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Inspection on 10/01/06 for Admirals Reach Residential & Nursing Home

Also see our care home review for Admirals Reach Residential & Nursing Home for more information

This inspection was carried out on 10th January 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The service has a sound medication procedure with all aspects of its practical application, efficiently carried out by the unit. The home was commended by a service user and their relative for the way in which their admission was handled and the approachability of both staff and management. The home has an efficient and organised system for ensuring the health and welfare of service users.

What has improved since the last inspection?

What the care home could do better:

The home must ensure that all service users are assessed in full and that the needs of the individual can be met, and are appropriate to the registration criteria. The home must ensure that the dependency needs of the service users are assessed and appropriate staffing ratios are employed to meet the assessed needs in line with the Department of Health guidelines.

CARE HOMES FOR OLDER PEOPLE Admirals Reach Residential & Nursing Home Ridgewell Avenue Chelmsford Essex CM1 2GA Lead Inspector Andrea Carter Nelson House Unannounced Inspection 10th January 2006 09:00 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 Admirals Reach Residential & Nursing Home DS0000015345.V280359.R01.S.doc Version 5.1 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. Admirals Reach Residential & Nursing Home DS0000015345.V280359.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Admirals Reach Residential & Nursing Home Address Ridgewell Avenue Chelmsford Essex CM1 2GA 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) 01245 266567 01245 280469 www.bupa.com BUPA Care Homes (CFHCare) Limited Mrs Chipema Chitambala Care Home 120 Category(ies) of Dementia (30), Dementia - over 65 years of age registration, with number (60), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (2), Old age, not falling within any other category (30), Physical disability (30), Physical disability over 65 years of age (60) Admirals Reach Residential & Nursing Home DS0000015345.V280359.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Jellicoe Persons of either sex, aged 60 years and over, who require nursing care by reason of dementia (not to exceed 30 persons) Two named persons with a mental illness whose names were made known to the Commission Persons of either sex, aged 65 years and over, who require nursing care by reason of dementia (not to exceed 30 persons) Nelson Persons of either sex, aged 60 years and over, who require nursing care by reason of a physical disability (not to exceed 30 persons) Persons of either sex, aged 65 years and over, who require nursing care by reason of a physical disability (not to exceed 30 persons) Persons of either sex, aged 40 years and over, who require nursing care by reason of a physical disability (not to exceed 5 persons) Benbow Persons of either sex, aged 65 years and over, who require nursing care by reason of dementia (not to exceed 30 persons) Mountbatten Persons of either sex, aged 65 years and over, who require nursing care by reason of a physical disability (not to exceed 30 persons) Persons of either sex, aged 65 years and over, only falling within the category of old age (not to exceed 30 persons) The total number of service users accommodated must not exceed 120 persons Date of last inspection Brief Description of the Service: The Admirals reach site consists of four single storey, purpose built houses each accommodating 30 residents. Each house is staffed on an individual basis and the central services include administration, laundry and kitchen. the home is situated approximately one mile from Chelmsford and within walking distance of the bus service. The home has a spacious car park. Nelson House is registered for up to 30 residents over the age of 60 years, and up to 5 residents over the age of 40 years who have a physical illness/disability. All residents on Nelson are accommodated in single bedrooms with en-suite facilities. The majority of rooms overlook the landscaped gardens. Admirals Reach Residential & Nursing Home DS0000015345.V280359.R01.S.doc Version 5.1 Page 5 Nelson has a dinning room and four different sitting areas to meet individual need. Admirals Reach Residential & Nursing Home DS0000015345.V280359.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day. Fieldwork included discussion and interviews with staff, service users and relatives. The inspection ran for a total of six hours and sampling of files was undertaken, including the case tracking of individual service users’ care plans and associated documentation in relation to this area. A full tour of the premises was undertaken and discussion with the home manager and unit leader also formed part of the inspection process. A total of thirteen NMS were focused on; with eleven standards being met, and two with minor shortfalls. What the service does well: What has improved since the last inspection? Admirals Reach Residential & Nursing Home DS0000015345.V280359.R01.S.doc Version 5.1 Page 7 The introduction of a pre admission document enables prospective service users to outline in full their needs and preferences prior to admission to the home. This helps to ensure that all areas of need are addressed. The home now ensures that current daily working practice includes the assessment of an individual’s psychological health, thus supporting the analysis of the individual and any change in needs. The home has refurbished the communal areas to a very high standard of décor. 