Inspection on 07/02/06 for Aegel House

This inspection was carried out on 7th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Aegel House 21/09/07

Aegel House 27/02/07

Aegel House 24/08/06

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 Mrs Marilyn Fellingham Unannounced Inspection 7th February 2006 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.V281126.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. Aegel House DS0000035120.V281126.R01.S.doc Version 5.1 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 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.V281126.R01.S.doc Version 5.1 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 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, with a bowling green; this is overlooked by a patio area. 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. Aegel House DS0000035120.V281126.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over three hours. Opportunity was taken to tour the home, speak with some service users and staff. Care and staff records were examined. An immediate requirement was made in relation to the safe handling of medication. What the service does well: What has improved since the last inspection? What they could do better: Aegel House DS0000035120.V281126.R01.S.doc Version 5.1 Page 6 Although the care planning has improved there are still areas that need to be addressed; records of evaluation are still absent from many of the care plans. Service users health care needs are not yet fully met, skin integrity assessments are still not carried out. The care plans lack records in relation to changes in care and it is difficult to monitor significant changes and follow a paper trail of events. The home could better manage the handling, administration and disposal of medication to ensure safety at all times. The home could improve its recording of medicines that have been administered or destroyed, many areas on the MAR charts were blank. The internal environment needs to be re decorated as many of the walls had areas where the paintwork was flaking or had signs of mildew. The home could improve its risk assessment strategy particularly for the individuals who smoke. The home could ensure all areas of the home are monitored in relation to infection control so that clinical waste bins are not left in the corridor. Training records need to be kept up to date. 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. Aegel House DS0000035120.V281126.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 Aegel House DS0000035120.V281126.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): No standards assessed. EVIDENCE: Aegel House DS0000035120.V281126.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9. Some improvement has taken place to ensure that the health care needs of the service users are identified, met and evaluated; however there are still areas that lack evaluation and changes in care. These shortfalls have the potential to place the service users at risk. The handling, administration and the disposal of medication is not managed well. EVIDENCE: Six care plans were examined and the Inspector noted that there had been some improvement in this activity since the last inspection. However it was noted that they still lacked detail and records of evaluation and significant changes in care. The care plans gave no indication that the service users skin integrity is assessed or if there is a risk involved in relation to the development of pressure sores. The care plans did record all professional visits by other agencies and records for this were good. Aegel House DS0000035120.V281126.R01.S.doc Version 5.1 Page 10 The administration of medication is not managed well and this in itself has the potential to place the service users at risk. The MAR charts were examined, these lacked many signatures in relation to if a medication had been given or refused; this made it difficult for the medication to be audited satisfactorily and this also has the potential to open up the field for errors to be made. Further examination of the MAR charts revealed that those tablets left in the blister packs and bottles did not tally with what had been recorded as having been given. It was also noted that there were vast discrepancies in relation to Warfarin calculations and references to the INR; for example one service user’s INR result indicated that 3 mgs should be given for 2 weeks, however the MAR chart indicated and showed it to be given for just five days and some days there were no signatures relating to the administration of this medication and if not given has the potential to once again put the service users at great risk. During the inspection process the Inspector noted that medication is not disposed of in a safe or acceptable manner and when questioned, the staff stated that they threw the discarded medication down the sink. This is a most unsafe and inappropriate way to dispose of medication and an immediate requirement was issued to ensure that this practice stopped immediately. One service user had been prescribed Chloramphenicol eye ointment, but there was no record of this ever having been applied. Too much stock was held and some had been reordered unnecessarily, a recommendation is made to encourage the staff to be more vigilant in their ordering system to reduce unnecessary amounts of medication being held at any given time. Training records were seen for all those members of staff who are responsible for the administration of medication, it was noted that they were in receipt of certificates to say they had attended training sessions for this. A requirement is made to ensure further training takes place so that all service users are protected and safe. Aegel House DS0000035120.V281126.R01.S.doc Version 5.1 Page 11 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): No standards assessed. EVIDENCE: Aegel House DS0000035120.V281126.R01.S.doc Version 5.1 Page 12 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 could be better protected from abuse. EVIDENCE: Inspection of training records and discussion with staff revealed that not all staff members had received training in matters related to the protection of vulnerable adults. This lack of training has the potential to put service users at risk and a requirement is made. Aegel House DS0000035120.V281126.