CARE HOMES FOR OLDER PEOPLE
Admirals Reach Residential & Nursing Home Ridgewell Avenue Chelmsford Essex CM1 2GA Lead Inspector
Andrea Carter Mountbatten House - Unannounced Inspection 30th 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.V284338.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.V284338.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.V284338.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 19th October 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.V284338.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place on one day. Fieldwork included discussion and interviews with staff, service users and the registered manager. The inspection took for a total of 4.5 hours and sampling of files was undertaken. Individual service user’s care plans were case tracked and associated documentation was observed. A full tour of the premises was undertaken and discussion with the home manager and the senior staff on duty also formed part of the inspection process. A total of twelve NMS were focused on; with nine standards being met, and two with minor shortfalls. What the service does well: What has improved since the last inspection?
The home has undertaken refurbishment work in the areas identified in the last inspection. A bathroom has had its shower seat and grab rail replaced. Staining to the bathroom floor had been rectified. Admirals Reach Residential & Nursing Home DS0000015345.V284338.R01.S.doc Version 5.1 Page 6 The home has cleaned thoroughly the area of slime in the sluice room and it is now presented to an appropriate standard. 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.V284338.R01.S.doc Version 5.1 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.V284338.R01.S.doc Version 5.1 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): 1 5 and 6 The home’s admission procedures and care planning ensures that service users are sure their needs can be met. The service does not currently provide intermediate care. EVIDENCE: Since the previous inspection the home has ensured that service users and their families are involved in the care planning process. Two individual service user files were case tracked and evidenced in depth information around assessment both prior to and during the admission process. Care plans contained consent forms signed by individuals to indicate their agreement and consent to specific areas of their individual plans of care. The documentation within the each care plan clearly identified when a transitional period of assessment was completed and a permanent placement had been offered to an individual. Admirals Reach Residential & Nursing Home DS0000015345.V284338.R01.S.doc Version 5.1 Page 9 Admirals Reach Residential & Nursing Home DS0000015345.V284338.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 10 The service users health, personal and social care needs are set out in an individual plan of care. Service users feel they are treated with respect and their right to privacy is upheld. EVIDENCE: Care plans of individual service users were case tracked and reflected clearly their ongoing involvement within the care planning process. The individual and their relatives sign the documents. There is a regular review of the care plans and documents evidenced this. These took place on a monthly basis focusing on general issues. A full review took place on an annual basis, which included risk assessments. Two service users were interviewed; one individual had resided within the service for a period of five years, and stated that they “loved living at the home.” They felt the staff were good, but at times communication could present as a problem due to individuals accents. They liked the fact that they could “do as they liked”. The assistance they received with their personal care was not consistent, as on occasions the workload of staff meant the individual
Admirals Reach Residential & Nursing Home DS0000015345.V284338.R01.S.doc Version 5.1 Page 11 had to achieve this task themselves with difficulty. The individual had their own phone within their room, and contacted their family regularly. They purchased and wore all their own clothing and felt the laundry system was acceptable A second individual interviewed, also outlined their concern in relation to the ratios of staff on duty, as they often had to wait for care and support to be given. They found staff to be “kind and helpful”. Regular contact was maintained with family members. A general practitioner held monthly surgeries within the unit, and additional visits were made as and when individual need required this. Admirals Reach Residential & Nursing Home DS0000015345.V284338.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): 15 Service users receive a wholesome, appealing balanced diet. This is served within pleasing surroundings at times convenient to individuals EVIDENCE: Two individual service users were interviewed. One spoke of the food being first class, and was asked daily what they would like, with there being several options for each meal. The second individual felt that the menu could be monotonous and more variety would be preferable. They felt the reintroduction of service user meetings would an appropriate forum to convey their views. On the day of the inspection, the lunchtime meal was observed. There was a calm and relaxed atmosphere within the dinning room. A variety of fruit juices were offered to accompany individual’s meals and this was complemented by the variety of food being served. Discussion with two individuals outlined that there was a good variety of food on offer daily. Breakfast commenced at 7:40am and consisted of a cooked meal with a range of cereals, fruit juice and porridge. The lunch and evening meal options are discussed the previous day and menus displayed on a white board located within the dinning room. Alternatives can be requested and each mealtime always has a vegetarian option available. The evening meal is a lighter option, with soup and rolls, sandwiches as examples.
