CARE HOMES FOR OLDER PEOPLE
Ailwyn Hall Care Home Berrys Lane Honingham Norwich NR9 5AY
Lead Inspector Ann Catterick Announced 05 April 2005 09:30 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 Version 1.10 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 Care Home 37 Category(ies) of Dementia - over 65 (11), registration, with number Old age, not falling within any other category of places (26) Ailwyn Hall Care Home Version 1.10 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Up to eleven (11) 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-seven (37) Date of last inspection 21st September 2004 Brief Description of the Service: Ailwyn Hall is a care home providing personal care and accommodation for 37 older people, 11 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 29 single rooms, 18 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 Version 1.10 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was announced and took place over 10.5 hours. The pharmacy inspector was at the home for part of the inspection to inspect the outcomes of standard 9. Since the last inspection there had been two visits to the home to follow up a two complaints. Discussion was had with the proprietor, manager staff, service users and some visitors. A general tour of much of the building also took place. Information received prior to the inspection in the form of a pre inspection questionnaire and feedback forms was also incorporated within the inspection. One of the staff on duty was spoken to formally and several others on an informal basis. Several service users as well as three relatives were spoken to. What the service does well: What has improved since the last inspection?
The manager has started to develop care plans and these have improved being more ‘user friendly’ and with more information. The dementia care unit has a new large lounge/conservatory/dining area that is light and airy improving the community facilities. Further work is being completed within the grounds that will make the outside facilities more accessible to service users. The pharmacist inspector felt that the overall view of medication practice had improved within the past twelve months.
Ailwyn Hall Care Home Version 1.10 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ailwyn Hall Care Home Version 1.10 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 Version 1.10 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) 0 None of these standards were looked at on this occasion. EVIDENCE: Ailwyn Hall Care Home Version 1.10 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 and 9. All service users have an individual care plan and these care plans offer information about the persons health. Social and personal care needs. There is opportunity for further development in this area. The pharmacist inspector’s overall view of medication practice at the home is that the home has worked well towards updating and improving medication practice over the most recent 12 month period. Systems in place for the administration of medicines are sound, however, as the inspector identified elements of unsafe medicine administration practice by carers during the inspection, further work is as yet required to ensure this Standard is met and that service users are protected by the home’s policy and procedures at all times. EVIDENCE: The manager has spent some time on improving and updating care plans. The care plans included most of the information required within this standard and those care plans seen were being reviewed on a regular basis. There was no evidence to suggest service users and/or relatives had been involved in the completion of the care plans. The inspector noted in one care plan that a resident enjoyed knitting and when the inspector met with the service user she had plenty of wool and was knitting in the lounge. The inspector was pleased to see this identified hobby being promoted. There is further opportunity to
Ailwyn Hall Care Home Version 1.10 Page 10 develop care plans and the inspector would expect further improvements. Those service users spoken to said that their needs were being met. Relatives of a service user who had lived in the home for some time spoke very positively about the care their relative received. A full inspection of Standard 9 relating to medication was simultaneously carried out by specialist pharmacist inspector Mark Andrew. The detailed findings of his inspection have been provided in a separate Pharmacy Inspection Report sent alongside this report. Ailwyn Hall Care Home Version 1.10 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 standard(s) 15 The meals provided lacked variety and imagination offering limited choices. The view of the quality of food expressed by service users and relatives was varied therefore suggesting opportunity for improvement. There appeared to be no quality assurance system by management in relation to the meals provided in the home. Some residents needed assistance with their meals and this assistance was not always offered in a suitable manner. The outcomes in this area are not fully met. EVIDENCE: Two weeks of menus were provided to the inspector prior to the inspection. They showed that out of fourteen lunches 12 of them included mash potato as one of the vegetables. The other two lunches offered shepherds pie and roast potatoes. The teatime menus were mainly either something on toast or sandwiches. When this issue was identified to the manager and proprietor they had not been aware of this lack of variety on the menu. Overall service users spoke positively about the food they received although some acknowledge the lack of variety. On the day of inspection the inspector sat at the table on Emily unit at lunch- time and the lunch provided looked appetising. For those service users that needed liquidised food this was liquidised separately.
Ailwyn Hall Care Home Version 1.10 Page 12 Staff were seen to be standing when assisting residents with lunch. The inspector believes that this is poor practice and had to ask two members of staff to sit or kneel when assisting with lunch. Ailwyn Hall Care Home Version 1.10 Page 13 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) 16 and 18 Complaints were dealt with appropriately and effectively. The home has a policy for the protection of vulnerable adults. The home has had experience of following these procedures and the inspector was satisfied that these were followed correctly. EVIDENCE: The complaints file was seen and the policies and procedures were satisfactory. Evidence was seen of the complaints, the response to the complainant and the outcome of any investigation or follow up. When a relative had made a complaint to the home she was satisfied with the response that she received from management. Those service users spoken to about this issue said that they would be happy to make a complaint if they needed to do so. A copy of the complaints procedure is in the service users guide. The home has a policy for the protection of vulnerable adults as well as a whistleblowing policy. The home has used both of these procedures in recent months and has followed the procedures correctly. A member of staff spoken to on the day of inspection had covered this area in some detail whilst completing her NVQ level 2 and evidence was seen on staff files of other training received by staff. Ailwyn Hall Care Home Version 1.10 Page 14 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, 20, 21, 23, 24,25 and26. The new extension and refurbishments to the home were satisfactory but other areas of the home were of poor repair and some essential facilities were well worn. The cleanliness of the home, in some areas, and the management of clinical waste were poor. More work needs to be completed within the home to ensure that the service users are living in a safe, well maintained environment. EVIDENCE: The inspector was able to view the new conservatory on Emily wing and the two new bedrooms. These areas all appeared to be satisfactory although the dining area needs another table to ensure that all residents could sit around the dining tables if they chose to do so. The home has four bathrooms and one shower. One bathroom was being used as a storing area for general bits of wood and parts of furniture as well as housing a plastic bin that was full of clinical waste. The bin was placed in the bath and had no lid. The bathroom was not fit for purpose and being used totally inappropriately.
