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Inspection on 27/09/07 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

Information about the home is readily available so that people can decide as to whether the home is suitable. Staff carry out a detailed assessment of a persons needs before they are offered a place at the home. Each person living in the home has a care plan, which describes the care, and support that they need. Staff review this information regularly so as to ensure that the plan of care is effective. Staff assess risks to residents health and safety and devise plans to minimise these risks. Residents have access to medical treatment and staff ensure that they receive medicines as prescribed. The majority of people living in the home feel that staff listen to them and act on what they say. The home is clean and comfortable and equipment such as hoists and pressure relieving cushions and mattresses are available as needed. Staff receive ongoing training and are supervised so as to promote consistency in the care provided to residents. Most people who were spoken with or who completed surveys are generally happy with the service provided by staff working at the home.

What has improved since the last inspection?

Most of the requirements made at the previous inspection had been met. There have been improvements in the way that information is recorded about residents. Staff now ensure that medicines are stored safely. The home is now kept clean and equipment is checked regularly and repaired as required. Staff now undertake a period of induction and training so as to be able to provide care and support for residents.

What the care home could do better:

Activities at the home are not meeting the needs of all the residents. The standard of the meals service needs to improve in relation to both serving and quality. The staff team need to ensure that individual choices are available at mealtimes. They need to improve the cleaning and/or replacement of carpets in the home and ensure that there are no unacceptable odours. Staffing levels need to be kept under review and the manager must ensure that there is sufficient cover so that residents` needs are met. Staff should be recruited more consistently so as to help safeguard residents.

CARE HOMES FOR OLDER PEOPLE Admirals Reach Residential & Nursing Home Ridgewell Avenue Chelmsford Essex CM1 2GA Lead Inspector Carolyn Delaney Unannounced Inspection 27th September 2007 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.V341382.R01.S.doc Version 5.2 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.V341382.R01.S.doc Version 5.2 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.V341382.R01.S.doc Version 5.2 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 25th May 2004 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. The central services building include administration, laundry, kitchen a hairdressing facility. There is a spacious car park. The home is situated approximately one mile from Chelmsford and within walking distance of the bus service. Nelson House is registered for up to 30 residents over the age of 60 years, and including up to five residents over the age of 40 who have a physical illness/disability. All residents are Nelson House are accommodated in single bedrooms with ensuite facilities. The majority of rooms overlook the Admirals Reach Residential & Nursing Home DS0000015345.V341382.R01.S.doc Version 5.2 Page 5 landscaped gardens. Nelson House has a dining room and four different sitting areas to meet individual needs. Mountbatten House is registered to provide care for up to 30 service users aged over 65 and those who need nursing care because of a physical disability. All residents have a single en-suite room. Mountbatten house has four communal rooms plus a dining room. The unit is surrounded by landscaped and accessible open space. Jellicoe House is registered to provide nursing care for up to 30 residents over the age of 65 years with dementia. All residents are accommodated in single bedrooms with en-suite facilities. The unit has its own lounge and dining areas. The majority of rooms overlook the gardens. Benbow House is registered to provide nursing care for up to 30 residents over the age of 65 years with dementia. All residents on Benbow House are accommodated in single bedrooms with en-suite facilities. The majority of rooms overlook the gardens. Benbow House has its own sensory room, a small lounge used for smoking, a quiet lounge and a large lounge dining area. The current weekly fees, dependent up on needs and facilities are Residential Care (from) £550 per week and Nursing Care (from) £700 per week. This information was provided by the registered manager. Additional fees relate to hairdressing, chiropody, personal toiletries and newspapers. The home has a statement of purpose and service users guide available. Admirals Reach Residential & Nursing Home DS0000015345.V341382.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was routine key inspection. As part of the inspection process an unannounced visit was made to the home. During this visit residents, relatives and staff were spoken with and a number of records such as care plans, staff records and information about how the home is managed and maintained were assessed. A brief tour of the home was carried out and communal areas such as dining rooms and lounge areas were viewed as well as a number of residents bedrooms. Prior to the inspection visit the manager provided the Commission with a copy of their Annual Quality Assurance Assessment (AQAA). This document included information as to what they do well, what could be done better and what needs improving. As part of the inspection process a number of residents and relatives were offered the opportunity to make comment about the home by completing ‘Have your say about…’feedback surveys. All but one of the key standards were assessed during this inspection. What the service does well: Information about the home is readily available so that people can decide as to whether the home is suitable. Staff carry out a detailed assessment of a