Inspection on 15/11/05 for Aden Mount

This inspection was carried out on 15th November 2005.

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

Aden Mount 15/04/08

Aden Mount 20/04/07

Aden Mount 16/06/05

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Aden Mount Perseverance Street Primrose Hill Huddersfield West Yorkshire HD4 6AP Lead Inspector Stephen French Unannounced Inspection 15th November 2005 09:30 X10029.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 Aden Mount DS0000061700.V266678.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 and Care Homes for Adults 18 – 65*. 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. Aden Mount DS0000061700.V266678.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Aden Mount Address Perseverance Street Primrose Hill Huddersfield West Yorkshire HD4 6AP 01484 515019 01484 515019 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) Aden House Ltd Mrs Wendy Lawson Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (17), Physical disability (28) of places Aden Mount DS0000061700.V266678.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The OP category of registration is for personal care service users only. Date of last inspection 16th June 2005 Brief Description of the Service: Aden Mount is a purpose built spacious home situated in Primrose Hill a residential area of Huddersfield. It is situated on the same site of its sister home Aden View. It offers care and accommodation for up to seventeen older people and offers nursing care and accommodation for up to twenty-eight younger physically disabled persons. All rooms are single en suit and are very spacious. There is a small garden area to the rear and side of the property. There are amble car parking spaces. Aden Mount DS0000061700.V266678.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on the 15th November 2006. The inspection was conducted over a five-hour period and during this time a tour of the building was undertaken. Service users care files and staff details were looked at. A number of staff and service users were spoken to and policies and procedures were examined. Service users spoke highly of the staff and the care that they receive. What the service does well: What has improved since the last inspection? What they could do better: Care plans for service users living in the residential part of the home should be more specific and identify to staff what they need to do for each service user. Aden Mount DS0000061700.V266678.R01.S.doc Version 5.0 Page 6 Consideration should be given to change the outline of the care plan document this will give staff more space to record outcomes/goals and staff intervention. 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. Aden Mount DS0000061700.V266678.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Aden Mount DS0000061700.V266678.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed during this Inspection. EVIDENCE: Aden Mount DS0000061700.V266678.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are 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 OP 6,16,18,19 YPD Each service users has a care plan which identifies their needs. Service users are able to exercise choice in most things they do. The health care needs of the service users are identified and met. EVIDENCE: Each service user has a care plan, which has been compiled following information gathered from the community care assessment, pre admission assessment and discussion with the service user and their family. Six care files Aden Mount DS0000061700.V266678.R01.S.doc Version 5.0 Page 10 were examined as part of the inspection. Care plans included risk assessments for nutrition, skin integrity and moving and handling these had been reviewed monthly. Staff should ensure that if a service user wishes to be involved in the review their signature is obtained to evidence that they agree with the review. Care plans examined from the Thompson Unit were detailed and included measurable outcomes. Care plans from the residential part of the home were difficult to follow and did not give enough detail informing staff what they needed to do. They did not contain an outcome for the problem identified. It was suggested to the manager that care plan documentation should be reviewed to enable staff to be more specific in recording outcomes and care intervention. One care file inspected identified that a service user nutritional status was compromised but there was no care plan or nutritional assessment. Evidence was seen in care files inspected that the staff access other members of the multidisciplinary team such as opticians, district nurses and members of the mental health team. Service users were observed to be spending their day in either one of the lounges or in their own room. Service users from the Thompson unit were seen integrating with the rest of the home and joining in social activities. Aden Mount DS0000061700.V266678.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,15 OP 12,15 YPD The home offers suitable social activities for this particular service user group. The meals are varied and nutritious. Service users are supported by staff to continue with further education. EVIDENCE: Following a recommendation from last inspection the home has employed a full time social activities co-ordinator. Daily social activities are recorded and include trips out to places of local interest; theatre visits and visits to the local public house. Staff at the home ensure that there is some form of activity Aden Mount DS0000061700.V266678.R01.S.doc Version 5.0 Page 12 going on within the home each day and service users are encouraged to join in if they wish. The manager stated that should service users within the Thompson unit wish to go away on holiday then this would be arranged and staff would accompany them. Service users are supported by staff to attend college to study such things as music and dance, should a service user wish to gain employment then staff would support this. The home operates a four-week menu and service users are able to choose from a variety of meals. Service users within the Thompson unit have helped develop their menu to include past, curries and pizza dishes. Service users said that the variety and standard of food was very good. Aden Mount DS0000061700.V266678.