Inspection on 14/05/07 for Ackworth House

This inspection was carried out on 14th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Ackworth House 11/11/09

Ackworth House 23/05/06

Ackworth House 04/01/06

Ackworth House 01/09/05

Ackworth House 04/11/04

Ackworth House 07/05/04

Ackworth House 22/01/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Ackworth House The Beach Filey North Yorkshire YO14 9LA Lead Inspector Mrs Rosalind Sanderson Key Unannounced Inspection 14th May 2007 09:30 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 DS0000027996.V335129.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. DS0000027996.V335129.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ackworth House Address The Beach Filey North Yorkshire YO14 9LA 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) 01723 515888 F/P01723 515888 info@ackworth-house.co.uk Ackworth House Limited Miss Anne Catherine Boland Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35), Physical disability (1) of places DS0000027996.V335129.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate one named service user in category PD under 65 years of age as detailed in the application for variation dated 15/02/2006. 23rd May 2006 Date of last inspection Brief Description of the Service: Ackworth House provides general nursing, personal care and accommodation for up to 35 residents. Day and respite care is also provided. The home is situated on the seafront at Filey, North Yorkshire and is within easy reach of the local amenities and facilities of a seaside town. The home is registered to accommodate up to 35 older people and can accommodate 1 person within those numbers who is under 65 years with a physical disability. It is arranged over 4 floors with a passenger lift to all areas. The communal accommodation is on the ground floor with bedrooms to the upper three floors. There is ramped and level access to the home, a large veranda to the front and a small garden area at the side. Parking is limited to roadside parking opposite the home. Information about the services the home provides are made available to prospective clients and/or their representatives and to placing authorities though the provision of a written Statement of Purpose and Service Users Guide and through CSCI reports. The provider has declined to provide information about the scale of charges at this time. Additional charges may be made for hairdressing, newspapers, personal toiletries and clothing, dental treatment, chiropody and eye care where applicable. DS0000027996.V335129.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection has used information from different sources to provide evidence for this report. These sources include: • • • • Reviewing information that has been received about the home since the last inspection. Information provided by the deputy manager on a pre inspection questionnaire; Comment cards returned from 2 relatives and 7 service users. A visit to the home carried out by one inspector. A site visit was carried out and lasted for six hours. Five people living at the home, two relatives and six staff were spoken with. Records relating to service users, staff and the management activities of the home were inspected. Observation of daily activities at the home was carried out. This helped the inspector to gain an insight of what life is like at Ackworth House for the people that live there. The Responsible Individual and the manager assisted the inspector during the day. They were given feedback from the inspection at the end of the day. What the service does well: The home is lead by a well-respected and competent manager. People and their relatives commented, ‘The home is superb, led by a fantastic matron’ ‘The staff team are led by a positive manager’. A staff member said, ‘Anne is a lovely matron, I haven’t met anybody who doesn’t appreciate her’. Her leadership ensures that people are well looked after and feel safe and secure. People feel confident that their needs will be met at the home following a detailed assessment of their needs which they have been party to. Healthcare needs are well met by caring, well trained staff. One person said they receive an ‘excellent’ standard of care at the home. People feel that they are listened to and feel safe. Comments include, ‘I feel happy and safe at Ackworth with very supportive staff’. A relative said, ‘Any matters that are brought to Anne’s (the manager) attention would be dealt with promptly’ Activities at the home are what people want and they feel satisfied with them. People living at the home said, ‘I feel so fortunate to live her’, ‘I fought hard to get a place at this home’. Their relatives commented, ‘‘People are provided with a loving and secure home’ and ‘Ackworth House is a positive place full of laughter and care’. DS0000027996.V335129.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. DS0000027996.V335129.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 DS0000027996.V335129.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 not applicable. People who use the service experience good quality outcomes in this area. People using the service have sufficient information needed to choose to live here and be assured that staff are able to meet their needs. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: Pre-admission information in relation to 4 people was checked and showed that a pre -admission visit from the manager had taken place to check the person’s needs. Where people are admitted from outside the area, then sufficient information is gathered about their needs. This enables the manager to decide whether the person’s needs can be met. The person they related to or their representative signed all assessments. This shows that they have been involved and agree with the assessment. One person said that they received ‘comprehensive’ information before they moved into the home. DS0000027996.V335129.