persons needs before they are offered a place at the home. Each person living in the home has a care plan, which describes the care, and support that they need. Staff review this information regularly so as to ensure that the plan of care is effective. Staff assess risks to residents health and safety and devise plans to minimise these risks. Residents have access to medical treatment and staff ensure that they receive medicines as prescribed. The majority of people living in the home feel that staff listen to them and act on what they say. The home is clean and comfortable and equipment such as hoists and pressure relieving cushions and mattresses are available as needed. Staff receive ongoing training and are supervised so as to promote consistency in the care provided to residents. Most people who were spoken with or who completed surveys are generally happy with the service provided by staff working at the home. Admirals Reach Residential & Nursing Home DS0000015345.V341382.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Admirals Reach Residential & Nursing Home DS0000015345.V341382.R01.S.doc Version 5.2 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.V341382.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information about the home and the assessment process assure residents that the home will be able to meet their needs. EVIDENCE: There is a detailed statement of purpose document, which clearly describes the aims, and objectives of the home and the range of services provided. In addition each person and or their relatives are provided with a copy of the homes service users guide which describes life in the home and gives detailed information about areas such as laundry service, meals, opportunities for activities and religious services etc. A number of residents care files were assessed and there was evidence that nursing staff had carried out a detailed assessment of each persons’ needs before the person moved into the home. Since the last inspection a new system (QUEST) has been implemented in BUPA homes for recording Admirals Reach Residential & Nursing Home DS0000015345.V341382.R01.S.doc Version 5.2 Page 10 information about residents needs and how they are to be supported. The new pre-admission assessment document allows for a more detailed assessment of people’s needs so that staff can better understand and support residents. Residents and relatives who were spoken with during the inspection visit and those who completed surveys indicated that they had received enough information before the prospective resident moved into the home. The manager’s Annual Quality Assurance Assessment (AQAA) says that prospective residents or their relatives are always offered and encourage to come and visit the home before a decision is made for the person to move into the home. Some people confirmed that they had visited the home and met with staff prior to moving in. Admirals Reach does not provide intermediate or rehabilitative care. Admirals Reach Residential & Nursing Home DS0000015345.V341382.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in Admirals Reach generally receive a good level of care and support and risks to their health and safety are well managed. However staff shortages may impact upon the outcomes for some residents. EVIDENCE: Since the last inspection a new system (QUEST) has been introduced for recording information about each residents needs and the care and support that each individual requires. The care plans for a number of people were sampled from each of the four houses. These were well written with clear details of the care and support each person required so that they can lead full and as far as possible, active lives. The staff team supports a ‘self care’ concept, which encourages residents to remain as independent as they can. Care plans include information about each persons level of capability and preferences in respect activities of daily living such as mobilising and eating and drinking etc. Admirals Reach Residential & Nursing Home DS0000015345.V341382.R01.S.doc Version 5.2 Page 12 Care plans were regularly reviewed and wherever possible the resident or the their relatives have the opportunity to have their views included. Some care plans had evidence that relatives had agreed to and were happy with the care provided by the home. Risks to each person’s health and safety such as risks of developing pressure sores for less mobile residents and risks associated with the use of bedrails, as a preventative measure to minimise falls, were clearly assessed. Where risks were identified there were detailed plans in place so as to minimise these. There were detailed management and treatment plans for people who have pressure sores and these were monitored closely so as to ensure that treatment is effective. Regular audits are carried out so as to monitor the number of accidents and occurrences of pressure sores. This is done so as to identify any trends and plans to minimise risks to residents. There is a detailed medication policy, which had been recently updated so as to ensure that it meets with current guidelines. The majority of people living in Admiral’s Reach depend upon staff to administer medication. Where a person is capable of and would choose to do so they may retain their medicines and this is recorded in the individuals care plan. Each person living in the home has a care plan developed in respect of his or her medication. These care plans are reviewed regularly so as to determine the effectiveness of the treatment and to identify any issues which may arise. There was evidence that their general practitioner reviews resident’s medication regularly. During the inspection visit nursing staff were observed to administer medicines, which had been prescribed for residents. Medicines were administered at the appropriate times and in accordance with the homes policy. Random samples of Medication Administration Records (MAR) were assessed and in general these were well maintained. However there were a few isolated occasions where staff had failed to sign some resident’s charts when they had administered medicines. Medicines