Inspection on 23/08/05 for Ailwyn Hall Care Home

This inspection was carried out on 23rd August 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ailwyn Hall Care Home 13/08/07

Ailwyn Hall Care Home 13/12/06

Ailwyn Hall Care Home 31/08/06

Ailwyn Hall Care Home 05/04/05

Ailwyn Hall Care Home 21/09/04

Ailwyn Hall Care Home 22/04/04

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 Ailwyn Hall Care Home Berrys Lane Honingham Norwich NR9 5AY Lead Inspector Ann Catterick Unannounced 23 August 2005 19.30 rd 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 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. Ailwyn Hall Care Home I55 s55861 Ailwyn Hall v244790 UN 230805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Ailwyn Hall Care Home Address Berrys Lane, Honingham, Norwich, Norfolk. NR9 5AY 01603 880624 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Gastank Ltd Ms Jennifer Anne Palmer Care Home 39 Category(ies) of Dementia - over 65 (13), registration, with number Old age, not falling within any other category of places (26) Ailwyn Hall Care Home I55 s55861 Ailwyn Hall v244790 UN 230805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to eleven (13) service users over the age of 65 years who have dementia may be accommodated. 2. Up to twenty-six (26) older persons, not falling into any other category may be accommodated. 3. The total number not to exceed thirty-nine (39) Date of last inspection 5th April 2005 Brief Description of the Service: Ailwyn Hall is a care home providing personal care and accommodation for 39 older people, 13 of whom have dementia. The home comprises of two units Emily unit and Rosie unit. The home is owned by Gastank Ltd and the responsible individual is Ashley Oliver George. The home is located in the village of Honingham. The home is close to the main A47 providing easy access to both Norwich and Dereham. The home has 31 single rooms, 20 of which are en suite and 4 double rooms, 2 of which are en suite. The home has a passenger lift. The home is set in a picturesque setting in its own grounds surrounded by mature trees and well maintained gardens. The exterior of the home can be accessed by wheelchair users and provides a pleasant environment for service users in the summer months. There is parking to the front and to the side of the property. Ailwyn Hall Care Home I55 s55861 Ailwyn Hall v244790 UN 230805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place during the evening, giving the inspector opportunity to meet with evening and night staff. The inspection lasted 2.5 hours and due to the length, and time, of the inspection the outcomes of many standards were not inspected. The outcome of any key standards not inspected on this occasion will be inspected at the next inspection. The inspector was able to speak with some service users and staff as well as look at some parts of the building and look at some staff files and a service users plan of care. Most service users were still up when the inspector arrived at the home at 7pm and within Rosie unit some were watching television and others were chatting in a corner area of the room. Emily unit accommodates service users with dementia and the communal area is open plan including the lounge and dining area. At the time of the inspection the staff on duty were assisting service users to bed and those service users left in the lounge appeared to be unsupported and rather left alone. This may be a time when additional staff may be of support on this unit. Overall the service users on Rosie unit spoke positively about their care. One service user was concerned that the Registered Manager was now working in another home and that other staff had handed in their notice. It was difficult to assess how those service users on Emily unit felt about their care and plans of their care will be looked at in much further detail at the next inspection. Not all of the requirements from the last inspection were looked at due to the time of the inspection and these will be fully inspected at the next inspection. What the service does well: The Proprietor is continuing to improve the environment, with two new bathrooms being installed on the day following the inspection. All of those staff spoken to on the evening of the inspection were clear on the fire procedures and what to do in the event of a fire. Ailwyn Hall Care Home I55 s55861 Ailwyn Hall v244790 UN 230805 Stage 4.doc Version 1.40 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. Ailwyn Hall Care Home I55 s55861 Ailwyn Hall v244790 UN 230805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Ailwyn Hall Care Home I55 s55861 Ailwyn Hall v244790 UN 230805 Stage 4.doc Version 1.40 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 standard(s) 6 Immediate care is not provided within this home. EVIDENCE: Ailwyn Hall Care Home I55 s55861 Ailwyn Hall v244790 UN 230805 Stage 4.doc Version 1.40 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 standard(s) 7 Service users care needs are identified in an individual care plan. EVIDENCE: A care plan was looked at and this included all of the information needed to offer appropriate care to the service user. The care plan had been reviewed on a regular basis. The service user was seen and the care plan appeared to describe and address his changing needs. Ailwyn Hall Care Home I55 s55861 Ailwyn Hall v244790 UN 230805 Stage 4.doc Version 1.40 Page 10 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 standard(s) 15 The service users are offered their meals in pleasing surroundings. There is opportunity to improve the quality and variety of meals. EVIDENCE: The dining areas in both Emily and Rosie wing are pleasant and attractive. Most service users choose to have their meals in these areas but can, if they choose, have their meal in their bedroom. The home uses hot trolleys to take food to the dining areas and a comment was made by a service user that often meals were not as hot as they should be. The menu in the kitchen was difficult to read and the home does not have a menu plan that can be easily read and understood by service users. Also the present system makes it difficult to look at the variety of meals offered over a given period. A comment was made by a service user that fresh fruit was not offered on a regular basis. Staff have said that they will now include a fruit bowl on the trolley with morning coffee and afternoon tea. A senior member of staff informed the inspector that she planned to spend time looking at all areas of quality relating to menu planning and meal times. Ailwyn Hall Care Home I55 s55861 Ailwyn Hall v244790 UN 230805 Stage 4.doc Version 1.40 Page 11 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 standard(s) None of the outcomes of these standards were looked at on this occasion and will be addressed at the next inspection. EVIDENCE: Ailwyn Hall Care Home I55 s55861 Ailwyn Hall v244790 UN 230805 Stage 4.doc Version 