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 OP 22,23 YPD Service users are confident that complaints are dealt with appropriately. Service users are protected from abuse. EVIDENCE: The home has a complaints policy, which is displayed in the reception area. Service users are given a copy of the policy on admission. The manager investigates all complaints and evidence was seen that the complainant is made aware of the outcome of any investigation undertaken. The home has received two complaints since the last inspection and these were handled appropriately. Following a requirement made during the last inspection care staff have received training in adult protection. New employees also receive this training as part of their induction. Care staff spoken to gave good responses to questions asked on this subject. Aden Mount DS0000061700.V266678.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed during this inspection. EVIDENCE: Aden Mount DS0000061700.V266678.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the 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 OP 32,34,35 YPD The home is staffed with sufficient numbers of trained competent staff. The homes recruitment procedures protect the service users from abuse. EVIDENCE: The Thompson unit is staffed twenty- four hours a day by qualified nurses who are supported by care staff. Service users who live in the residential part of the home are looked after by care staff that either have an N.V.Q level 2 qualification or who are working towards the award. Staff have received training in moving and handling, health and safety and fire prevention. New employees complete induction training within the first six weeks of commencing employment. This training gives them an insight into what the care needs of the service users are and how these are to be met. It also covers the homes policies and procedures, care staff spoken to confirmed this. Aden Mount DS0000061700.V266678.R01.S.doc Version 5.0 Page 16 Three staff details were examined, two contained the required information and checks but one did not contain two written references. The manager stated that these had been obtained but she was not aware that they were not in the file. Aden Mount DS0000061700.V266678.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,38 OP 8,39,42 The health and safety of service users and staff is protected. The home is well managed and service users are encouraged to air their views and systems are in place to action any shortfalls. EVIDENCE: Aden Mount DS0000061700.V266678.R01.S.doc Version 5.0 Page 18 The manager is available throughout the day to discuss any concerns the service users may have. She frequently visits service users in the Thompson unit and appears to have a good rapport with them. Evidence was seen that service users suggestions had been actioned and the home works with the service users to ensure that their expectations are being met. At present the manager holds formal service user and relative meetings every three months were any concerns can be expressed. Monthly meetings for service users living in the Thompson unit are currently being developed. The manager is aware of her responsibilities surrounding the health and safety of service users and staff. Accidents to service users are recorded and monitored. Certification in relation to servicing of electricity, water and electrical appliances are up to date. Fire alarms are checked weekly. Risk assessments are in place and reviewed. All documentation seen during the inspection was up to date and stored appropriately. Aden Mount DS0000061700.V266678.R01.S.doc Version 5.0 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 X 2 X 3 X 4 X 5 X 6 x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 ENVIRONMENT Standard No Score 19 X 20 X 21 X 22 X 23 X 24 X 25 X 26 x STAFFING Standard No Score 27 3 28 3 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No Score 31 x 32 x 33 3 34 x 35 x 36 x 37 x 38 3 Aden Mount DS0000061700.V266678.R01.S.doc Version 5.0 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 OP7 Regulation 15 (1) Requirement Prepare a written plan as to how the service users needs in respect of his health and welfare are to be met. Keep the service user plan under review. Evidence that the service user has been involved in the review. Two written references must be obtained for new employees; these should be kept within the staff file. Timescale for action 31/12/05 2 OP7 15(2) b c 31/12/05 3 OP29 19 (1) b 15/11/05 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 OP7 Good Practice Recommendations The care plan documentation should be reviewed to include goals/outcomes and more space provided so staff can write specific details of what staff are to do, how they are to do it and when. Nutritional deficits identified in the assessment should Aden Mount DS0000061700.V266678.R01.S.doc Version 5.0 Page 21 have a care plan in place and a risk assessment should be completed and reviewed at regular intervals. Staff should ensure that when writing in care documentation their writing is legible. Aden Mount DS0000061700.V266678.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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. 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