Inspection on 08/11/06 for Aigburth

This inspection was carried out on 8th November 2006.

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

Aigburth 27/06/08

Aigburth 13/04/05

Aigburth 03/11/04

Aigburth 05/05/04

Similar services:

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

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

CARE HOMES FOR OLDER PEOPLE Aigburth 21 Manor Road Oadby Leicester Leicestershire LE2 2LL Lead Inspector Joanna Carrington Unannounced Inspection 8th November 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Aigburth DS0000001660.V318314.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. Aigburth DS0000001660.V318314.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Aigburth Address 21 Manor Road Oadby Leicester Leicestershire LE2 2LL 0116 2715086 0116 2714288 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) home.fxg@mha.org.uk Methodist Homes for the Aged Mrs Sarah Haines Care Home 32 Category(ies) of Dementia - over 65 years of age (8), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (8), Old age, not falling within any other category (32) Aigburth DS0000001660.V318314.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service user numbers. No person to be admitted to the home in categories MD(E) or DE(E) when 8 persons in total of these categories/combined categories are already accommodated within the home. 21st September 2005 Date of last inspection Brief Description of the Service: Aigburth care home cares for thirty-two older people in a purpose built property. It is set in a quiet residential area close to a variety of amenities in Oadby town centre. The premises consist of three floors. Residents occupy the ground and first floor and staff members and volunteers occupy the third floor. Access to all three floors is by use of the passenger lift or stairs. There are a variety of aids and adaptations throughout the home to enable residents to be as independent as possible. The home has thirty single bedrooms and one double bedroom all with en-suite facilities. There are gardens accessible to residents at the front and rear of the property. The weekly fees for living at the home range from £427 to £500 per week, dependent on individuals’ needs. Aigburth DS0000001660.V318314.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over eight hours on 8th November 2006. The main method of inspection was ‘case tracking’ which meant selecting three residents and tracking the quality of their care by checking records, discussion with them and with staff and observation of care practices. Four residents were case tracked; three residents and three staff members were spoken with. Information gathered prior to the inspection has also been used to reach judgements about the quality of care. Staff records were looked at and a partial tour of the premises also took place in order to assess environmental standards. The registered manager was available for discussion and feedback throughout. What the service does well: What has improved since the last inspection? Some maintenance and redecoration work on some communal parts of the home and also bedrooms has been carried out since the last inspection. Aigburth DS0000001660.V318314.R01.S.doc Version 5.2 Page 6 No requirements or recommendations were made at 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. Aigburth DS0000001660.V318314.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 Aigburth DS0000001660.V318314.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): 1, 2 and 3 (Intermediate care is not provided at the home) Quality in this outcome area is good. The assessment process is good in identifying residents care needs prior to them moving into the home and there is good information about the home to help people make a choice about moving there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a Statement of Purpose and a brochure that all service users have a copy of, which provides information about the philosophy of the home and what services are provided. It is recommended that the Statement of Purpose be reviewed, to ensure all information is current. Information about the staffing structure was out of date. Residents spoken with confirmed that they signed contracts stating the terms and conditions of their residency, when moving to the home and copies of these were seen on their files. All four residents’ case tracked had assessment documentation on their files, either the placing authority’s community care assessment or a needs-led Aigburth DS0000001660.V318314.R01.S.doc Version 5.2 Page 9 assessment carried out by senior staff at the home, completed before they moved to the home. Aigburth DS0000001660.V318314.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. There are good arrangements in place for meeting the health and personal care needs of residents that upholds their right to privacy and respect. Some improvement to medication management is necessary, to ensure practice is safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans seen indicate that all aspects of residents’ individual health and personal care needs are being attended to. Care plans are reviewed on a monthly basis so that any changes or increases in need are identified. Notifications to the Commission since the last inspection indicated that there have been a high number of falls at the home. There are risk assessments in place for residents’ mobility and for one resident case tracked daily records show that a physiotherapist has been involved and a walking frame provided. The service user when spoken with confirmed this aid has helped her become more independent again. There was some inconsistency noted on relevant care plans and accompanying risk assessments. This must be rectified to ensure the residents safety. Aigburth DS0000001660.V318314.R01.S.doc Version 5.2 Page 11 Daily records show that residents have access to a doctor and other relevant healthcare professionals when needed, which residents spoken with confirmed. Assessment tools are used regularly to monitor continence and risks of developing pressure sores. All of the residents spoken with said that staff treat them with dignity and respect. Staff were observed interacting with residents in a meaningful and respectful manner and staff spoken with gave good examples of how they ensure individuals’ dignity when assisting with intimate care. A staff member was observed signing the Medication Administration Record before actually giving the medicine to the resident. This is not safe practice. Not all quantities of medication are accounted for in the home. The quantities were counted for two boxed medicines, neither tallied with the quantity recorded on the MAR and what has been signed as given. It is recommended that any remaining medication at the end of the cycle be carried forward onto the next MAR, so that there is a clear audit trail. Aigburth DS0000001660.V318314.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. Meeting residents’ recreational needs and maintaining contact with family and friends is managed well in accordance with residents’ wishes. There are good arrangements in place for providing wholesome appealing meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three residents’ spoken with are happy with the recreational activities that on offer at the home. A service user spoken with commented on enjoying the beanbag game and playing magnetic darts. Religious needs are well served both in and outside the home. On the morning of the inspection a local church minister came to the home to hold a service and there are regular trips on Sundays to the local Church service. Daily records indicate that service users have regular visits by their friends and relatives and residents spoken with confirmed that their visitors are welcomed and can be spoken with on the phone in private. Residents spoken with also confirmed that they still feel in control of their own lives. One resident said she continues to vote in local and general elections and all residents confirmed they spend their time as they wish, either with Aigburth DS0000001660.V318314.R01.S.doc Version 5.2 Page 13 others and participating in activities or time to themselves in their own rooms. One resident commented, “I feel safe” and “I come and go as I please”. Dinnertime was observed to be a relaxed affair. Those service users that require assistance eat in another dining area, which promotes their dignity. The meal served on the day of the inspection was a choice of gammon with white sauce or chicken kiev, mashed potatoes with leeks and carrots. Residents spoken with said they enjoy the meals. Questionnaires have been sent out to residents asking them what are their favourite meals and for any suggestions. Aigburth DS0000001660.V318314.