Ailwyn Hall Care Home Version 1.10 Page 15 The water temperature at some bath water outlets and some sink taps outlets was over 60 degrees and the inspector believed this was putting residents at significant risk. This information was gained from a person servicing the baths and from a resident who was talking to the inspector. It was confirmed when the inspector tested several water outlets. Many areas of the home were not cleaned adequately. This was noted by the inspector on the day of the inspection and had been commented upon in feedback from a relative as well as a comment from a resident. Soiled continence pads were stored in a plastic bin without a lid in the unused bathroom and in the most used bathroom. This was totally inappropriate and did not meet with the homes policy and procedures with the storage and management of clinical waste as well as being visually unpleasing for any resident having a bath. There was no written maintenance plan and it appeared that no one effectively inspected the home in relation to the environment on a regular basis. Ailwyn Hall Care Home Version 1.10 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 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) 27,29 and 30. The number of care staff on duty at any one time is adequate, however the amount of domestic care hours appears to be insufficient. The home plans to increase its service users number by two. Before this happens the home needs to increase the number of night staff to three. Domestic care hours would also need to increase. The recruitment and selection process had not been fully completed for all staff and therefore was not fully protecting service users. Induction, foundation and NVQ training was being completed appropriately although the training relating to dementia was limited. Overall the home is aiming to ensure that staff are trained to meet the requirements of their job description. EVIDENCE: The inspector was able to look at the care rota and speak to the manager, staff and service users about the amount of care staff working in the home. The manager felt that adequate numbers of staff were on duty at all times. Some feedback from relatives and service users suggested that staffing level were adequate and some thought that more staff were needed. Staff levels were seen as adequate and will be review them on a regular basis. The inspector was able to look at some staff files. It was noted that for one new member of staff only one reference was on file. The manager informed the inspector that a verbal reference had been sought by telephone but no record had been made of this and it was therefore of no value. Staff files lacked any order and information appeared to be in no specific order.
Ailwyn Hall Care Home Version 1.10 Page 17 All staff receive induction training and this was seen on file. Staff either complete NVQ level 2 or 3 or receive foundation training. No dementia training had taken place although some was planned for a future date. Ailwyn Hall Care Home Version 1.10 Page 18 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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, 32, and 35. The manager is relatively new within her role and is completing her registered managers award. She has applied to become the registered manager. She has developed some management skills and has gained some knowledge since being in post. There is opportunity for further development of the manager within her role. EVIDENCE: At the time that the manager was promoted from deputy to manager the home was taken over by the new proprietor. She has been involved in many changes around policy and procedures as well as having to manage the home whilst some refurbishment was being completed. The inspector was surprised to find that the manager was not aware of some of the concerns identified in this report, especially those relating to health and safety and the general cleanliness of the home. Ailwyn Hall Care Home Version 1.10 Page 19 Those staff spoken to on the day of inspection spoke positively about the manager and this view was supported by residents, relatives and some of the feedback forms received prior to the inspection. The manager takes responsibility of small amounts of money for service users. This money is to cover the cost of hairdressers, chiropodists, toiletries or other small items the residents may wish to buy. Records of all incomings and outgoings of money were seen by the inspector and these were recorded correctly. Ailwyn Hall Care Home Version 1.10 Page 20 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 2 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 1
COMPLAINTS AND PROTECTION 1 2 1 x 3 1 1 1 STAFFING Standard No Score 27 2 28 x 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 3 x x 3 x x x Ailwyn Hall Care Home Version 1.10 Page 21 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 provider must ensure that the home provides suitable, wholesome food which is nutritious and varied. The registered provider must ensure that the home provides facilities and services in accordance with the statement of purpose of the home. The home needs to be safe, well maintained meeting service users needs in a comfortable and homely way. The registered provider must ensure that the home has suitable bathing facilities and/or showers that are of good quality,accessible to residents and are in sufficient numbers to meet needs. The registered provider must ensure that all bedroom doors are lockable and that each resident has a lockable facility within their room. (PREVIOUS TIMESCALE OF 01/12/04 NOT MET.) The registerd provider must ensure that water being discharged from taps at sinks and baths is of the appropriate
Version 1.10 Timescale for action 01/05/05 2. 19 16(1) 01/05/05 3. 21 13(4)a 12/04/05 4. 24 12(4)a 01/06/05 5. 25 13(4)c 12/04/05 Ailwyn Hall Care Home Page 22 6. 26 13(3) 7. 29 19(4(b)i 8. 31 9 9. 9 13.2 temperature and does not put residents at any unnecessary risk to their health and safety. The registered provider must ensure that they make suitable arrangements to prevent infection, toxic conditions and the spread of infection in the care home. The registered provider must ensure that the recruitment and selction process includes all of the information as decribed in Schedule 2(ammended version) The registered provider must ensure that the manager is in control of the day to day delivery of care within the home. The registered provider must ensure that arrangemetns are made for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care hom at all times. 06/04/05 05/04/05 05/04/05 As advised in pharmacy report. 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 7 20 30 Good Practice Recommendations That the progress with care oplans be continued and that whenever possible residents and/or relatives are involved in their making and in the reviewing process. That the provider ensures that there are adequate dining tables and chairs to enable all residents to sit at the dining tables for meals if they choose to do so. That staff receive training relating to the care of older people with dementia and this training is continuous and kept up to date. Ailwyn Hall Care Home Version 1.10 Page 23 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
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