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26. Service users do not live in a well-maintained environment. The service users rooms were clean and tidy. EVIDENCE: During a tour of the home the Inspector noted that many areas were in desperate need of re decoration. Many of the walls had paint pealing away from them and some showed evidence of mildew. A requirement is made. One area behind the dyers in the laundry room was found to be dirty the pipes were very dusty and constituted and infection hazard; the room itself was in need of re painting. Many of the internal window frames around the home, need re painting. The carpet in the smoking room is covered in burn holes, as was the table that was in the room it looked unsightly and very unpleasant for visitors. Aegel House DS0000035120.V281126.R01.S.doc Version 5.1 Page 14 The Inspector also noted during the tour of the home a clinical waste bin that was kept outside the clinical room in the corridor: she was informed by the staff that this was at the behest of the community nurses. This is an unacceptable practice and a considerable risk to the safety of residents especially in relation to the control of infection; a requirement is made. One of the downstairs bathrooms had a damp area on its wall and the shelves in all bathrooms were littered with tins of talcum powder and body creams; this is an unsafe practice and can contribute to hazards in relation to infection control. It was noted that there was no lampshade in the lounge opposite the office. Aegel House DS0000035120.V281126.R01.S.doc Version 5.1 Page 15 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): 27,29. The numbers, or skill mix of the staff does, not always meet service user’s needs. The service users are protected by the home’s recruitment policies and practices. Training records need to be updated. EVIDENCE: The manager explained to the Inspector that recruitment does pose a problem for the home and staffing levels could be much better. Agency staff have been used and these might not always possess the skills and qualifications appropriate to meeting the needs of those service users in residence. The home tries as far as possible to use the same agency staff so that there is some continuity of care. Examination of the duty rosters confirmed the use of agency staff; the home was adequately staffed on the day of inspection and those service users spoken to did not feel that their care was in any way compromised. The main office carries out recruitment, for social services, all recruitment records and required checks were found to be in order. The training records that were inspected highlighted that there is room for further training of staff so that they all possess the skills needed to care for Aegel House DS0000035120.V281126.R01.S.doc Version 5.1 Page 16 those service users living at Aegal House; as mentioned before these records also need to be kept up to date and relevant to those persons employed at the home. Aegel House DS0000035120.V281126.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,35 It would appear that the home is run in the best interests of the service users. The financial interests of the service users are safeguarded by the home’s policies and practice. EVIDENCE: The home has commenced a monitoring of quality system; records were seen for surveys that had taken place also action plans in relation to various concerns and improvement of care. The system needs to be developed further with more detailed action plans in place. The home hols small amounts of cash for service users, transactions for this were seen and found to be in order. Auditing of this money takes place and records were seen for this. Aegel House DS0000035120.V281126.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 X 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 x COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X x Aegel House DS0000035120.V281126.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement The registered person shall prepare a written plan as to how the service users needs in respect of his health and welfare are to be met and keep the plan under review Then registered person shall ensure that unnecessary risks to the health and welfare of service users are identified and so far as possible eliminated. The registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The registered person shall make arrangements, by training or by other measures to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. The registered person shall make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home. Timescale for action 02/02/06 2. OP8 13 02/02/06 3 OP9 13 (2) 02/02/06 4 OP18 13 (6) 02/02/06 5 OP19 13 (3) 02/02/06 Aegel House DS0000035120.V281126.R01.S.doc Version 5.1 Page 20 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. 3 Refer to Standard OP30 OP19 OP27 Good Practice Recommendations It is recommended that records are produced and maintained for training purposes. It is recommended that the home is well-maintained. It is recommended that consideration is given to the deployment of more staff. Aegel House DS0000035120.V281126.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Aegel House DS0000035120.V281126.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!