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. The complaints procedure and the safeguarding adults procedure are appropriately followed, which ensures all concerns and allegations are taken seriously and acted on. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents spoken with are familiar with the complaints procedure and are content with how any complaints or concerns raised are responded to. Records of complaints show that concerns are taken seriously and investigated, within timescales as specified under the Complaints Procedure. Staff spoken with were given two scenarios and asked what action they would take. All staff responded appropriately and demonstrated that they understand their responsibilities to alert the manager in accordance with safeguarding adults and whistle-blowing policies and procedures. There have been a couple of investigations as a result of allegations made by residents. Records show that Social Services have been involved and there is ongoing support with this resident in line with allegations made. Neither of these investigations was notified to the Commission. Refer to outcome group Conduct and Management in respect of this. Aigburth DS0000001660.V318314.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, 24 and 26 Quality in this outcome area is good. Residents’ surroundings are clean and well maintained, with living space that promotes their independence and suits their needs and tastes. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On a partial tour of the premises it was evident that the home is kept clean and hygienic. The laundry facilities are appropriate to the needs of residents. There is a small kitchen area on the first floor, which residents can access to make their own cups of tea. Communal parts of the home are warm and homely. Bedrooms seen indicate that residents can bring their own personal items and furniture when they move there otherwise furniture is provided. There have been some changes to the environment since last inspection. The pre-inspection questionnaire states that nine bedrooms have been redecorated and there is a new carpet on the ground floor hallway, which residents helped choose. Aigburth DS0000001660.V318314.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. Residents’ needs are well met by sufficient numbers of trained staff. Some improvements to recruitment practice are necessary for the protection of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Specialist training relevant to the needs of residents is accessed. For example, dementia training and a course in managing violence and aggression, following some incidents in which a resident has presented significant challenges to the service. Senior staff are currently doing an external course on end of life care. Records and discussion with staff and the manager indicate that the majority of staff hold at least the National Vocational Qualification level 2 in Social Care. Residents spoken with said they are happy with the staffing numbers and that a staff member is available when needed. This was observed during the inspection. The care rota and from discussion with staff indicates that staffing levels are seen flexibly and fluctuate depending on the number and needs of residents. The files of four staff members were randomly selected. All contained two written references, which were obtained before the staff member commenced their employment. Two of the four files did not contain current criminal record bureau checks, which is required. Aigburth DS0000001660.V318314.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 and 38 Quality in this outcome area is good. Health and safety and the home in general are managed well and there are excellent systems in place for monitoring quality underpinned by the views of residents. Some changes to record keeping practices will help ensure residents’ rights and best interests are safeguarded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Evidence throughout this report indicates that the home is run effectively. Residents’ views are taken very seriously when finding ways to improve the service. Three times a year an audit takes place that includes sending out questionnaires and spending time with residents to discuss their opinions. This information is then collated and a report formulated identifying ways to change the service. Aigburth DS0000001660.V318314.R01.S.doc Version 5.2 Page 18 An inspection of the financial procedures in the home indicate that the procedures are robust in ensuring individuals’ money is held securely and safely. Residents spoken with confirmed that they have access to money and spend it when they wish. Some documentation in the home, for example complaints records, does not comply with data protection and freedom of information because confidential information is contained about more than one resident. A recommendation is made in respect of this. There have been a couple of Safeguarding Adults investigations, which were not notified to the Commission. This is required so that the Commission can effectively regulate the service. Alternatively, some unnecessary notifications have been made. There have been 112 notifications since the last key inspection, most of which have been falls. Only accidents involving residents where medical assistance is sought must be notified. The pre-inspection questionnaire shows that the necessary servicing of equipment and gas and electrical systems are undertaken. The fire log indicates that the required fire system tests and drills are carried out. Aigburth DS0000001660.V318314.R01.S.doc Version 5.2 Page 19 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 2 3 X X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 X 2 3 Aigburth DS0000001660.V318314.R01.S.doc Version 5.2 Page 20 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. 1. Standard OP29 Regulation 19 Requirement Ensure new staff do not commence employment until the return of a criminal record bureau check (or evidence of a POVA First check is on file) Ensure all notifications, as specified under this regulation are made to the Commission. Timescale for action 30/11/06 2. OP37 37 30/11/06 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. 2. 3. Refer to Standard OP1 OP8 OP9 Good Practice Recommendations Update Statement of Purpose and Service User Guide, to ensure the information contained is current. Ensure information about mobilising is consistent in care plans and risk assessments, so that residents and staff are fully aware of the level of support required. Ensure the MAR is not signed until the medication has been given to the service user and that all quantities of medication are accounted for in the home. Carrying over medication from the previous cycle onto the next cycle’s MAR will ensure this. DS0000001660.V318314.R01.S.doc Version 5.2 Page 21 Aigburth 4 OP37 Ensure all records used in the home comply with data protection and freedom of inspection, to safeguard confidentiality. Aigburth DS0000001660.V318314.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Aigburth DS0000001660.V318314.R01.S.doc Version 5.2 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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