1.40 Page 12 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 standard(s) 19,21 and 26 Most parts of the home seen on the day of inspection were safe and well maintained. New baths were to be installed the day after the inspection and when this has happened the home will have suitable lavatory and washing facilities. Those areas of the home seen on the evening of the inspection were clean and tidy. Ailwyn Hall Care Home I55 s55861 Ailwyn Hall v244790 UN 230805 Stage 4.doc Version 1.40 Page 13 EVIDENCE: Overall the home is well maintained and provides comfortable accommodation. The home is divided into two units each unit having its own lounge and dining area. In Emily unit the dining and lounge area are open plan. At the last inspection some concerns had been made about the bathing facilities and two new baths were being installed the day following the inspection. Those service users spoken to were satisfied with their bedrooms and a service user was happy to show his room to the inspector. The home has very pleasant grounds. One service user said he went in the grounds at least once a day and enjoyed this very much. The driveway towards the home is shingle and a pathway would give easier access to service users in this area. A gate was being put in place outside the back of Emily Unit to ensure the area was safe and secure. Two of the bathrooms were in a poor state of repair when inspected at the last inspection but were being replaced the day following the inspection. Radiators in the bathrooms need to be covered and a requirement has been made in this area. A carpet shampooer was being stored in a bathroom and it has been recommended that an alternative storage space be found. Those bathrooms that are not being replaced could be made more attractive and welcoming by adding plants, pictures and other bathroom ornaments. Not all radiators were covered or of low temperature surface and a requirement has been made in this area. The inspection was unannounced and took place during the evening therefore not all areas of the home were seen. Those areas seen were reasonably clean and tidy. Ailwyn Hall Care Home I55 s55861 Ailwyn Hall v244790 UN 230805 Stage 4.doc Version 1.40 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29 The rota suggested that adequate numbers of staff are on duty at any one time and this was the case on the day of inspection relating to the evening and night staff. The homes recruitment policy protects service users although the procedures had not been followed for all staff appointed and therefore practice was not fully protecting service users. Ailwyn Hall Care Home I55 s55861 Ailwyn Hall v244790 UN 230805 Stage 4.doc Version 1.40 Page 15 EVIDENCE: On the evening of inspection two staff were working on Emily unit and two staff working on Rosie unit. It was the time that some service users were choosing to go to bed and those service users in the lounges were on occasion left alone whilst other service users were being assisted to bed. Staff spoken to said that generally they felt there were enough staff but on occasions they had asked one of those staff who live on the premises to assist if need be. If this is a very busy time for staff the management may want to consider having extra staff at busy times. Three night staff were on duty as seen on the rota and three night staff were at work on the evening of inspection. The night staff appeared knowledgeable and confident. They said that there was always three night staff on duty and that this was sufficient to meet the needs of the service users. Two staff files were inspected, one of these had all the information needed but the other did not have an up to date CRB related to the home nor was there evidence of references. It was agreed that these would be sought immediately and a requirement was made in this area. Ailwyn Hall Care Home I55 s55861 Ailwyn Hall v244790 UN 230805 Stage 4.doc Version 1.40 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 and 38 The home is managed by a person who is of good character and fit to be in charge of the home. Some areas of the health, safety and welfare of service users and staff were inspected and most of these areas promoted safety. Ailwyn Hall Care Home I55 s55861 Ailwyn Hall v244790 UN 230805 Stage 4.doc Version 1.40 Page 17 EVIDENCE: The home has a registered manager although at the time of the inspection she had been temporarily placed within another home. The home had a named person for acting manager in this interim period. The inspector was able to ask evening and night staff to talk through what they would do in the event of a fire and all were clear on the homes fire procedures and what their role and responsibilities would be. The inspector was pleased to find that the front door was locked at the time of the evening inspection. When the inspector left the building it was dark and the inspector noticed that she had to walk a significant distance from the building before the outside light came on. The inspector would recommend that this be addressed as it could put staff and/or visitors at risk when leaving or entering the building from the car park. Ailwyn Hall Care Home I55 s55861 Ailwyn Hall v244790 UN 230805 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 2 COMPLAINTS AND PROTECTION 3 x 2 x x x x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 3 x x x x x x 3 Ailwyn Hall Care Home I55 s55861 Ailwyn Hall v244790 UN 230805 Stage 4.doc Version 1.40 Page 19 YES Are there any outstanding requirements from the last inspection? 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 15 Regulation 16(1)i Requirement The registered person must ensure that the home provides suitable, Wholesome food which is nutritious and varied. The registered person must ensure that all radiators have been risk assessed and those that service users have access to are covered or are of low temperature. The registered person must ensure that the recruitment and selection processes and procedures are followed to ensure the protection of service users. Timescale for action 01/10/05 2. 25 13(4)c 01/10/05 3. 29 19(1) 01/09/05 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 21 21 27 Good Practice Recommendations That bathrooms are free from unecessary clutter such as the homes carpet shampooer. That bathrooms are made to look less stark and more homely. That the proprietor consider having more staf on duty at I55 s55861 Ailwyn Hall v244790 UN 230805 Stage 4.doc Version 1.40 Page 20 Ailwyn Hall Care Home 4. 38 busy times during the evening. That consideration be given to ensuring the outside lighting facility promote safety for staff, visitors and service users when it is dark early morning and evening. Ailwyn Hall Care Home I55 s55861 Ailwyn Hall v244790 UN 230805 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection 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. 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