within the home are stored safely and appropriately and there are processes in place so as to ensure that stock levels are maintained. Twenty-four people completed feedback surveys. Of these eleven people said that residents always receive the care and support they need. Some people made very positive comments about the home and staff. One person said that the ‘care staff are ‘excellent’, another person commented that ‘staff are very helpful’ and one person said that after seven years at the home they are ‘very content’. Twelve people said that they usually receive the care and support they need and two of these people commented that shortages of staff affected the level of care and support provided by the home. One person said that they sometimes receive care and support they need. This person also commented that shortages of staff affected the care and support received. Admirals Reach Residential & Nursing Home DS0000015345.V341382.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst there is a programme of activities carried out in the home, not all residents feel that the activities reflect their choices for how they wish to spend their time. The meals service at the home is generally good but does not meet the expectations of all the residents. EVIDENCE: From the homes AQAA we were informed that the programme of activities had been structured to take into consideration the needs and preferences of the people living in the home. The homes system for recording information about residents includes a section for the person’s interests and preferred activities. This section of the care plan was not completed for a number of people whose care files were examined. The homes AQAA acknowledge that documentation could be improved in some areas. Admirals Reach Residential & Nursing Home DS0000015345.V341382.R01.S.doc Version 5.2 Page 14 Activities are planned on a monthly basis and the programme is displayed in each of the houses. Activities provided include bingo, painting, and seated exercises and sing a long. Residents also have access to a sensory room. During the inspection visit residents were observed to participate in quizzes, bingo and seated exercises. All of the residents appeared to enjoy the activities provided. Plans were in place to mark Breast Cancer Awareness month and Jeans for Gene’s day with coffee mornings and raffles. Of the twenty people who answered the question about the provision of activities in the survey five said that there were always activities in the home that they can take part in. Of the remaining fifteen, six said that there usually and the remainder said that there sometimes were. A number of people commented that they did not wish to or were not capable of participating. One relative said that while her father could not participate, that staff spent time with him on a one to one basis. Two people commented that they would like more outings / trips outside of the home. From the AQAA we were told about BUPA’s Personal Best training for staff. This is designed to show staff a resident’s perspective so that staff have a greater understanding of what is like to live in the home and therefore to work in a way which would enhance this experience for residents. As part of the inspection the way in which staff caring for people who have dementia was observed. This was carried out on Benbow house using an assessment tool called Short Observation for Inspection (SOFI). Four residents were observed for a period of two hours. During this time the way that staff interact with residents and how residents respond was observed in periods of five minutes. Generally staff were observed to interact in a positive way with residents. Staff did not appear to have much time to spend with residents. When some staff did speak with residents, they responded positively by looking up and smiling. One member of staff was observed to help a resident a cup of tea. While doing this, the member of staff engaged in a conversation with another resident. In doing this the member of staff was providing the drink the resident too quickly for the resident to swallow comfortably. There is an open visiting policy and relatives who were spoken with said that they were always made to feel welcome in the home. The majority of people who completed surveys said that staff listen and act on what residents say. Some people made positive comments and said that staff were ‘helpful and friendly’ and that ‘staff always take the time to listen’ to residents. A small number of people felt that staff do not always listen to residents and two made the comment that this was due to shortages of staff. The AQAA says that there is a BUPA Menu Master system, which is used so as to ensure that residents receive meals, which are nutritionally balanced. A new Admirals Reach Residential & Nursing Home DS0000015345.V341382.R01.S.doc Version 5.2 Page 15 ‘Night bite’ menu had been introduced, which provides snacks and ensures that food, is available 24 hours a day. The majority of residents who were spoken with during the inspection said that they enjoyed the meals provided by the home. Four people who completed surveys said that they always like the meals provided by the home and one person said that meals were of an ‘excellent standard’. Nine people said that they usually enjoy meals. Eight people said that they sometimes like the food and of these three commented on the lack of fresh vegetables and two said that the food is not always served hot. The latter comments are disappointing as the issue of food not being served hot was highlighted at the last inspection. During both days of the inspection mealtimes were observed on each house. Meals looked appetising and residents appeared to enjoy their food. Alternative dishes were available such as omelettes for residents who did not like or want the choices on the main menu. Residents on Mountbatten and Nelson houses were offered choice of sauces and condiments with their meals. However this is not carried out on Benbow and Jellicoe houses where residents have dementia so as to offer residents the opportunity to make choices about their meals. Admirals Reach Residential & Nursing Home DS0000015345.V341382.