Monsell Drive Leicester Leicestershire LE2 8PN 0116 2915602 0116 291 5603 None Mrs Margaret Madden Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 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 C51 S6356 Aberry House V228662 070605.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 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. No person falling within 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. 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. Date of last inspection 17th February 2005 Brief Description of the Service: Aberry House is registered to accommodate older people. Since the last inspection the home has increased the number of beds from 34 to 35. 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. The staff are committed, cheerful and have a good relationship with each other and the service users. Staff training is provided on a regular basis with a large proportion of staff completing various levels of the National Vocational Qualification awards. Aberry House C51 S6356 Aberry House V228662 070605.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced during a weekday afternoon over a four hour period. We spoke with residents, visitors, and the Registered Provider /Manager and the General Manager. A full tour of the premises took place and care records were inspected as well as some home records and policies and procedures. What the service does well: What has improved since the last inspection? Photographs of each resident are now included with medicine records to aid staff whilst administrating medicines. Managers confirmed that the ordering, receipt, storage and returning of medication are now signed by a nominated staff member. Aberry House C51 S6356 Aberry House V228662 070605.doc Version 1.30 Page 6 What they could do better:
The home’s written Statement of Purpose must be updated and made available to every resident and any representative of a resident. The Registered Provider/Manager must carry out a written Needs Assessment for any new resident coming into the home. Effective consultation regarding the assessment will ensure that the care home is suitable for the purpose of meeting each new resident’s needs. The Registered Provider/Manager to monitor key aspects of resident’s health care needs are being met for: oral care, sight and hearing aids. Additional security measures must be put in place for the safe keeping of medicines in the home. Staff training to be provided around physical and verbal aggression by residents. This must be followed through by a robust review of the home’s adult protection policies and procedures. Ensure laundry fire doors are kept closed so as to safe guard residents and staff at all times. A review of the staff compliment in the home to ensure the numbers and skill mix of staff meets resident’s needs. The General Manager to submit a Registered Manager’s application to the CSCI. This will ensure residents live in a home, which is run and managed by a person fit to be in charge. A job description for the Registered Manager to be provided enabling her to take responsibilities for fulfilling her duties. Develop a family tree format to be drawn up that outlines the resident’s lifestyle, previous work/vocation and position within the family. Such information is useful when drawing up an individual’s care plan; Enlarge upon the care plan format, to include more detailed care to be delivered. Some residents are unable to be weighed due to mobility difficulties. It is recommended a sit down weighing scale be obtained to enable the recording of residents weight and any action to be taken. To ensure safe keeping of controlled drugs more appropriate storage to be explored and considered. Provide improved fridge monitoring systems for the storage of medicines. It is recommended all staff job descriptions be reviewed to ensure clarity and understanding of staff’s roles and responsibilities.
Aberry House C51 S6356 Aberry House V228662 070605.doc Version 1.30 Page 7 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 C51 S6356 Aberry House V228662 070605.doc Version 1.30 Page 8 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 Standards Statutory Requirements Identified During the Inspection Aberry House C51 S6356 Aberry House V228662 070605.doc Version 1.30 Page 9 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 standard(s) 1,3 Prospective residents have some information they need to make an informed choice about where to live. The needs assessment system for new residents is not fully implemented. EVIDENCE: There is a Statement of Purpose available in the home. This is not current and needs reviewing but is still displayed in the home. The Registered Provider/Manager spoke of still using the Statement of Purpose, discussing and making copies available to relatives and residents. Some aspects such as the organisational structure and the number, relevant qualifications, and experience of staff working at the home are not included. Aberry House C51 S6356 Aberry House V228662 070605.doc Version 1.30 Page 10 During the inspection several residents care was examined from the point of entry to the home, to their current needs. One resident had recently entered the home and had been admitted the same day as the arrival of her social worker’s comprehensive assessment. This didn’t allow for staff at the home to properly check if they had the capacity to meet this residents needs. The Registered Provider/Manager had visited the prospective resident for an assessment two weeks before but no written records were made at this time. The Registered Provider/ Manager is now required to carry out a written Needs Assessment for any new resident coming into the home. Aberry House C51 S6356 Aberry House V228662 070605.doc Version 1.30 Page 11 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 standard(s) 7,8,9, The residents personal and social care needs are generally satisfactory and set out in an individual plan of care. Resident’s health care needs are not fully met. Some shortfalls around medication policies and procedures, which have the potential to place residents at risk. EVIDENCE: The care plan format should indicate care to be provided in more detail. The Registered Provider /Manager agreed to review and draw up a more comprehensive care plan format. Care plans are reviewed monthly with records held. Risk assessments are in place. Information was shared with the managers around the safe use of bed rails. The General Manager spoke of once a year writing to each resident’s family to gain information around the resident’s previous home life. It is recommended a formal family tree format be drawn up. This maybe a short document that outlines the resident’s lifestyle, previous work/vocation and position within their family. This could be given to residents and their relatives for completion at the point of entering the home and utilised for providing a more personal understanding of the resident.
