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Inspection on 23/01/06 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

All the relatives spoken with said that the residents they visited were very happy in the home. One relative said, "I think it`s an excellent place, the staff are really good. He`s well looked after and the food is nice". Another said, "They take good care of them".

What has improved since the last inspection?

There had been a considerable emphasis on staff training since the last inspection. Overall staff interaction with residents had improved since a number of the staff had completed a three day dementia course. The staffing levels on the morning shift had been increased from 6 to 7 staff. This had resulted in improved supervision of residents and more assistance at mealtimes. Blinds and solar film had been installed in the conservatory area, to try and reduce high temperatures in this area during the summer months.

What the care home could do better:

Jellicoe House did not have regular activities each day. One relative said "there`s not a lot to do here, they sit around and sleep". The manager was in the process of recruiting for additional activity coordinator hours. Odour control was not as good as at the last inspection, but staff were taking steps to address this.

CARE HOMES FOR OLDER PEOPLE Admirals Reach Residential & Nursing Home Ridgewell Avenue Chelmsford Essex CM1 2GA Lead Inspector Francesca Halliday Jellicoe House Unannounced Inspection 23rd January – 3rd February 2006 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.V279686.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.V279686.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.V279686.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 Admirals Reach Residential & Nursing Home DS0000015345.V279686.R01.S.doc Version 5.1 Page 5 Date of last inspection 5th July 2005 Brief Description of the Service: Jellicoe House is registered to provide nursing care for up to 30 residents over the age of 60 years with dementia. All residents on Jellicoe House are accommodated in single bedrooms with en-suite facilities. The majority of rooms overlook the gardens. 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 the kitchen. There is a spacious car park. The home is situated approximately one mile from Chelmsford and within walking distance of the bus service. Admirals Reach Residential & Nursing Home DS0000015345.V279686.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was to Jellicoe House only. The unannounced inspection took place on 23rd January 2006. The inspection lasted 5 hours. The inspection process included: discussions with 7 residents (although advanced dementia made communication difficult with the majority of residents), 4 relatives, and 4 members of staff (including the charge nurse for Jellicoe House and the home manager). The premises and a sample of records were inspected. Further information was requested following the inspection. The information arrived on 3rd February 2006, and this concluded the inspection process. 11 of the 38 standards were inspected: 6 met the standard and 5 standards had minor shortfalls. The judgements made within the report are based on the observations and evidence gathered during this inspection. What the service does well: What has improved since the last inspection? What they could do better: Jellicoe House did not have regular activities each day. One relative said “there’s not a lot to do here, they sit around and sleep”. The manager was in the process of recruiting for additional activity coordinator hours. Odour control was not as good as at the last inspection, but staff were taking steps to address this. Admirals Reach Residential & Nursing Home DS0000015345.V279686.R01.S.doc Version 5.1 Page 7 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.V279686.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.V279686.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): EVIDENCE: Standards 1, 3, 4, and 5 were assessed as met at the last inspection on 5th July 2005 (standard 6 not applicable). Admirals Reach Residential & Nursing Home DS0000015345.V279686.R01.S.doc Version 5.1 Page 10 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 and 10 The standard of care documentation is improving, but would benefit from being more resident focused. Relatives are confident that health care needs are met. Medicines management is generally sound. Staff are making efforts to ensure that residents’ privacy and dignity are upheld. EVIDENCE: The standard of care plans was generally good, and a number demonstrated excellent knowledge of residents’ individual needs and preferences. Monthly evaluations had been carried out; some provided an evaluation of care and care needs, but others only described the treatment or care in the care plan. The wound care documentation had improved considerably, but on some occasions staff stated that a wound had been dressed and did not describe the progress of healing. Staff said that residents, and relatives where appropriate, were involved in developing and reviewing care and care plans, but there was not always evidence of this. A discussion was held about the benefit of making the care plans more resident focused. Relatives spoken with were very happy with the quality of care and access to local healthcare services, and considered that they were kept well informed about any health concerns. Admirals Reach Residential & Nursing Home DS0000015345.V279686.R01.S.doc Version 5.1 Page 11 Medicines management was generally sound. Medicines were being stored at safe and appropriate temperatures, and the medicine administration charts sampled were well completed. Controlled Drugs and homely remedies were checked and stock levels found to be correct. A few medicines with a limited shelf life on opening had not been dated on first use. Some out of date items were disposed of at the time of inspection. The charge nurse confirmed that every effort was being made to keep the net knickers labelled so that they were not used communally. Confidential information was no longer on display on the office white board. Admirals Reach Residential & Nursing Home DS0000015345.V279686.R01.S.doc Version 5.1 Page 12 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 and 15 Staff interaction with residents is much improved but the home does not offer regular activities. Residents are satisfied with the food, and staff are now able to provide more supervision and assistance at mealtimes. EVIDENCE: Overall staff interaction with residents had improved considerably since a number of the staff had completed a three day dementia course. However, Jellicoe House only had three sessions of activities each week, and the role of the activity coordinator was not covered if she was on leave or absent. The manager said that she was planning to