Inspection on 08/02/06 for Aitken House

This inspection was carried out on 8th February 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 found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Aitken House 25/08/06

Aitken House 03/06/05

Aitken House 07/10/04

Aitken House 22/04/04

Similar services:

Chesham House

Argyll House

Dorset Lodge

Acacia House

Falcon House

Dial House Nursing Home

Cromwell Avenue (9)

Abbey Lodge

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

CARE HOME ADULTS 18-65 Aitken House 28 Yarmouth Road North Walsham Norfolk NR28 9AT Lead Inspector Maggie Prettyman Unannounced Inspection 8th February 2006 10:15 Aitken House DS0000027309.V282773.R01.S.doc Version 5.1 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 Aitken House DS0000027309.V282773.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 Adults 18-65. 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. Aitken House DS0000027309.V282773.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Aitken House Address 28 Yarmouth Road North Walsham Norfolk NR28 9AT 01692 404502 NO FAX # 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) Mr Khemraj Joory Mrs Toongbhadra Joory Mr Khemraj Joory Care Home 20 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (19), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) Aitken House DS0000027309.V282773.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd June 2005 Brief Description of the Service: Aitken House is a two storey building situated in the town of North Walsham that accommodates up to 20 adults with mental health problems. There are 14 single and 2 shared bedrooms situated on both the ground and first floors. The communal rooms consist of one quiet lounge, and one lounge with an attached smoking area, with two small dining rooms situated off the kitchen. The home has a large garden that is laid to lawn with a wild life pond. There is ample parking to the front of the building. The home is owned and managed by Mr & Mrs Joory. Aitken House DS0000027309.V282773.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted by a single inspector and took place over a period of approximately 5 hours. Inspection of the premises and written records as well as interviews with care staff and managers constituted the bulk of the time. Service users were observed and some short conversations took place. The home was found to be clean, tidy and welcoming. The atmosphere was peaceful and pleasant. Most service users were at home pursuing personal interests. The staff team were found to be well motivated and caring. The owners/managers are clearly fully involved in the daily running of the home, and are freely accessible to staff and service users. What the service does well: What has improved since the last inspection? A cook has been appointed to release care staff from these duties and give more support to service users. A continuing programme of training for both care staff and management has been followed. A range of work has been undertaken to maintain and improve the premises. Aitken House DS0000027309.V282773.R01.S.doc Version 5.1 Page 6 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. Aitken House DS0000027309.V282773.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Aitken House DS0000027309.V282773.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5 Prospective service users have the information they need to make an informed choice about where to live. Prospective users individual needs and aspirations are assessed. Prospective users know that they choose will meet their needs and aspirations. Prospective users have an opportunity to visit and “test drive” the home. Each service user has an individual written contract or statement of terms and conditions of the home. EVIDENCE: The Statement of Purpose and Service User Guide are both of a good standard with more than adequate information to met the requirements of the standards. The only slight shortfall was that the inspection report included was not the most recent. Evidence of comprehensive needs assessment was seen in service user files. The home has developed its own comprehensive documents to be used in the case of new admission. Aitken House DS0000027309.V282773.R01.S.doc Version 5.1 Page 9 Information in service user files and discussion with the owners and staff demonstrated that great effort is made to ensure that any new admission reflects not only that persons’ needs, but also does not negatively affect existing service users and their needs. Introductory visits and home assessments take place prior to admission. This process needs to be documented in the admissions procedure. Suitable contracts for service users were seen in individual files. Consideration could be given to annually updating this document by way of letter to keep individual service users informed in changes to payments made by the local authority on their behalf. Aitken House DS0000027309.V282773.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8 and 10 Service users could be consulted more, and could participate more in aspects of life in the home. Service users know that information about them is handled appropriately, and that their confidences are kept. EVIDENCE: Records of residents meetings showed that there have been none in the past year. Discussion with care workers demonstrated that individual choice and participation does take place, however this is on an informal basis and is not incorporated in the structures of the home. An example of this was the menu, which is chosen by the manager and prepared by the cook. Undoubtedly individual choice is taken into account, but greater involvement in the planning and preparation of food could offer benefit for some of the less actively motivated service users. Information about service users is confidentially stored. Wording of reports and other information is appropriate. An appropriate procedure relating to this standard is in place. Aitken House DS0000027309.V282773.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11 and 16 Service users have opportunities for personal development. Service users’ rights are respected and responsibilities recognised in their daily lives. EVIDENCE: Interviews with staff demonstrated that service users are enabled to maintain and develop social independence. Evidence of detailed information about life choices being taken prior to admission is in service users files. Appropriate social and educational activities are promoted by care staff. Religious beliefs are respected; three service users regularly attend local churches. Aitken House DS0000027309.V282773.R01.S.doc Version 5.1 Page 12 The routines of the home are flexible to promote independence and choice. Staff were observed entering service user rooms appropriately. Service users have keys to their own rooms and to the front door. People come and go as they wish, with an appropriate system of self-recording of when people go out. Post is sorted and given to service users unopened. Service users have unrestricted access to communal areas, but are only allowed to smoke in the designated lounge. No restrictions exist for the reasonable consumption of alcohol. Pets are allowed, and the home is in the process of considering acquiring a cat to replace the one that died last year. Aitken House DS0000027309.V282773.