Inspection on 27/02/07 for Aegel House

This inspection was carried out on 27th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Aegel House 21/09/07

Aegel House 24/08/06

Aegel House 07/02/06

Aegel House 05/07/05

Aegel House 04/01/05

Aegel House 24/06/04

Aegel House 04/12/03

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Aegel House Burgh Road Aylsham Norfolk NR11 6AS Lead Inspector Ann Catterick Unannounced Inspection 27th February 2007 09:30 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 Aegel House DS0000035120.V332711.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. Aegel House DS0000035120.V332711.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Aegel House Address Burgh Road Aylsham Norfolk NR11 6AS 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) 01263 733171 01263 731456 aegelhouse.socs@norfolk.gov.uk www.norfolk.gov.uk Norfolk County Council-Community Care Ms Molly Swee Tin Lim Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Aegel House DS0000035120.V332711.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 35 Service Users only Older People not falling in any other category Date of last inspection 24th August 2006 Brief Description of the Service: Aegel House is a purpose built, two-storey residential Care Home managed by Norfolk County Council. The Home is situated on the outskirts of the market town of Aylsham and provides care for up to 35 older people. Originally built in 1962 the Home was extensively modernised during 1996/7 and now provides attractive accommodation in mainly single rooms. Aided bathing and toilet facilities are strategically positioned around the building and the Home is well equipped with hoists and handrails, etc. A shaft lift provides assisted passage to the first floor. There are a variety of communal areas dotted around the Home including a small library room. There is a large dining room on the ground floor that leads to a small room used as a shop for the residents where they can make small purchases of toiletries and confectionary. The Home stands in its own extensive grounds, which include a large, secluded garden area to the rear of the premises. The patio area is furnished with very acceptable garden furniture that has been provided by the Friends of Aegal House, who are a very supportive group to the home. A day centre for older people is located within the Home and this is in active use on weekdays. The day centre, which can cater for up to twelve persons each day has its own exterior entrance, facilities and staffing compliment. This area of the building was not inspected, as it does not form part of the residential accommodation. The cost of a placement at Aegal House is £368.72 a week. Aegel House DS0000035120.V332711.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was a key inspection and took place on the 27th of February and was over a period of 8 hours. The registered manager was absent from the home and David Wootton has recently been appointed as the relief manager. Prior to the inspection a pre inspection questionnaire had been sent to the manager for completion and comment cards were sent for service users and their friends and relatives. All comments received were positive. The Pharmacy Inspector completed an independent report and his conclusion was that the outcome in this standard area had improved and the quality for this standard was adequate. On the day of inspection the inspector was able to speak with service users, staff, make a tour of the building and inspect files, documents and policies. All service users and staff were very positive about living and working in the home and the overall quality of care provided was good. What the service does well: All service users spoke very positively about the care provided in the home saying that staff were kind and supportive, offering care in a dignified and respectful way. Staff working in the home are caring and competent and able to provide a good quality service to service users. Aegel House DS0000035120.V332711.R01.S.doc Version 5.2 Page 6 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. Aegel House DS0000035120.V332711.R01.S.doc Version 5.2 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 Aegel House DS0000035120.V332711.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prior to admission the needs of prospective service users are assessed to ensure that the home will be able to meet need. Those service users living in the home at the time of the inspection were having their assessed needs met. The home does not provide intermediate care. Aegel House DS0000035120.V332711.R01.S.doc Version 5.2 Page 9 EVIDENCE: Prior to a service user being admitted to the home the manger receives an assessment from the placing social care worker. A member of the senior team would also visit the prospective service user in their own home or invite them into the home to enable an independent assessment to by made to ensure that the home would be able to provide for their needs. The assessments of service users recently admitted to the home were inspected and had all relevant information. A service user who had recently been admitted to the home was spoken to and she confirmed this process and felt that her needs were being met in the home. Comment from service user “I couldn’t be better looked after.” “Wouldn’t be anywhere else.” Aegel House DS0000035120.V332711.