CARE HOMES FOR OLDER PEOPLE
Ackworth House The Beach Filey North Yorkshire YO14 9LA Lead Inspector
Mary Slattery Unannounced Inspection 4th January 2006 09:55 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.V273422.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ackworth House DS0000027996.V273422.R01.S.doc Version 5.0 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) of places Ackworth House DS0000027996.V273422.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 1st September 2005 Brief Description of the Service: Ackworth House provides personal care and general nursing care for up to 35 service users. Day and respite care is also provided. The home is situated on the seafront at Filey and is within easy reach of the local amenities and facilities offered by the seaside town. The home has four floors and there is a passenger lift giving access to the upper floors. There is a range of communal accommodation on the ground floor and the service users bedrooms are located on the upper three floors. There is a flight of steps and a ramp giving access to the home, there is a large veranda to the front and a small garden area at the side of the home. Parking is limited on the roadside opposite the home. Ackworth House DS0000027996.V273422.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This report relates to an unannounced inspection carried out on the 4th January 2006. The inspection took four hours plus 2 hours preparation time. A tour of the premises was carried out, which included the service users accommodation. Time was spent observing the activity in the home, talking and listening to the views of service users, staff and visitors. The focus of the inspection was on a number of key standards and establishing if the requirements and recommendations of the previous inspection had been addressed. The registered manager was available throughout the inspection and the findings were discussed and agreed at the close of the inspection. What the service does well:
Ackworth House provides nursing care and accommodation for older people, personal care and accommodation for older people and day and respite care. Up to date information is made available about what the home provides including details of the type of care service users will expect to receive. The staff provide an environment in which service users choose what they do each day and they arrange varied activities for their enjoyment. There is a robust staff recruitment and selection procedure to make sure all staff employed are suitable thus ensuring the safety of the service users. Good information is gathered about service users before they are admitted to the home and a care plan is produced to ensure that all staff are fully aware of each individual need and how each need is to be met. Service users and relatives are consulted about life in the home, the standard of care and if there are any changes they wish to see happen. All of the staff have a training and development programme in place and they are supervised on a regular basis. Service users said that they are well cared for and that all the staff were kind to them. They enjoyed the food and they had plenty of opportunities to go out and to keep in contact with their family and friends. Relatives said that they were very happy with the care that their loved ones received from the staff, that they as relatives were also supported and kept informed of any changes to the condition of their relative.
Ackworth House DS0000027996.V273422.R01.S.doc Version 5.0 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. Ackworth House DS0000027996.V273422.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ackworth House DS0000027996.V273422.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. People are provided with information about what the home offers to provide. EVIDENCE: The statement of purpose and the service user guide have been reviewed and contain accurate information about the services, the facilities and the accommodation provided. There is information about the assessment and admission process for service users who are looking to move in on a permanent basis and for those looking for day and respite care. Copies of the statement of purpose and the service user guide are available in the home and displayed on a central notice board. The terms and conditions are agreed with the service users or their representatives and copies of these are kept on each individual file. Ackworth House DS0000027996.V273422.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 and 10 There are good systems in place to make sure that service users needs are met in a safe manner from a well trained staff group. EVIDENCE: A full review of the medication administration process has been carried out. There is a system in place for monitoring staff practice to make sure that all service users medication is administered as required, that all medication is administered from its original container and the administration records are signed when the medication has been administered. The practice of giving service users medication whilst they are eating their meals has stopped except where medication is prescribed to be taken with food. All of the service users looked well cared for, there was evidence of attention from the staff to make sure the service users were well groomed and comfortable. Staff were also observed taking people to the bathroom and this was carried out in a very respectful way. Ackworth House DS0000027996.V273422.R01.S.doc Version 5.0 Page 10 Two relatives told me that they are always made welcome by the staff and that their loved ones receive a high standard of care at all times and due to that their conditions have improved. The staff always keep them informed of any changes to their health and welfare and they, as family, are also supported by the staff. Ackworth House DS0000027996.V273422.R01.S.doc Version 5.0 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 and 15. Visitors are welcome and the home provides a wide range of activities preferred by the service user. EVIDENCE: The service users are encouraged and supported to keep good contact with their family and friends. A number of the service users spend time with their family either in Ackworth House or at their family homes. They have enjoyed a number of seasonal activities and more are planned for the coming months. Locks are being fitted to the service users bedroom doors, which will enable them to have greater privacy should they wish and to keep their personal belongings safe. Time was spent with service users at lunchtime, they were offered choice and there were sufficient staff to give assistance where needed. There was a range of feeding aids available so that the service users could remain independent at meal times. The food was well presented and the service users said it was always of good quality. The cooks came into the dining room and asked if they were enjoying their meal. Ackworth House DS0000027996.V273422.R01.S.doc Version 5.0 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): 18. All staff are thoroughly checked before they commence working at the home to make sure service users are protected. EVIDENCE: There is a robust recruitment and selection process in place and all the required checks are carried out on all staff. There is a good induction and supervision programme in place to assist in establishing if staff are suitable to deliver care to older people. An adult protection training programme has been developed and all staff will attend training in the next few months. Ackworth House DS0000027996.V273422.R01.S.doc Version 5.0 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, 21, 25 and 26. Improvements have been made to the environment to make sure service users have a safe place in which to live. EVIDENCE: The home was found to be clean and free from offensive odours and there were sufficient staff to carry out domestic duties. The home was meeting the fire safety standards and work has been done to fit magnetic door closures to all fire doors. This makes sure people are kept safe and gives staff and service users free and easy access throughout the home. The required and agreed work regarding the decoration and refurbishment of the home has commenced. The second and third floor corridors have been decorated and the remainder of the work including the upgrading of the bathrooms is due to be completed by June 2006. Ackworth House DS0000027996.V273422.R01.S.doc Version 5.0 Page 14 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 and 30. There are sufficient staff on duty to provide care to the service users and to maintain their safety. EVIDENCE: The home employs nursing staff, care and ancillary staff in sufficient numbers to meet the assessed needs of the service user. There is a training and development plan in place for all staff. Nine of the care staff have gained NVQ qualifications and 2 have completed foundation training in Palliative Care. The qualified nursing staff are given supernumerary time to work alongside the care staff to observe their practice and formal supervision. The staffing levels overnight have been increased from 2 to 3. This increase makes sure that the needs of the service users are met and that they are safe. Ackworth House DS0000027996.V273422.R01.S.doc Version 5.0 Page 15 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, 32, 33 and 38. The service users benefit from a well managed home where their needs and wishes are put first. EVIDENCE: The registered manager is a qualified nurse and is experienced in managing a service for older people. She has completed the Certificate in Management and Social Care and undertakes regular training to update skills and practice. There are good systems in place for the day-to-day management of the home, for the training and supervision of staff and for seeking the views of the service users to make sure that their needs are met in a consistent manner and in accordance with their conditions. There is a health and safety policy and procedure and all staff are subject to health and safety training as required. Ackworth House DS0000027996.V273422.R01.S.doc Version 5.0 Page 16 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 X 3 X X X 3 3 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X X X 3 Ackworth House DS0000027996.V273422.R01.S.doc Version 5.0 Page 17 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. Standard Regulation Requirement Timescale for action 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 Ackworth House DS0000027996.V273422.R01.S.doc Version 5.0 Page 18 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
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