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Inspection on 19/10/05 for Admirals Reach Residential & Nursing Home

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

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

There is good rapport between the service users and the staff. Activities are provided on a daily basis. The menu is varied and there are alternatives for every meal. Snacks and fruit are always avliable.

What has improved since the last inspection?

Communication with the chef manager.

What the care home could do better:

Cleaning of the shower room (no.39), the bathroom and the sluice room. Care plans need to be signed and dated showing that the care plan process has included residents, family/advocates and staff.

CARE HOMES FOR OLDER PEOPLE Admirals Reach Residential & Nursing Home Ridgewell Avenue Chelmsford Essex CM1 2GA Lead Inspector Clare Walker Unannounced Inspection at Mountbatten House 19th October 2005 10:00 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.V257348.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. Admirals Reach Residential & Nursing Home DS0000015345.V257348.R01.S.doc Version 5.0 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 BUPA Care Homes (CRHCare) Limited No. 2741070 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.V257348.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 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) 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 40 years and over, who require nursing care by reason of a physical disability (not to exceed 5 persons) 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) Persons of either sex, aged 65 years and over, who require nursing care by reason of a physical disability (not to exceed 30 persons) Benbow Persons of either sex, aged 65 years and over, who require nursing care by reason of dementia (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 25th May 2004 Date of last inspection Brief Description of the Service: Mountbatten house is one of four single storey purpose built houses on the Admirals Reach site in Chelmsford. The site is within one mile of the town centre and within walking distance of a bus service. Mountbatten house is registered to provide care for up to 30 service users. The home is registered to provide personal and nursing care. All residents have a single en-suite room. The home has it’s own staffing complement but administration, laundry and the kitchen services are provided centrally. Mountbatten house has four communal rooms plus a dining room. The unit is surrounded by landscaped and accessible open space. Admirals Reach Residential & Nursing Home DS0000015345.V257348.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine unannounced inspection took place on the 19th of October over 6.5 hours. The inspection included a tour of the premises, discussions with 7 service users, 2 relatives, the senior carer, a carer, the maintenance person and the administrator. The registered manager was not on the premises on the day of inspection. Mountbatten house offers a good standard of care in a homely environment. Service users told the inspector that “I feel really safe here” “they are all caring”” they give me all the care I need.” Daily activities are offered and a well attended movement class was underway during the inspection. All individuals had care plans that were regularly reviewed. All food is cooked in a central kitchen. The menu shows a varied range of food, and there are always choices within the daily menu. There is a comment book in the dining room that the chef manager regularly reviews. One service user commented, “the food is wholesome, some people are fussy but it is always wholesome.” Visitors are encouraged “people can come whenever they like.” What the service does well: What has improved since the last inspection? Communication with the chef manager. Admirals Reach Residential & Nursing Home DS0000015345.V257348.R01.S.doc Version 5.0 Page 6 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.V257348.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 Admirals Reach Residential & Nursing Home DS0000015345.V257348.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): 3,5 A full assessment of need is carried out on each individual before that person moves into the home. All residents and their representatives are offered opportunities to visit the home and to undertake a trial stay prior to moving in, to enable them to make their own decision based on information gained. EVIDENCE: All the care files reviewed had an assessment of need on file. These assessments form the basis of the initial care plan. However it was not clear on the file when the trial period of stay was over and who was involved in the decision that a person should remain permanently at the home. The care plans do not clearly indicate who has been involved in care plan changes particularly were the service users and their family involved and have they agreed with the changes. Admirals Reach Residential & Nursing Home DS0000015345.V257348.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): 7,8,9 There are full and comprehensive care plans. Medication is well managed and promotes good health. EVIDENCE: The care plans cover all aspects of a person’s health, personal and social care needs. Health care needs are clearly identified and a range of services engaged to meet assessed needs. There is no documentary evidence of service users and their families being involved in the care planning process. There s evidence of a range of resources being mobilised to meet assessed needs. Residents were clear that they are well cared for” they give me all the care I need.” Medication records were up to date at the time of inspection. All staff handling medication are trained to do so. Admirals Reach Residential & Nursing Home DS0000015345.V257348.R01.S.doc Version 5.0 Page 10 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): 12,13,15 There are a range of activities provided. Social contacts are maintained. A varied and wholesome diet is offered. EVIDENCE: There is a regular daily activities programme. Social contact with friends and family is encouraged and maintained and there were visitors in the unit on the day of inspection. Some residents were going out with friends and family others were being visited at the home. There is a varied and changing menu with several choices at each meal. The food was said to be wholesome and enjoyed. The comments book showed that there were few complaints and the chef manager attends service user meetings as well as receiving comments via a comments book held n the dining room. Admirals Reach Residential & Nursing Home DS0000015345.V257348.R01.S.doc Version 5.0 Page 11 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 There is a clear complaints procedure. Complaints are taken seriously. EVIDENCE: There is a complaints system, which is clear. Complaints made were investigated in line with the procedure. Admirals Reach Residential & Nursing Home DS0000015345.V257348.R01.S.doc Version 5.0 Page 12 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): 19,20,21,23,24,26 Overall the quality of fixtures and furnishing is of a good standard Individuals are encouraged to personalise their rooms. Overall the home is clean, pleasant and hygienic with the exception of a shower-room and a bathroom. EVIDENCE: The communal areas are homely and appropriately furnished and are safe inside and out.. There are activity and quiet spaces. This means that friends and family can be entertained in a room other than the person’s bedroom if they wish. All rooms are en-suite. However the inspection of the communal shower and bathrooms showed much room for improvement. In the shower room the shower seat was rusty and broken and there was a rusty grab rail. The flooring was stained as was the flooring under the toilet. In the bathroom the bath had staining and there was a build up of dust on the waste pipes. In the sluice room the tray holding the washing liquid for the sluice machine was sitting in a tray of green slime. All these issues pointed out to the senior carer. There has been a recent reduction in domestic hours which may need to be reviewed. Admirals Reach Residential & Nursing Home DS0000015345.V257348.R01.S.doc Version 5.0 Page 13 Admirals Reach Residential & Nursing Home DS0000015345.V257348.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): Not able to look at this as the registered manager not available. EVIDENCE: Admirals Reach Residential & Nursing Home DS0000015345.V257348.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): 32,33,35,38 The atmosphere on the unit was welcoming and there was an open style of teamwork. Morale is high and staff are positive in their practice which promotes residents welfare. Health and safety is well managed ensuring a safe environment. EVIDENCE: The unit was warm and welcoming to the inspector, this practice was also observed towards visitors on the day of inspection. Observation of practice demonstrated a clear understanding of the tasks and in discussion staff members were clear about their roles and functions. The senior carer knew her job and was in control of the shift. The unit is run in the best interests of the service users’ and there are regular meetings between residents and the manager of the home. No money is managed for service users. Residents said that they felt safe and well cared for. Feedback is sought via regular meetings between managers and the residents. The outcomes of these meetings inform Admirals Reach Residential & Nursing Home DS0000015345.V257348.R01.S.doc Version 5.0 Page 16 practice for example menu changes. Certificates and maintenance records were available and up to date showing an attention to detail and the importance of health and safety matters within the unit. Records for testing of fire appliances, electricity, gas, portable electrical items, hoists and legionella were all seen. Admirals Reach Residential & Nursing Home DS0000015345.V257348.R01.S.doc Version 5.0 Page 17 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 2 X 2 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 X 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 3 17 X 18 X 3 3 3 X 3 3 X 2 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 3 X 3 X X 3 Admirals Reach Residential & Nursing Home DS0000015345.V257348.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? Yes 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 OP3 Regulation 12(3) Requirement The registered manager must ensure that service users and their representative are included in the care planning process. The registered manager must ensure that the care planning file shows the date that a trial period of stay begins, when it ends and those involved in the decision making process of making the trial stay into a permanent one. The registered manager must ensure that there is a record on the care plan file to demonstrate that the service user and their representative has been involved in the changes to a care plan. The registered manager must ensure that 1) the rusty grab rail and the rusty, broken shower seat in shower room (no.39) are replaced. 2) The stained floor is cleaned or replaced. The registered manager must ensure that the staining in the bath is cleaned and that the room is dust free. DS0000015345.V257348.R01.S.doc Timescale for action 31/01/06 2 OP5 15(1) 31/01/06 3 OP7 15(1) 31/01/06 4 OP26 23(2)(d) 31/12/05 5 OP26 23(2)(d) 31/12/05 Admirals Reach Residential & Nursing Home Version 5.0 Page 19 6 OP26 23(2)(d) The registered manager must ensure that the green slime in the washing liquid tray in the sluice is cleaned away. 31/12/05 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 OP26 Good Practice Recommendations The registered person should ensure that the domestic cleaning hours in the unit are reviewed. Admirals Reach Residential & Nursing Home DS0000015345.V257348.R01.S.doc Version 5.0 Page 20 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.V257348.R01.S.doc Version 5.0 Page 21 - 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. 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