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The new care plan format sets out the individual needs of service users making this a good working document enabling carers to care for individuals in a way that meets their needs and preferences. Those service users living in the home seemed to be having their health needs met. This view was supported by local health professionals. The home has made improvement to its medicine management practices safeguarding the health and welfare of residents. Staff were seen to interact with service users in a way that promoted dignity and respects privacy. This enables service users to feel comfortable with the way they were being cared for. Aegel House DS0000035120.V332711.R01.S.doc Version 5.2 Page 11 EVIDENCE: The home now has a new care plan format and this had made a significant improvement to the care plans. Each care plan has a front page with a picture of the service user and all relevant information that may be needed at a glance. Care plans seen had a good social history and recent history that informed the reader of how the service user came to be in their present placement and what significant events or people they had been involved with within their earlier life. The personal plan aims to be person centred and evidence of this was seen within the care plans. For example whether or not a resident preferred her bedroom door open or shut, preferences about where they would wish to take their meals and at what time they would wish to go to bed. Nutritional information was included and service users weight and well being is monitored. Service users spoke of getting support from the local community health staff. Feedback from health services was positive. For example, “provide a caring supportive environment for residents.” A medical profile was included and information regard medication. Risk assessments were seen where appropriate with information with regard any falls. An independent pharmacy inspection took place alongside the key inspection and the pharmacy inspector concluded that the home continues to show significant improvement in this area with the homes policy and procedure aiming to ensure safe practice. One requirement was made within the pharmacy report and all other previous requirements had been met. Staff were observed working with service users in a way that promoted dignity and respected privacy. . For example, within a care plan clear instruction were given as to how to give a service user with sight impairment her medication in a way that they felt in control and empowered. Comments from service users “The district nurse comes and looks after my ulcerated leg.” “I like to lock my bedroom door as this gives me privacy.” “Respect is a very important word and I feel respected here.” Aegel House DS0000035120.V332711.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The lifestyle for service users has improved with more activity and stimulation offered during the day. Family and friends are always made welcome in the home and service users can make day to day decision on how they spend their time and the general pattern of their day. Food is provided in comfortable surroundings and appears to be appetising and nutritious. Service users were seen to enjoy their midday meal and this seemed like a social occasion. Aegel House DS0000035120.V332711.R01.S.doc Version 5.2 Page 13 EVIDENCE: The home now has a carer who takes particular responsibility for the activity programme within the home. Staff felt that there has been significant improvement in this area and that they now had more time to spend with service users. Service users spoken to were mostly satisfied with the activities that took place. Some commented that they had made biscuits the previous day and were planning to make gingerbread the following week. Service users said that they could meet with their visitors in private and that family and friends were always welcomed in the home. Service users spoken to said that they were in control of their day to day lives and could make choices of how they spent their days. Service users said that they could rise and retire when they wished, eat their meals in their rooms or in the communal areas and become involved, or choose not to become involved in any social activity within the home. Positive feedback was given about the food within the home. The dining area is large and airy and service users were able to eat their lunch in an unrushed way. Service users are able to choose what they want for lunch on the day that they eat it. Food looked appetising and nutritious on the day of inspection. The inspector was able to speak with the cook who said the home now keeps to the menu to ensure variety and a balanced diet. Comments from service users “My relatives have been invited for lunch.” “Food is alright.” “Not much goes on here.” “I have help with my bath and all my clothes are washed here.” “Respect is an important word and I get that here.” Aegel House DS0000035120.V332711.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a clear complaints procedure that is displayed in the home and part of the service users guide. This gives service users and their families the information they would need if they chose to make a complaint. The home has a policy and procedure to follow to enable the protection of service users. EVIDENCE: Over the past 12 months four complaints have been made and two of these were substantiated. The home has a clear policy and procedure and evidence was seen that the home follows the correct procedures. Staff have received training around safeguarding adults and all staff spoken to were clear that they would always report poor practice to the manager and if it was not addressed at this level would go to the manager’s line manager. All service users felt that they were treated well by staff. Comment from staff “I would always report poor practice.” Comment from service user “I have never had to make a complaint.” Aegel House DS0000035120.V332711.