Aberry House C51 S6356 Aberry House V228662 070605.doc Version 1.30 Page 12 Feedback was received from a visiting relative of a resident around missing dentures and hearing aids. It was agreed the Registered Provider/Manager would check and monitor key aspects of care needs are being met for, oral care, sight and hearing aids for residents. This monitoring should be ongoing to ensure quality of care for residents. Some residents were being weighed on a periodic basis with records held. Other residents were not being weighed due to mobility difficulties. It is recommended a sit down weighing scale be obtained so as all residents weight maybe monitored. Medicine administration is well organised and carried out. Photographs of each resident are now included with medicine records to aid staff whilst administrating medicines. Staff that administer medication are at the point of going on certified medication training. The Registered Provider shall make arrangements for the recording, handling, safe keeping, safe administration of medicines received into the care home: 1. Ensure additional security measures for the medicine area door. 2. Obtain additional security measures for the window of the medicine area. 3. Obtain a cupboard for controlled drugs. To comply with the Misuse of Drugs (Safe Custody) Regulations 1973. 4. For the cold storage of medicine. Daily written records should include the minimum, maximum and current fridge temperatures. Aberry House C51 S6356 Aberry House V228662 070605.doc Version 1.30 Page 13 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 standard(s) 12, 13,15, There are sufficient social and cultural, religious and recreational interests to meet the expectations and preferences of residents. Residents maintain contact with family, friends and the local community. Residents receive a wholesome and appealing diet in pleasant surroundings. EVIDENCE: A group of residents were enjoying chair aerobics with an external instructor the afternoon of the inspection. Other residents were observed sitting talking with visitors. An aromatherapist comes to see residents once a month and plays music and massages resident’s hands. Residents can choose to move and sit in the different lounges in the home. Arrangements are made for clergy to make personal visits to the home. A local choir comes regularly and sings for the residents. A relative spoken with confirmed the warm reception she received from the managers at the home when she arrived with her relatives to live at the home. They were made very welcome with a waiting reception and fresh flowers placed in the room. The home is commended. There is a four weekly-varied menu that rotates and is appealing and balanced.
Aberry House C51 S6356 Aberry House V228662 070605.doc Version 1.30 Page 14 Meals are largely home cooked with roast meals on Sundays. With the warmer weather coming residents will be offered salad on the menu. Managers confirmed the freshly made puddings are favourites with residents of plum sponge, apple crumble and queens pudding. Drinks are offered at intervals to residents and fluid charts for residents are kept. Aberry House C51 S6356 Aberry House V228662 070605.doc Version 1.30 Page 15 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 standard(s) 16, 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 relative confirmed in the past she had raised concerns with managers at the home and these had been largely dealt with. A recent concern is that items of clothing belonging to her relatives have gone missing. The Registered Provider /Manager agreed to look again at this matter. Information was passed onto the home around the revised “No Secrets” Multi Agency Policy and Procedure for the Protection of Vulnerable Adults. A recent reportable incident around physical aggression by residents was discussed with managers and a requirement to provide training for the staff group. This must be followed through with a robust review of the home’s adult protection policies and procedures. Aberry House C51 S6356 Aberry House V228662 070605.doc Version 1.30 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 standard(s) 19, 21,23,26, The premises are well maintained, clean and hygienic throughout. A shortfall around fire safety will put people at risk of harm. Bedrooms are personalised and suit individual needs. EVIDENCE: The home is very well maintained with many areas of bright cheerful décor. Each room contains the items of furniture as specified by the standards. All bedrooms have en-suite facilities. Room sizes vary from 10 sq metres to just over 20 sq metres. Bedrooms were personalised to suit individual needs. The indoors areas are safe comfortable and accessible. The outdoor area is very well presented with green shrubberies and border plants. An attractive pathway leads around the garden with garden benches available. The whole garden area is reported to be greatly enjoyed by the resident group. Aberry House C51 S6356 Aberry House V228662 070605.doc Version 1.30 Page 17 In line with best practice alcohol based gels are available to staff and visitors. This is to minimise any cross infection issues. Colour coded disposable aprons are available and a range of disposable clothes. Sheets and towels are washed by outside contractors as another way of reducing cross infection in the home. These sound measures are to be commended by the home. The fire laundry door was wedged open. The laundry fire door must be kept closed when not in use, as this is a potential fire hazard. Aberry House C51 S6356 Aberry House V228662 070605.