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. Admirals Reach Residential & Nursing Home DS0000015345.V280359.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Admirals Reach Residential & Nursing Home DS0000015345.V280359.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 4 The home’s admission documentation enables prospective service users to have the information they require to make an informed choice as to where they will live. The service users and their representatives know that the home they enter will meet their needs; however, the home needs to have closer regard to their registration category when admitting service users. EVIDENCE: The home has developed its pre admission document. There is now an additional section that clearly identifies the areas of preference around eating, drinking, the individual’s social interests, family involvement; and religious and cultural needs. The last two individuals admitted to the home were case tracked and evidence of this in practice was observed. The home should ensure that the documentation is signed and dated upon completion. This standard was a requirement from the previous inspection. Admirals Reach Residential & Nursing Home DS0000015345.V280359.R01.S.doc Version 5.1 Page 10 The previous inspection identified the home was currently providing services to an individual with mental health needs. The home has undertaken a review of this individual’s needs, and is now awaiting the move to suitable accommodation to come to fruition. Nelson House currently does not provide intermediate care. Admirals Reach Residential & Nursing Home DS0000015345.V280359.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 9 The service user’s health, personal and social care needs are set out in an individual plan of care. Service users are protected by the home’s policies and procedures for dealing with medication. EVIDENCE: The previous inspection identified that the psychological health of individual service users are monitored and recorded systematically. The care plans of two service users were case tracked and documentary evidence that this information is now being recorded consistently was evident. This working practice now takes place on a daily basis for individuals whom are resident within the home. Thus supporting the provision of care received by individuals. Discussion with two individuals confirmed their involvement in their plan of care upon admission of the home. Admirals Reach Residential & Nursing Home DS0000015345.V280359.R01.S.doc Version 5.1 Page 12 A relative spoke highly of the level of care and support provided to their relation. The home has an in depth medication policy, covering all aspects of the medication administration and associated protocols. Currently no service users self administer, but appropriate documentation is available for those assessed able to do so. Medication files were checked and found to be fully in order. This included the medication received for each individual, administration sheets, discharge of medication and the controlled drugs registrar All medication was kept in a separately locked room with appropriate storage facilities for the purpose identified. Admirals Reach Residential & Nursing Home DS0000015345.V280359.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 Service users are supported to exercise choice and control over their lives. EVIDENCE: Two service users were interviewed during the course of the inspection. One individual spoke of the happy relaxed atmosphere within the home and the support given upon their admission. The individual’s room was decorated to their choice of colour; photographs and personal effects personalized the room to the individual’s taste. The completion of the assessment document had included choices around the level and form of care given and associated risk assessments in relation to specific areas were present. Specific choices around family involvement and social activities were also included. One individual stated that the home “makes you feel as though you are a person”. The service users relative commented on the atmosphere within the home and the support given upon their admission. Admirals Reach Residential & Nursing Home DS0000015345.V280359.R01.S.doc Version 5.1 Page 14 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): These standards were not inspected during this inspection EVIDENCE: Admirals Reach Residential & Nursing Home DS0000015345.V280359.R01.S.doc Version 5.1 Page 15 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 and 26 Service users live in a safe, well maintained environment. The home presents as clean pleasant and hygienic. EVIDENCE: The main communal areas of Nelson House have now been refurbished with a high standard of décor and carpeting. This gives the home a clean and presentable feel. This was a requirement from the previous inspection. The domestic staff were interviewed and outlined that currently no alternative laundry products had been identified. The current use of stain removal Admirals Reach Residential & Nursing Home DS0000015345.V280359.R01.S.doc Version 5.1 Page 16 products was satisfactory for their purpose. This was a recommendation from the previous inspection. Admirals Reach Residential & Nursing Home DS0000015345.V280359.R01.S.doc Version 5.1 Page 17 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 29 and 30 The numbers and skill mix of staff meets service user’s needs. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. EVIDENCE: The current and previous rotas were observed and current shift cover is split into three. The two daytime shifts are of a six hour period; with the awake night shift being from eight pm to eight am. The current rota did not indicate in what capacity individual staff were working whilst on shift. It was noted that the dependency needs of service users had changed since the previous inspection; the unit manager was unable to confirm that the current staffing ratios had been amended to reflect the changing needs of the service users. There was no evidence that the residential Forum or any other tool for indicating appropriate staffing levels for the needs of the service users had been used. Domestic staff help to ensure the overall cleanliness of the Admirals Reach Residential & Nursing Home DS0000015345.V280359.R01.S.doc Version 5.1 Page 18 establishment. The recent refurbishment of the communal areas has enhanced the overall homely feel of the unit. The files of three staff members were checked and found to contain all appropriate documentation, in relation to the recruitment and appointment process. Terms and conditions were issued to staff and copies held on file. One staff member interviewed confirmed they had undergone an induction process when they commenced work in the home. This incorporated three days of shadowing staff and information in respect of the service and its users. They outlined that they found the staff to be friendly and supportive and felt clear about the routines and associated procedures upon completion of their induction. The manager has a staff training development programme that clearly identifies the needs of staff within the unit. Evidence of induction for staff upon appointment was clearly available from the files that were sampled. BUPA have a sound induction package for staff. All mandatory training was up to date and the programme identified clearly the provision for staff, for refresher training in the forthcoming months. Admirals Reach Residential & Nursing Home DS0000015345.V280359.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): 33 35 and 38 The home is run in the best interests of the service users. Service users’ financial interests are safeguarded. The health, safety and welfare of service users and staff are promoted and protected. EVIDENCE: Admirals Reach Residential & Nursing Home DS0000015345.V280359.R01.S.doc Version 5.1 Page 20 The service has an appropriate and effective quality assurance process. This includes the distribution of surveys to service users, family friends and stakeholders. These are distributed annually and collated and form part of the overall annual report for the organisation. Supporting this process is the quarterly service users’ meetings. One service user and their relative indicated clearly their approval of the home and the involvement both they and their relatives had been given during the transition in to the unit. The management and staff they found to be approachable and they were supported in regular contact with their partner accommodated within the home. The senior administrator outlined the current system in place for dealing with service users’ financial matters. There is a robust procedure for this area of practice and evidence of all deposits and debits were clearly documented. Individuals finances were checked and found to be correct. Individuals’ have access to an onsite salon and use this facility regularly. Invoices are sent and paid from the individuals’ account for this and other services such as daily newspapers and chiropody. Safe working practices were evident across the service; files that were sampled clearly showed the efficient management of this area. The individual appointed to oversee this area, had an extremely efficient and organised system for ensuring that all health and safety aspects were inspected and checked with regularity. Certification around fire, gas, electrical appliances and other relevant areas were sampled and found to be current and uptodate. Staff files indicated that all mandatory training participated in by staff was current and up to date. Thirteen staff were undertaking a food hygiene course on the day of the inspection. Appropriate polices were sampled within the organisation’s health and safety manual, around COSSH, risk assessments and accident forms ensuring the monitoring of the health and safety of the unit and those whom reside and work within it. Admirals Reach Residential & Nursing Home DS0000015345.V280359.R01.S.doc Version 5.1 Page 21 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 X X 2 X x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 X 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 x 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X x 3 x 3 X x 3 Admirals Reach Residential & Nursing Home DS0000015345.V280359.R01.S.doc Version 5.1 Page 22 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 OP4 Regulation 4(3)(b) Requirement The registered person must ensure that the home only offers care within the category for which they are registered. This relates to the resident with a mental illness currently in Nelson House who must be found a more appropriate placement. This is a repeat requirement form the last inspection. The registered person must ensure that appropriate numbers of staff are employed to support the health and welfare of service users. This is done in conjunction with recommended guidance from the department of health. Timescale for action 31/03/06 2. OP27 18(1)(a) 31/03/06 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 Good Practice Recommendations DS0000015345.V280359.R01.S.doc Version 5.1 Page 23 Admirals Reach Residential & Nursing Home Standard Admirals Reach Residential & Nursing Home DS0000015345.V280359.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Admirals Reach Residential & Nursing Home DS0000015345.V280359.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!