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints are dealt with promptly in accordance with the homes policy and residents are generally, but not always safeguarded. EVIDENCE: There is a policy and procedure for dealing with complaints. This is readily available for residents, relatives and any other interested parties and is displayed throughout the home. The AQAA told that all complaints are dealt with within specific timescales and records viewed during this inspection visit confirm this. Records evidence that complaints are dealt with fairly and that where needed a full investigation is carried out and appropriate action is taken to resolve the issues. All of the people who were spoken with during the course of the inspection said that they had not had any cause to make complaint about the home. Eighteen of the twenty people who completed surveys said that they knew who to speak to if they were unhappy about anything and that they knew how to make a complaint. One person indicated that they had had made a complaint and that this had been dealt with to their satisfaction. There have been no complaints made to the Commission in respect of the home since the last inspection. There is a robust policy and procedure for dealing with safeguarding the welfare of people living at the home. Staff receive training in respect of how to Admirals Reach Residential & Nursing Home DS0000015345.V341382.R01.S.doc Version 5.2 Page 17 deal with any issues of inappropriate behaviour towards residents so as to protect residents from abuse. Residents and relatives who were spoken of commented on the caring nature of staff. All staff working at the home receive training for safeguarding residents from abuse, harm and neglect. There have been a number of alerts raised since the last inspection as a result of alleged ‘rough handling’ of residents by some staff and ‘poor attitude’ of some staff. The local safeguarding team investigated these and as a result a number of staff were dismissed from the home. One social care professional who completed a survey commented that staff recruitment could possibly be more robust to minimise these occurrences. It is noted that the manager responded promptly to all allegations and there are plans for staff to receive training provided by the local safeguarding unit. The manager stated in the AQAA that she will access training for staff through the local safeguarding team. Admirals Reach Residential & Nursing Home DS0000015345.V341382.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admirals Reach generally provides a clean, safe and comfortable environment for residents and there are plans for refurbishment and improvement in the future. More could be done so as to eliminate odours where they persist. EVIDENCE: There are dedicated cleaning and maintenance staff employed in the home. The manager said in the AQAA that a specialist micro fibre cleaning system is used, which has reduced the need for the use of chemicals in the home. Eighteen people who completed surveys commented that the home is usually clean and fresh. One person said that the standard of hygiene was ‘very good’. One person commented that there is ‘sometimes a smell of urine’. On the day of the inspection there were some stale odours detected on Jellico & Benbow Houses. There were no odours detected on the other houses. Communal areas and resident’s bedrooms, which were seen, were noted to be Admirals Reach Residential & Nursing Home DS0000015345.V341382.R01.S.doc Version 5.2 Page 19 clean and tidy. Residents are encouraged to bring in personal items and bedrooms, which were viewed, were homely and personalised. Each resident has their own bedroom, which is equipped with ensuite facilities. There are sufficient communal toilet and bathing facilities on each house. Residents in the home have appropriate equipment and aids as required such as pressure relieving mattresses and cushions. Hoists and wheelchairs are checked and maintained regularly. There were no health and safety issues noted during the inspection of the home. Residents who spoke with the inspector were happy with their bedrooms and the communal spaces available to them. Some carpets were noted to be stained, particularly in the communal lounge areas. There are plans for refurbishment and redecoration of the home during the next financial year. From the AQAA we were told that residents have been making more use of the homes sensory room and garden in the past twelve months and that there are plans to create two courtyards within the homes gardens within the next twelve months. Admirals Reach Residential & Nursing Home DS0000015345.V341382.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff at the home are supported by a robust training programme however Staffing levels are not always maintained so as to ensure that resident’s needs are fully met. Shortfalls in recruitment practices may impact upon outcomes for residents. EVIDENCE: The home’s manager advised that staffing levels had been increased following the last inspection and the issues highlighted within the previous inspection report. Staff duty rotas, which were examined confirmed this, however it was noted that these increased staffing levels are not maintained consistently, particularly on Benbow and Jellicoe houses. It is disappointing as these were the houses where shortfalls were identified at the time of the last inspection. The manager stated n the AQAA that more could be done to increase staffing for nursing units. It was positive to note that extra staff are employed on days where residents general practitioners visit to review their care, as these tend to be busier days. A number of people who were spoken with during the inspection visit and those who completed the surveys commented that at times staff shortages impacted upon the care provided by the home. Admirals Reach Residential & Nursing Home DS0000015345.V341382.R01.S.doc Version 5.2 Page 21 The staff recruitment files for four members of staff who had been employed at the home since the last inspection were assessed. Generally