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 21 The ageing, illness and death of a service user are handled with respect and as the individual would wish. EVIDENCE: Evidence of discussion of individual wishes relating to funeral arrangements is in service user files. Some service users have taken out co-op funeral plans to ensure that all arrangements are to their exact wishes. The management of the home deal with this area proactively, particularly in relation to service users who have no immediate family. Aitken House DS0000027309.V282773.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Service users are protected from abuse, neglect and self-harm. EVIDENCE: POVA information provided by the commission is in the office and clearly marked for reading by new staff. Care workers spoken to described appropriate action to be taken in the event of suspicion of abuse. Recognition of signs and symptoms of abuse is covered during induction training. Appropriate policies and procedures for dealing with behaviour that challenges are available to all care staff. Money held for service users is held securely, and all records and monies checked were correct. Aitken House DS0000027309.V282773.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 and 29 Shared spaces complement and supplement service users individual rooms. Service users have the specialist equipment they require to maximise their independence. EVIDENCE: A range of comfortable, safe and accessible shared space is available. There are two no smoking lounges, with a further lounge where smoking is allowed. The garden areas are easily accessible and pleasant. Good sleeping in facilities are available for staff. Wheelchair using service users are accommodated on the ground floor. Appropriate hoist and bathing/ showering facilities are available. Grab rails and non-slip flooring were seen in all bathing areas. Aitken House DS0000027309.V282773.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 34 and 36 Service users benefit from clarity of staff roles and responsibilities. Service users are not always supported and protected by the home’s recruitment policy and procedures. Service users benefit from well-supported and supervised staff. EVIDENCE: Job descriptions are in place for all care staff. Staff spoken to are clear about their roles and responsibilities. Tasks for workers are relevant to their role, and it is clear that high levels of support are available from the owners/managers. Appropriate relationships and boundaries were observed between service users and care and support staff. No policy and procedure is in place to support this good practice, it is recommended that one be put in place to support new staff. Examination of staff files demonstrated that not all paperwork required by the standards is kept on staff. Additionally, staff files are kept in the owner’s home and not on the premises for inspection. No written recruitment policy and procedure is in place. The homes management must address all these shortfalls. Aitken House DS0000027309.V282773.R01.S.doc Version 5.1 Page 17 Evidence of regular staff support and supervision was seen in staff files as well as during interviews with staff. Appraisal takes place annually. Supervisors are trained and experienced in supervision. Aitken House DS0000027309.V282773.R01.S.doc Version 5.1 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40 and 41 Service users benefit from a well run home. Service users benefit from the ethos leadership and management of the home. Service users do not know that their views underpin the review and development of the home. Service users’ rights and best interests are generally safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Aitken House DS0000027309.V282773.R01.S.doc Version 5.1 Page 19 EVIDENCE: The management of the home is competent and qualified. As owner/manager the responsible person makes sure that aims and objectives are achieved, and that all policies and procedures, budgets, licensing, contracts and requirements are met. Both of the homes owners are appropriately qualified nurses and have recently been undertaking their NVQ Level 4 in management. The atmosphere within the home is relaxed and warm. Care staff are clearly well motivated, hard working, professional and committed to their tasks. Care staff spoke positively about the availability of management support and a positive approach to comment or complaint. A recent survey of service user views has taken place. This has yet to be incorporated into a formal report. The manager spoke positively about doing this and canvassing other interested parties about their views about the home. It is recommended that this process be completed. Many policies and procedures exist and are available to care staff. Inspection of these policies and procedures demonstrated that they might not full comply with the requirements of appendix 2 of the standards. It is recommended that the homes management look carefully at this list to ensure that any shortfall is covered. Good and accurate record keeping protects Service users rights and best interests. Service users have access to their records and are involved in them. Records are held securely and are up to date. Aitken House DS0000027309.V282773.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 3 29 3 30 X STAFFING Standard No Score 31 3 32 X 33 X 34 2 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X 2 X 3 LIFESTYLES Standard No Score 11 3 12 X 13 X 14 X 15 X 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X 3 3 3 2 2 3 X X Aitken House DS0000027309.V282773.R01.S.doc Version 5.1 Page 21 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 YA34 Regulation 19 and Schedule 2 Requirement Timescale for action 31/03/06 2 YA39 12 and 24 A written policy and procedure detailing the full recruitment process to be written and implemented, with all paperwork required by schedule 2 available for inspection in the homes office as required by the standards. The quality assurance survey for 30/04/06 the home to be completed. 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 4 5 Refer to Standard YA1 YA4 YA5 YA8 YA31 Good Practice Recommendations The most recent inspection report to be available as part of the statement of purpose. Introductory visit process to be included in the admissions policy and procedure An annual contract renewal letter for residents’ information should be produced. Service users should have greater involvement in decisionmaking, and opportunities for other involvement in day-today activities within the home. A policy defining appropriate roles and relationships DS0000027309.V282773.R01.S.doc Version 5.1 Page 22 Aitken House 6 YA40 between service users and staff should be written. Management to check compliance of policies and procedures with the list required in appendix 2 of the standards. Aitken House DS0000027309.V282773.R01.S.doc Version 5.1 Page 23 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 Aitken House DS0000027309.V282773.R01.S.doc Version 5.1 Page 24 - 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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