Admirals Reach Residential & Nursing Home DS0000015345.V284338.R01.S.doc Version 5.1 Page 13 Admirals Reach Residential & Nursing Home DS0000015345.V284338.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 Service users are protected from abuse EVIDENCE: The service had an appropriate policy in place that protects the individual from abuse. Training records evidenced that all staff had undertaken appropriate training in this area. Booklets supporting this training were issued to staff as part of their induction. Appropriate checks were undertaken on staff prior to employment. Admirals Reach Residential & Nursing Home DS0000015345.V284338.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): 26 The home is generally clean and hygienic. EVIDENCE: The previous inspection identified specific areas for the home to address The home had undertaken appropriate cleaning in the sluice room. The replacement of the grab rail and toilet seat had improved the overall presentation of one of the bathrooms. One of the bathrooms required further cleaning as the skirting boards and edges of the vinyl floor were dirty in their presentation, also the mirror located to the wall of the bathroom was broken. Admirals Reach Residential & Nursing Home DS0000015345.V284338.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 28 29 30 The skill mix of staff generally meets Service users needs, however there is concern that individuals’ needs are not always met due to lack of staff. Staff have appropriate qualifications and service users are supported and protected by the homes recruitment policy and associated practices. Staff are trained and competent to do their jobs. EVIDENCE: Sampling of the staff rota indicated that currently each daytime shift has five staff on duty. One of which is a qualified nurse. The waking night staff are identified as one senior and two carers on duty during the nighttime hours. The domestic staff covers seven days per week; between the hours of 9:30am to 6:30 pm daily; on a rota basis. The manager has developed a full training programme for staff that clearly demonstrates the homes commitment to induction and training. Two staff member files were case tracked Both files contained all relevant documentation; which included evidence of all mandatory training undertaken and completed with appropriate certification. Currently one senior staff has completed and achieved their NVQ level III. Five staff have completed and achieved their NVQ level II. There are a further four staff who have commenced the Level II.
Admirals Reach Residential & Nursing Home DS0000015345.V284338.R01.S.doc Version 5.1 Page 17 Individual staff files evidenced that the home’s recruitment policy and associated procedures ensures that staff are appointed through a robust systems that ultimately helps to ensure the protection of the individual, and adheres to the National Minimum Standards. Admirals Reach Residential & Nursing Home DS0000015345.V284338.R01.S.doc Version 5.1 Page 18 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): 31 Service users live in a home that is run and managed by a person who is fit to be in charge. They are of good character and able to discharge their duties and responsibilities in full. EVIDENCE: The current registered manager has been in post since 2001.They have a solid knowledge base, in relation to the service provision and the individuals whom reside within it. The manger has undertaken periodic training and has a wide range of experience in relevant areas. Diploma in management, Mentor D32/33,Train the trainers qualification, as examples. The job description clearly outlines the specific role and responsibilities for this post. There is regular contact with the operations manager; on a weekly basis.
Admirals Reach Residential & Nursing Home DS0000015345.V284338.R01.S.doc Version 5.1 Page 19 A full home inspection undertaken on a monthly basis, which includes the regulation 26 visits. Formal supervision takes place on a 3 monthly basis. Admirals Reach Residential & Nursing Home DS0000015345.V284338.R01.S.doc Version 5.1 Page 20 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 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 2 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 3 X X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X X Admirals Reach Residential & Nursing Home DS0000015345.V284338.R01.S.doc Version 5.1 Page 21 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 OP10 Regulation 18(1)(a) Requirement The registered manager must ensure that there are appropriate numbers of staff working at the home to support individual service users with their personal care needs. The registered manager must ensure that the bathroom floor is cleaned to an appropriate standard and that the broken miror is replaced. The registered manager must ensure that the ratio of staff is appropriate to meet the individual needs of service users Timescale for action 30/04/06 2. OP26 23(2)(d) 30/04/06 3. OP27 18(1)(a) 30/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP15 Good Practice Recommendations The registered person should reintroduce service user
DS0000015345.V284338.R01.S.doc Version 5.1 Page 22 Admirals Reach Residential & Nursing Home meetings as a forum to enable individuals to express their personal preferences relating specifically to their diet. Admirals Reach Residential & Nursing Home DS0000015345.V284338.R01.S.doc Version 5.1 Page 23 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
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