Inspection on 23/05/06 for Ackworth House

This inspection was carried out on 23rd May 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

Ackworth House 11/11/09

Ackworth House 14/05/07

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 Mavis Pickard Key Inspection 23rd May 2006 09:45 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 Ackworth House DS0000027996.V296026.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. Ackworth House DS0000027996.V296026.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 01723 515888 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 Ackworth House DS0000027996.V296026.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. 4th January 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 with easy reach of the local amenities and facilities of a seaside town. The home 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, 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 current scale of charges is from £395 to £430 plus any funded nursing contribution. Additional charges may be made for hairdressing, newspapers, personal toiletries and clothing, dental treatment, chiropody and eye care where applicable. Ackworth House DS0000027996.V296026.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This ‘site visit’ is the first to be undertaken in this new inspection year 2006/7. The overall view of this service during this inspection cycle is that the home is running well the providers, manager and staff are working hard to ensure that any concerns raised by previous inspections will be met. During the site visit management and staff were spoken with in respect to the running of the home and in respect to the physical environment, which is the subject of a detailed action/improvement plan. In the main the improvement plan is met although there is some slippage and a further timescale will be required. A re-decoration programme is presently being undertaken Many residents were spoken with in an informal way during this visit. 4 people who have been recently admitted or who have recently had been at the home for respite care were ‘tracked’ to look at all aspects of their assessment and care. At the time of publication the Commission has received a detailed action plan that will ensure the requirements of this report are met in a timely fashion. What the service does well: The service provides a well-managed care home for older people who require residential and/or general nursing care. The health and personal care provision is of a high standard. Residents’ families spoken with on the day of this visit said that staff “go the extra mile” for residents. Feedback from residents GP’s and/or health care professionals and from families says that staff are friendly, concerned, caring and pleasant that the home seems very well run and that the Matron is very good. Staff working at the home are approachable and pleasant. The service values individuals and provides lifestyle experiences and leisure facilities that suit individual tastes and preferences. Ackworth House DS0000027996.V296026.R01.S.doc Version 5.2 Page 6 The food provided by the service is of a high quality and residents can choose from a daily menu, where to take their meals and have assistance to eat where this is needed. The premises are situated on opposite the beach in Filey, many private rooms, all communal rooms and the veranda provides spectacular views of the sea and coastline. 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. Ackworth House DS0000027996.V296026.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 Ackworth House DS0000027996.V296026.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): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence about the service including a site visit. Prospective resident’s needs are assessed before they move into the home. The home does not provide intermediate care services. EVIDENCE: Pre-admission information in relation to 4 recently admitted residents was checked 2 showed that a pre -admission visit from the manager had taken place to check the prospective residents needs. Both people also have a care management assessment on file which detail the level of provision required and have received written acceptance that the service can meet their assessed needs. 2 residents who had been accommodated for respite care from an area outside North Yorkshire and who and have visited the home for several holidays received a telephone assessment. The placing authority provided a care management assessment document prior to admission setting out in detail the resident’s current needs. Ackworth House DS0000027996.V296026.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 & 11 Quality in this outcome area is excellent. This judgement has been made using available evidence about the service including a site visit. Individual care plans set out in detail the nursing health and personal needs of residents and are reviewed regularly. People are treated with respect and their medication is handled safely. EVIDENCE: The service has generated care plans from detailed pre-admission assessments. The care plans are drawn up with the involvement of the resident and/or their representatives. Reviews of care planning are regular and where concerns are raised or a risk assessment determines it amended care plans are introduced. Where people are admitted for respite care, the care planning is not as detailed, it is however adequate for the purpose of ensuring that their shortterm needs are met. Ackworth House DS0000027996.V296026.R01.S.doc Version 5.2 Page 10 All residents are registered with a local GP practice. A GP has provided feedback to the Commission that the service is operating well and that the Matron is good. Continence needs are met and people are given support to remain continent. There are opportunities within the home for physical activity. Risk assessments are in place where any unreasonable risk is identified. Nutritional screening is undertaken and special diets provided. People are assisted discreetly to eat their meals if this help is required. Hearing and sight tests are available. The home provides equipment to assist people to move about the home and to bathe. However the service does not provide sufficient assisted bathing facilities on each level where bedrooms are situated. [Please refer to environment outcomes] Medication is dealt with safely and in accordance with current legislation. The practice of dispensing medication into pots in the medication room rather than where the resident is has ceased. People living at the home are treated with dignity and their privacy is upheld. Staff were observed to knock on doors and wait before being invited into private rooms. It was observed that the way management and staff interact with residents and visitors is open and pleasant. The death of a resident had occurred during the night prior to this visit. The death was expected and the service had provided the resident’s wife a place to stay near her husband and ensured that she was comfortable during the days and hours leading to his death. Speaking with the family later they said they could not thank the manager and staff enough for their kindness and consideration during this difficult time. Ackworth House DS0000027996.V296026.