increase the activity hours on Jellicoe House in the near future. The activities included seated exercises, hand massages, bingo and one to ones with individual residents. Residents had also recently enjoyed cake making, and the activity coordinator was hoping to set up regular visits from a “PAT dog”. The activity coordinator was on a six month distance learning course on activities and over half the staff had received some training on activities suitable for residents with dementia. Residents at the last inspection were very happy with the meals and choices available. Residents who could express a view at this inspection, said that the Admirals Reach Residential & Nursing Home DS0000015345.V279686.R01.S.doc Version 5.1 Page 13 food was nice. The staffing levels on the morning shift had been increased from 6 to 7 staff, and staff said that they were now able to give residents much more supervision and assistance at breakfast and lunchtimes. Standards 13 and 14 were assessed as met at the last inspection on 5th July 2005. Admirals Reach Residential & Nursing Home DS0000015345.V279686.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): 18 Training in the protection of vulnerable adults has started, but has still to be completed for all staff. EVIDENCE: The home has policies and procedures for the prevention of abuse and whistle blowing. One member of staff spoken with was not fully familiar with the different types of abuse that could occur. The manager said that all staff had been issued with a distance-learning booklet on the protection of vulnerable adults in July 2005. She said that this was being followed up in the near future with a training session to consolidate staff knowledge. Standard 16 was assessed as met at the last inspection on 5th July 2005. Admirals Reach Residential & Nursing Home DS0000015345.V279686.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): 20 and 26 The safety of the conservatory and pathways in the garden are improved. Staff are taking steps to improve odour control. EVIDENCE: New blinds and solar film had been installed in the conservatory area, as this part of the lounge had become excessively hot on some days in the summer months. Uneven paving stones in the garden had been re-laid. One chair with very dirty armrests was seen. Two recliner chairs had very damaged armrests. The manager said that the chairs had only been purchased about six months previously, and said that the residents had caused the damage. The home was generally clean but odour control was not so good as at the last inspection. The manager said that the carpets had only been cleaned the previous night, but she would make sure that carpet cleaning was repeated on the day of the inspection. Standards 19, 21 and 24 were assessed as met at the last inspection on 5th July 2005. Admirals Reach Residential & Nursing Home DS0000015345.V279686.R01.S.doc Version 5.1 Page 16 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 Staffing levels have been increased and staff are now more able to meet residents’ needs. EVIDENCE: Staffing levels had been increased from 6 to 7 staff on the morning shift since the last inspection, and this had resulted in improvements in the supervision of residents and in the assistance provided at mealtimes. Standards 28 and 30 were assessed as met at the last inspection on 5th July 2005, and standard 29 was assessed at the inspections of Nelson and Mountbatten Houses on 10th and 30th January 2006. Admirals Reach Residential & Nursing Home DS0000015345.V279686.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 The quality of care and services are regularly monitored. EVIDENCE: The home has a quality assurance programme with systems in place to regularly monitor the quality of services and care. A number of staff had completed a “personal best” course. The course encourages staff to reflect on the care and services they provide, and to identify areas where they can improve and provide their personal best. One member of staff said that the personal best and dementia care courses had helped them to provide more resident centred care. Standards 31, 36, 37 and 38 were assessed as met at the last inspection on 5th July 2005. Standard 35 was assessed as met at the inspection of Benbow House on 6th February 2006. Admirals Reach Residential & Nursing Home DS0000015345.V279686.R01.S.doc Version 5.1 Page 18 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X 3 X X X X X 2 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X X Admirals Reach Residential & Nursing Home DS0000015345.V279686.R01.S.doc Version 5.1 Page 19 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 OP7 Regulation 15 Requirement Timescale for action 23/01/06 2. OP9 13(2) 3. OP12 16(2)(m) (n) The registered person must ensure that the condition of the wound is recorded at each dressing change, and ensure that the care plans have a monthly evaluation of care and care needs from the resident’s point of view. This has been a requirement in a previous report – timescale of 05/07/05 not met. 23/01/06 The registered person must ensure that preparations with a limited shelf life are dated on opening and discarded within the recommended timescale, and ensure that regular stock checks are carried out and out of date medicines discarded. Informed at the time of inspection. This has been a requirement in a previous report – timescale of 05/07/05 not met. 23/01/06 The registered person must ensure that there are activities on a daily basis. Informed at the time of inspection. This has been a requirement in previous reports – timescales of 01/08/04, 01/11/04 and 05/07/05 not met. DS0000015345.V279686.R01.S.doc Version 5.1 Admirals Reach Residential & Nursing Home Page 20 4. OP12 16(2)(m) (n) 5. OP18 13(6) 6. OP26 23(2)(d) The registered person must 23/01/06 ensure that the role of the activity coordinator is covered when they are absent or on leave. Informed at the time of inspection. This has been a requirement in a previous report – timescale of 05/07/05 not met. The registered person must 01/04/06 confirm that all staff have completed training in the protection of vulnerable adults. The registered person must 23/01/06 ensure that armchairs are cleaned on a regular basis, and ensure that the frequency of carpet cleaning on Jellicoe House is reviewed, and that staff are able to respond flexibly to need. Informed at the time of inspection. 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 OP20 Good Practice Recommendations The registered person should consider alternative methods of protecting armchairs, where residents regularly damage the surfaces. Admirals Reach Residential & Nursing Home DS0000015345.V279686.R01.S.doc Version 5.1 Page 21 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.V279686.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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