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Since the last inspection there have been improvements to the environment. The home offers service users a comfortable place to live. The home was clean and free from any offensive odours. EVIDENCE: The manager was expecting a property inspection later in the week and assumed that at this inspection areas for improvement would be identified. Since the last key inspection there has been several improvements to the environment. The laundry room, smoking room and two bedrooms have been redecorated and new carpet has been laid in the smoking room. There are plans to decorated two further bedrooms and the dining room. A bath had been awaiting repair and this is now in working order. Aegel House DS0000035120.V332711.R01.S.doc Version 5.2 Page 16 One service user spoke of the garden area saying that this was very pleasant in the summer months. The home was clean and tidy making a comfortable environment for service users to live. Comment from staff “Have been some improvements in the environment.” Comments from service users “Would not be anywhere else, I like my room.” “Not too bad but not like your own home.” “In the summer you can get out in the grounds most days and we have a summer house.” Aegel House DS0000035120.V332711.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home employs sufficient numbers of trained staff to meet the needs of service users. The home has safe recruitment and selection procedures to ensure that the service users welfare is protected. Staff are given training to enable them to fulfil their role and offer a good service to service users. EVIDENCE: Staff spoken to felt that there had been a significant improvement in the home over recent months and the temporary manager who had been in the home until very recently had motivated and encouraged staff to be feel positive in their roles. The home now has a new temporary manager who aims to continue in the same way. Aegel House DS0000035120.V332711.R01.S.doc Version 5.2 Page 18 All coordinator posts have now been filled and this has made the rota much easier to cover as less ‘acting up’ is needed. The home still uses some agency staff but much less than previously and the staff moral was now good. Staff files were inspected and all of the documents and information needed, prior to appointment, were collated prior to the employee commencing work. Files included statements of terms and conditions. Staff received training although some of the new staff were not clear about what the common induction standards are. It was also disappointing that some staff have to wait several months before being offered a place on the induction training programme. A recommendation has been made in this area. The home needs to encourage staff to complete NVQ level 2. A recommendation has been made in this area. All of those service users spoken to were very complimentary about staff saying that they were kind and helpful. Comments from service users “I am pleased I came and couldn’t be better looked after.” “Wouldn’t be anywhere else.” “Pretty well cared for.” “Staff are very busy.” “Not sure if I have a keyworker.” Comments fro staff “I have not heard of common induction standards.” “We have a good staff team.” “Would be happy to do my NVQ level 2.” “Plenty of training available.” Aegel House DS0000035120.V332711.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manger for the home has been on sick leave for some time however it appears to have been well managed by the temporary managers. The home has a way of monitoring the quality of care provided and this ensures that all aspects of care provided are monitored to ensure that the service users needs are met. Any service user’s money that is cared for by the home is done in a way that safeguards their interests. The health and safety of service users is protected by the policies and procedures within the home. Aegel House DS0000035120.V332711.R01.S.doc Version 5.2 Page 20 EVIDENCE: Whist the registered manager has been on sick leave the County Council have provided temporary cover. This appears to have worked well and all staff spoke very positively about the temporary manger who was in post for six months. She has recently left and another temporary manager is now in post. The quality of the care provided suggests that the home is well managed. The local authority has a clear format for the collation of information to enable them to monitor the quality of the service being provided. This includes questionnaires to service users, their relatives and other interest parties. Regular regulation 26 visits take place and copies of these are sent to the Commission. The home looks after some monies for most residents and this was spot checked and found to be in order. All deposits and money taken out was clearly documented with two signatures, one being the service users wherever possible. Staff receive regular supervision. This has improved significantly for care staff since all of the care coordinator posts have been filled. All staff receive training relating to manual handling, first aid, food hygiene, fire safety and infection control. Evidence of this was seen on file and spoken of in discussion with staff. Risk assessments were seen on file and safety posters are displayed in the home. Incidents and accidents are recorded and regulation 37 forms are completed when appropriate. All staff receive induction training although they sometimes have to wait for some time to start the common induction standards. A recommendation has been made in this area. Comments made by staff “I have had supervision.” “Staff morale is up.” “We are now on top of things, have been supported by the manager.” “Manager has been excellent and very supportive.” Aegel House DS0000035120.V332711.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 3 x 3 Aegel House DS0000035120.V332711.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 OP28 OP30 Good Practice Recommendations It would be good practice to ensure that care staff are encouraged to complete NVQ level to as the percentage of staff with this qualification is less than recommended. It would be good practice if the time between commencing work and being offered the induction course was as little time as possible as for some this was several weeks or months. 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