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. People who use the service experience excellent quality outcomes in this area. The health and personal care that people receive is based on their individual needs and delivered in a way that promotes safety, respect, dignity and privacy. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: Care plans are based on the detailed pre-admission assessments. The care plans are drawn up with the involvement of the person they relate to where possible. They are reviewed and updated regularly to ensure that continue to be applicable. Staff were observed referring to the care plans for guidance on individuals needs and wishes. People at the home have access to all health care professionals when and if they need this. People are registered with a GP of their choice and are able to DS0000027996.V335129.R01.S.doc Version 5.2 Page 10 see them on request. Staff are provided with sufficient training to enable them to meet the full needs of people living at the home. A service user said they receive an ‘excellent’ standard of care at the home. The home provides equipment to assist people to move about the home and to bathe. However people only have access to one assisted bathing facility at this time. A development plan submitted by the organisation indicates that by December 2007 this situation will change with the addition of additional assisted baths and wet rooms for showering. The situation is well managed by the staff and people reported that they are able to have a bath at anytime they wish and as often as they wish. However the situation has the potential to compromise peoples dignity. Medication is dealt with safely and in accordance with current legislation. The medication procedures are audited regularly and any discrepancies discussed with the people involved. The nursing staff at the home have valuable links with other healthcare professionals in the area to ensure that people living at the home have access to up to date practice at all times. These links include contact with professionals involved in the following areas, tissue viability, continence promotion, infection control, diabetes and palliative care. DS0000027996.V335129.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. People who use the service experience excellent quality outcomes in this area. People are able to make choices about their life style and the social and recreational activities meet their expectations. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: People said that they are happy with the services provided by the home. They said that they have opportunities for activities and that there is always something going on in the home. A relative said, ‘The activities are a particularly positive aspect of Ackworth House. Any opportunity for a party or social occasion is taken advantage of and is well co-ordinated’ During the visit people were observed to be doing things that they wanted, knitting or reading or just chatting to other people. DS0000027996.V335129.R01.S.doc Version 5.2 Page 12 People are encouraged to go out for walks either with the assistance of staff or relatives or by themselves if they feel able. Ministers visit the home on a monthly basis to give communion to those wanting to receive this. Individual and collective dietary needs are met. People are offered real choices of meals and are provided with a daily menu card to indicate their choices. Residents who needed it have a soft or liquidised diet and are assisted to eat in a considerate way. Many people commented on the excellent quality of the food. DS0000027996.V335129.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. People who use the service experience good quality outcomes in this area. People who use the service are able to express their concerns, and have access to a robust, effective complaints procedure. They are protected from abuse. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The home has a complaints policy and procedures that management follow should a complaint be received. There have been no complaints received since the last inspection. People living at the home are confident that any complaints would be dealt with swiftly. One said, ‘I feel happy and safe at Ackworth with very supportive staff’. A relative said, ‘Any matters that are brought to Anne’s (the manager) attention would be dealt with promptly’ Staff have undertaken training with respect to protection of people. They said that they know the different types of abuse that could take place in a care home and that they would have no hesitation to report any potential or actual abuse to the manager, to Social Services or to the Police if that were more appropriate. DS0000027996.V335129.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. People who use the service experience adequate quality outcomes in this area. The home is clean and comfortable however people would benefit from additional bathing facilities and general refurbishment of some areas. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The service provides equipment that people require to live their daily lives. However assisted bathing facilities are reduced to 1 bathroom on the first floor. It is intended as part of the improvement plan that these will be re-designed as ‘wet rooms’ a showering facility that allows people to be wheeled in and out. The timescale provided by the organisation is for completion by December 2007. Additional bathing facilities will be provided in the proposed new extension to the home. DS0000027996.V335129.R01.S.doc Version 5.2 Page 15 Residents and families spoken with about their experience of living in the home they said that although there are parts of the premises that need re-decorating they are not unhappy with the way the home looks, its homely and comfortable and that the spectacular views from the front makes up for some of the shortfalls. People said that the home is clean and welcoming and feels like home. Some improvements have been made to the environment since the last inspection and include some refurbishment to the dining area and communal lounges and fitting locks to people’s bedroom doors to ensure privacy is respected. One resident said, ‘I know that there are areas that need redecoration but the home is clean and I am very happy here.’ There is provision for people that wish to smoke. However this is in the main entrance lobby. The manager is aware of changes in legislation regarding smoking in communal areas from 01/07/07. One relative commented, ‘The only criticism to make is that the entrance lobby smells of tobacco smoke…not a good start’ DS0000027996.V335129.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. People who use the service experience excellent quality outcomes in this area. People at the home are cared for by sufficient staff that are trained and competent in their roles. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: People spoken with said that there are enough staff available and that they are not kept waiting a long time if they ring their bell. One relative said, ‘The staff take time to sit and talk with residents’. Somebody living at the home said, ‘The staff are excellent and look after us well, we get whatever help we need’ People and their relatives said that staff are pleasant, caring and professional when dealing with them. People also said that it’s easy to approach staff and that they feel comfortable to do that. There is a dedicated staff member who plans the training, keeps the training records and was able to demonstrate the level of training people undertake, Evidence that nurses, care and other staff receive detailed induction is available. The induction can last as long as necessary to ensure that people DS0000027996.V335129.R01.S.doc Version 5.2 Page 17 working in the home know the layout and understand their role. Staff receive regular supervision and are able to attend the regular staff meetings. All qualified staff are responsible for the upkeep of their professional status through regularly updating of their practice. Records that this is done are maintained. All staff undertakes regular training in respect to issues related to the provision of care. Currently 66 of care staff hold a qualification in care at NVQ level 2 or above. DS0000027996.V335129.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38. People who use the service experience excellent quality outcomes in this area. The management and administration is based on openness and respect with effective quality assurance systems in place to ensure that this continues. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The manager is qualified and competent to carry out her role. She is well liked and respected by people at the home, their relatives and the staff. The atmosphere in the home is open and comfortable. People spoken with said they feel content and safe. Relatives commented, ‘The home is superb, DS0000027996.V335129.R01.S.doc Version 5.2 Page 19 led by a fantastic matron’ ‘The staff team are led by a positive manager’. A staff member said, ‘Anne is a lovely matron, I haven’t met anybody who doesn’t appreciate her’. Comments received from people living at the home include, ‘I feel so fortunate to live her’, ‘I fought hard to get a place at this home’. Their relatives commented, ‘‘People are provided with a loving and secure home’ and ‘Ackworth House is a positive place full of laughter and care’. Records examined during this site visit were detailed and well maintained. A random check was undertaken to look at resident’s personal finances. All records seen were up to date and accurate. Quality assurance audits are carried out on a regular basis and include annual surveys to people living at the home and their relatives, audits of documentation in the home, health and safety audits and medications. Information about the results of these are passed to interested parties in the regular newsletter published by the organisation. Health and safety documents are kept on the premises and were properly maintained. The electrical wiring certificate was due to be renewed. There is a detailed fire risk assessment and staff spoken with said that knew what to do in the case of a fire alarm being activated. Regular fire drills are carried out. DS0000027996.V335129.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 4 X X 3 DS0000027996.V335129.R01.S.doc Version 5.2 Page 21 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 OP19 Regulation 23(2) Requirement Timescale for action 30/06/07 2. OP37 13(4(a) Assurances must be given that additional bathing facilities at the home will be provided by the agreed date of 31/12/07. This will ensure people have access to sufficient facilities and their dignity is preserved at all times. A copy of the fixed wiring 30/06/07 certificate must be forwarded to the Commission for Social Care Inspection when received. This will provide evidence that the installation is safe. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000027996.V335129.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000027996.V335129.R01.S.doc Version 5.2 Page 23 - 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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