there was evidence that staff are recruited according to a robust process which includes carrying out all of the relevant checks so as to determine that the person employed is suitable to care for people living in the home. Staff were subject to check including PoVA First and Criminal Records Bureau (CRB) disclosures before they were employed at the home. There was evidence for two of the four that an interview had been carried out to determine their fitness to work at the home and satisfactory references had been obtained three of the four. A reference had not been obtained from one person’s previous employer. There was evidence that one new member of staff had undergone a probationary period and that all had undertaken Skills for Care induction training. The potential impact on residents from inconsistent recruitment practices was highlighted by one social care professional. The manager provided a copy of the homes training matrix. There is an ongoing programme of training for staff which includes core training such as safe moving and handling, health and safety, fire safety, and safeguarding people. In addition training in respect of care planning, managing risks, pressure area care, managing bereavement and managing aggression. Records were clear and kept up to date. Records indicate that all staff have received recent updates for core training. Staff who spoke with the inspector said that the receive regular training. From the AQAA we were told that 20 of care staff have achieved National Vocational Qualification (NVQ) level 2 in care and a further 20 of staff were undertaking this training. The manager Admirals Reach Residential & Nursing Home DS0000015345.V341382.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Admirals Reach is generally well managed and the service is monitored and reviewed regularly. But shortfalls in some aspects of the service are affecting the outcomes for residents. EVIDENCE: There have been no management changes since the last inspection. Senior staff are employed on each of the four houses. These senior staff managed the day-to-day running of individual house and report to the home’s manager. The majority of people who were spoken with or who completed surveys indicated that they were generally happy with the home. However the issues with regards shortage of staff remain a concern and it is disappointing that Admirals Reach Residential & Nursing Home DS0000015345.V341382.R01.S.doc Version 5.2 Page 23 staffing levels have not been maintained on Benbow and Jellioce house where residents require a lot of support and supervision. From the homes AQAA we were informed that the home has achieved Investors in People (IIP) accreditation. The manager said that residents and relatives have the opportunity to attend regular meetings so as to discuss any issues or make suggestions about the service provided. Residents may keep monies and items of valuables with them should they choose. The home provides facilities for safekeeping of resident’s monies and records in respect of these inspected and were well maintained. BUPA’s operations manager visits the home regularly to carry out assessments of the home in accordance with Regulation 26 of the Care Homes Regulations and reports in respect of these visits are sent to the Commission each month. There was evidence that staff working at the home receive regular supervision so as to monitor and maintain quality in staff practices. Staff spoken with confirmed that they receive regular supervision and support. Records and certificates in respect of the maintenance, repair and renewal of systems and equipment in the home were examined. These were organised, up to date and evidenced that all equipment including fire safety, gas and electrical installations were maintained in good working order. We were told in the AQAA that regular Health and Safety meetings are held and the home has the back up of the organisations policies, procedures and a team of staff within BUPA’s Quality and Compliance Directorate. Admirals Reach Residential & Nursing Home DS0000015345.V341382.R01.S.doc Version 5.2 Page 24 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 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X 3 X 3 Admirals Reach Residential & Nursing Home DS0000015345.V341382.R01.S.doc Version 5.2 Page 25 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 OP12 Regulation 16(2) (m) (n) Requirement The range of activities provided should be reviewed taking into account the needs and wishes of residents so as to ensure that residents can spend their time how they would choose to. Meals must be served to residents at an appropriate temperature and that more fresh vegetables are provided so that meals reflect resident’s preferences. This requirement is partially outstanding from the previous inspection. 3. OP26 16(2)k Action must be taken to deal with odours where they persist (Benbow & Jellicoe so as to provide a pleasant environment for residents and their visitors. This requirement is outstanding from the previous inspection. 01/04/08 Timescale for action 30/04/08 2. OP15 16(2)i & 18 30/03/08 Admirals Reach Residential & Nursing Home DS0000015345.V341382.R01.S.doc Version 5.2 Page 26 4. OP27 18(1)a Staffing levels must be reviewed and maintained so as to ensure that resident’s needs are met. This requirement is outstanding from previous inspections. 30/03/08 5. OP29 19 (1) (2) Staff must be recruited consistently in line with BUPA’s policy and current regulatory requirements so as to safeguard the people living in the home. 30/03/08 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. 2. Refer to Standard OP15 OP19 Good Practice Recommendations Staff should offer choices of sauces and condiments to residents who have dementia at mealtimes so as to enhance resident’s enjoyment of meals. Carpets need to be replaced in some communal areas. Admirals Reach Residential & Nursing Home DS0000015345.V341382.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V341382.R01.S.doc Version 5.2 Page 28 - 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. 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