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, Overall staffing levels were in sufficient numbers but the deployment of staff must be addressed to meet the needs of the residents. EVIDENCE: There is a large care staff group. A review of the staffing structure is required. The following aspects were noted on the staffing rota: 1.Both managers actual hours worked, were not recorded on the rota. 2.Both managers worked similiar hours and not at opposite ends of the day to allow for the monitoring of care practices. 3.No senior staff were on duty during the day (apart from managers) according to the rota. 4.Carer’s in charge were employed, but not recorded on the rota. 5. A designated senior staff member was not indicated on the staffing rota at weekends. The managers were open to suggestions as to how to make staffing changes to improve the service. It is recommended all staff job descriptions be reviewed. Aberry House C51 S6356 Aberry House V228662 070605.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 The General Manager’s ability to discharge her responsibilities does not meet this Standard. EVIDENCE: The General Manager has been in post for 4 years but as yet has not been proposed for registration. The General Manager assists the Registered Provider / Manager and is responsible for the day- to- day running of the home. The General Manager does not have a job description. Her lines of accountability were unclear within the current management structure with. (Refer to Standard 27. Staff Compliment). Discussions took place with the General Manager around training at level 4 National Vocational Qualifications, or an equivalent training. A requirement for the registration of a manager was made. Aberry House C51 S6356 Aberry House V228662 070605.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x
COMPLAINTS AND PROTECTION 2 x 3 x 3 x x 3 STAFFING Standard No Score 27 1 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 2 x x x x x x x Aberry House C51 S6356 Aberry House V228662 070605.doc Version 1.30 Page 21 no Are there any outstanding requirements from the last inspection? 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 1 Regulation 4 Requirement To update the homes Statement of Purpose ensuring all the required information is included; and made aviable to every resident and any representative of a resident. The Registered Provider/ Manager to carry out a written Needs Assessment for any new resident to the home. Timescale for action 7th July 2005 2. 3 14 From here onwards 3. 8 13 The Registered Provider/Manager From here and General Manager to monitor onwards and check aspects of care needs are being met for, oral care, sight and hearing aids for residents. The Registered Provider shall 7th July make arrangements for the 2005 recording , handling, safekeeping of medicines: 1.Provide additional security measures for the medicine area door. 2.Obtain additional security measures for the window of the medicine area. 4. 9 13 Aberry House C51 S6356 Aberry House V228662 070605.doc Version 1.30 Page 22 5. 18 18 Training to be provided around physical and verbal agression by residents. This should be followed through with a robust review of the homes written policies and procedures. Keep the fire laundry door closed and permanently remove the door wedge, as this is a potential fire hazard. 31st July 2005 6. 19 23 Now and ongoing. 7. 27 18 At all times suitably qualified, 24th June competent and experienced 2005 persons are working at the care home. The following aspects were noted: 1.Both managers actual hours worked were not recorded on the rota. 2.Both managers worked similiar hours and not at opposite ends of the day to oversee care practices. 3.No seniors were on duty during the day (apart from managers) according to the rota. 4.Carer’s in charge were employed but not recorded on the rota. 5. Seniors were not evident on the staffing rota at weekends. A review of the management structure is required to meet the needs of the residents. The General Manager must submit an application to CSCI for Registered Managers status. Draw up a job description for the General Manager (Registered Manager). 30th June 2005 30th June 2005 8. 9. 31 31 9 9 Aberry House C51 S6356 Aberry House V228662 070605.doc Version 1.30 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 7 Good Practice Recommendations The care plan format is brief and should indicate care to be provided in more detail. The Registered Provider /Manager agreed to draw up a more comprehensive care plan format. It is recommended a formal family tree format be drawn up. This maybe a short document that outlines the resident’s lifestyle, previous work/vocation and position within their family. Some residents were unable to be weighed due to mobility difficulties. It is recommended a sit down weighing scale be obtained. The following points of good practice are recommended to ensure safe keeping of medicines: 1.Obtain a cupboard for controlled drugs. To comply with the Misuse of Drugs (Safe Custody) Regulations 1973. 2.For the cold storage of medicines. Daily written records should include the minimum, maximum and current fridge temperatures It is recommended all staff job descriptions are reviewed. 2. 7 3. 4. 8 9 5. 6. 7. 8. 27 Aberry House C51 S6356 Aberry House V228662 070605.doc Version 1.30 Page 24 Commission for Social Care Inspection 5 Smith Way Grove Park Enderby Leicestershire 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 C51 S6356 Aberry House V228662 070605.doc Version 1.30 Page 25 - 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!