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence about the service including a site visit. Residents are able to make choices about their lives, they and their representatives are satisfied with the services provided. EVIDENCE: People spoken with prior to, during and since this site visit have said that they are happy with the services provided by the home. People accommodated said that they have leisure opportunities and that there is always something going on in the home. During the visit people were observed to be doing things that they wanted, residents were sitting in the sun on the veranda, knitting or reading or talking to others residents, visitors and/or staff. The main meal of the day was served during the visit, it presented as being wholesome and nutritious. The cook said that she has fresh meat, vegetables and fruit delivered daily from local sources. Menus were checked and found to provide choice and variety. The cook said that should a resident not want what is offered they will be offered something else. Residents who needed it have a soft or liquidised diet and are helped to eat. Ackworth House DS0000027996.V296026.R01.S.doc Version 5.2 Page 12 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence about the service including a site visit. Complaints are investigated robustly and residents are protected from abuse. EVIDENCE: The home has a complaint policy and procedures that management follow should a complaint be received. A complaint raised in January 2006 that included concerns about poor moving and handling practices, poor management of continence and the lack of support with meals, has been investigated by the home though its complaint procedures. Records of the complaint, which were considered by the Commission to have been appropriately and fully investigated, were available in the home. Residents and others spoken with about their confidence that the home would deal with complaints and abuse properly said that they have every confidence that would be the case but they have had no reasons to complain. Staff have undertaken training with respect to their understanding of abuse. People spoken with said that they know the different types of abuse that could take place in a care home. Staff said 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. Ackworth House DS0000027996.V296026.R01.S.doc Version 5.2 Page 13 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): 19,20,21,22,23,25,25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence about the service including a site visit. The home is safe, clean and comfortable. However there are parts of the home that require re-furbishment and there are not sufficient assisted bathing facilities provided. EVIDENCE: A full tour of the home was undertaken with the registered manager. It was found that the only identified safety issue was that in a couple of areas the carpet seams were coming apart. The carpets are due to be replaced as part of a general improvement plan for the home. In the meantime the manager was asked to ensure that these areas are made safe for residents. Ackworth House DS0000027996.V296026.R01.S.doc Version 5.2 Page 14 The inspection visit in August 2005 made requirement regarding the environment of the home including fire safety requirements. Since that time all fire doors have been fitted with alarm activated door openers, the rear security lighting has been increased and all fire routes kept clear. The passenger lift has had its suspension ropes renewed. The requirements still to do include the provision to some bedrooms of door locks and lockable storage facilities, replacement of some carpets, the replacement of some window frames, the re-furbishment of assisted bathing facilities to the 2nd and 3rd floor areas and the completion of decorating. It is essential that these actions are undertaken within a reasonable timescale and the provider will be asked to submit an action/improvement plan as a requirement of this report. In general 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. The bathrooms on the second and third floors are out of use. 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. 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 and remedial work to replace windows fames etc, 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. Ackworth House DS0000027996.V296026.R01.S.doc Version 5.2 Page 15 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence about the service including a site visit. There are sufficient staff employed who are trained and competent to do their job and residents are in safe hands. EVIDENCE: The service has increased the numbers of care staff on duty at night and has increased the numbers of nurses and care staff during the day. People spoken with said that there are enough staff and that they are not kept waiting a long time if they ring their bell. The recruitment files of 2 most recently employed staff were examined. It was found that all checks were completed before employment began. Residents and 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. It is clear that the service takes the training of its staff very seriously and has a dedicated staff member who plans the training, keeps the training records and who was able to demonstrate the level of training people undertake, which is considerable. Ackworth House DS0000027996.V296026.R01.S.doc Version 5.2 Page 16 Evidence that nurses, care and other staff receive detailed induction is available. The induction can that can last as long as necessary to ensure that people working in the home know the layout and understand their role. 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 and care staff undertake National Vocational Training [NVQ] as is necessary. Ackworth House DS0000027996.V296026.R01.S.doc Version 5.2 Page 17 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, 35,37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence about the service including a site visit. The service is led by a registered manager who ensues that residents come first that their interests are safeguarded and that they are safe. EVIDENCE: The atmosphere in the home is open and comfortable. People spoken with said they feel content and safe. 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. Ackworth House DS0000027996.V296026.R01.S.doc Version 5.2 Page 18 Health and safety documents are kept on the premises and were seen to be properly maintained. 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. There are people living at the home who smoke and there is a smoking policy that shows people can smoke only on the veranda. Ackworth House DS0000027996.V296026.R01.S.doc Version 5.2 Page 19 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 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 1 1 3 3 3 3 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 3 X 3 X 3 X 3 3 Ackworth House DS0000027996.V296026.R01.S.doc Version 5.2 Page 20 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 OP19 OP21 OP22 Regulation 23(1)(a) 23(2)(b) (d)(j)(o) Timescale for action The registered person must 30/07/06 forward to the Commission a detailed action/improvement plan giving realistic timescales for the completion of the action plan initially submitted to the Commission on 1/9/05. The registered person must have 30/07/06 a maintenance plan that evidences regular planned maintenance to all areas of the home. Requirement 2 OP19 23(2)d) 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 OP24 Good Practice Recommendations It is recommended that locks fitted to resident’s private accommodation are of the type that can be opened from the inside without the use of a key and from the outside by the use of a key and accessible to staff in emergencies. Ackworth House DS0000027996.V296026.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Ackworth House DS0000027996.V296026.R01.S.doc Version 5.2 Page 22 - 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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