Inspection on 21/11/05 for Aldington House

This inspection was carried out on 21st November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Aldington House 06/04/08

Aldington House 24/04/06

Aldington House 06/12/04

Aldington House 01/07/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Aldington House 107a Blackheath Park Blackheath London SE3 OEX Lead Inspector Ms Pauline Lambe Unannounced Inspection 21st November 2005 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 Aldington House DS0000006853.V259345.R01.S.doc Version 5.0 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. Aldington House DS0000006853.V259345.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Aldington House Address 107a Blackheath Park Blackheath London SE3 OEX 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) 020 8463 0641 020 8297 8985 New Century Care Limited Mr Simon Michael Collins Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Aldington House DS0000006853.V259345.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th June 2005 Brief Description of the Service: Aldington House is a care home registered to provide accommodation and personal care for thirty -one older people. The home is part of a group of Nursing and Care homes managed by New Century Limited. The home is situated in a quiet residential road on a private estate in Blackheath. It is approximately 15 minutes walk to the shops, local facilities and public transport connections in Blackheath Village. Accommodation in the home is provided on three floors. The home has twenty -nine single and one shared bedroom. There are pleasant and well-maintained gardens to the front and a small patio area accessible from the lounge on the lower ground floor. Aldington House DS0000006853.V259345.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 7 hours. The service was last inspected on 28th June 2005. At the time of this inspection the manager was in charge and twenty-nine residents were in the home. The inspection process included speaking to residents, relatives, staff and management. Records required by regulation were inspected and a tour of the premises was undertaken. Compliance with requirements and recommendations made at the last inspection were reviewed. A regional manager from the organisation assisted with the inspection. What the service does well: What has improved since the last inspection? What they could do better: Efforts must be made to comply with all requirements made following inspection. Records in relation to residents at risk of developing or having pressure sores must be kept up to date and reflect prevention and care provided. More effort must be made to involve residents or their relatives with the preparation of care plans. Care plans must be prepared for all residents to show how their assessed needs are to be met. Aldington House DS0000006853.V259345.R01.S.doc Version 5.0 Page 6 Staff must sign for medicines at the time of administration and must record why a medicine was omitted. Recruitment procedures must ensure all information is obtained for employees as required by regulation. The provider must send reports to the Commission as required by regulation 26. A system must be in place to ensure staff receive appropriate supervision. 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. Aldington House DS0000006853.V259345.R01.S.doc Version 5.0 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 Aldington House DS0000006853.V259345.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. Adequate information was provided about the service in the statement of purpose and service user guide. All residents were assessed prior to admission to ensure the home could meet their needs. EVIDENCE: The statement of purpose and service user remained unchanged since they were assessed as complying with regulation. Improvements were needed to ensure the contract for service complied with regulation. A requirement relevant to this made at the last inspection was not met. Three care plans were assessed. All had pre-admission assessments and one had a letter confirming the home could meet the resident’s assessed needs. Requirement 1. Aldington House DS0000006853.V259345.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11. Residents said staff respected their dignity and privacy and they were satisfied with the quality of care provided. Further work was needed to ensure care plans were prepared to show how all resident’s assessed needs were to be met. Medicine management had improved since the last inspection. EVIDENCE: The care plans for three residents were inspected. Two were well written and included risk assessments and relevant care plans. The third one included risk assessments but had only a night care plan in place even though the resident had been in the home for about two months. Systems were in place to review care plans and risk assessments. There was evidence in two care plans seen of resident or relative involvement. All care plans seen included a social history of the person and risk assessments had been completed to identify residents at risk of developing pressure sores. One resident identified as being at risk of developing pressure sores did not have a care plan to show how the risk would be managed. None of the residents in the home had pressure sores. Staff supported residents to access medical services as needed. A GP visited the home weekly. Aldington House DS0000006853.V259345.R01.S.doc Version 5.0 Page 10 The home had policies and procedures on medication management, which were reviewed on October 2005 and reflected the current practice in the home. Since the last inspection a second medicine trolley was provided to store medicines for administration. This had reduced the risk of staff removing medicines from the dispensed containers. Internal and external medicines were stored separately, eye drops were dated when opened, two members of staff signed hand written entries on medication charts and records were kept for all medicines brought into the home. The home had complied with all but one of the requirements made in relation to medication management at the last inspection. The outstanding requirement was in relation to the temperature in the medicine storage area and this was being addressed. Medicines were stored in an adequately sized room on the lower ground floor. Records showed the temperature of the room was above 29C degrees most of the time. The inspector was told that an air conditioning unit was due to be fitted into the room but no date was available for when the work would start. Medicines for two residents were reviewed and both had inaccuracies. Residents and relatives seen said staff treated them with respect. The home had policies and procedures on death and care of the dying. Residents could stay in the home during their final days provided their care needs could be met. Requirements 2,3,4 and 5 Aldington House DS0000006853.V259345.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14. Residents said staff helped and supported them to make decision about their daily lives. EVIDENCE: Standards 12,13 and 15 were exceeded at the last inspection. As no changes had been made these standards were not assessed on this occasion. Staff were observed interacting appropriately with residents. Several residents said staff helped them to choose their daily outfits, choose their meals and decide where and how to spend their day. Some residents choose to spend time in their bedrooms and some like to sit in the lounge. Aldington House DS0000006853.V259345.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 and 18. The home had a complaints procedure and residents and relatives said they knew how to make a complaint. Staff displayed an understanding of adult protection. EVIDENCE: No complaints or adult protection issues had been referred to the provider of the Commission since the last inspection. The home had policies and procedures in place to manage complaints and adult protection issues. The home had a system in place to record complaints made about the service and the outcome. Residents were included on the electoral role and supported to vote if they wished. Management ensured all residents had access to their personal allowance and had the opportunity to voice their views of the service through resident / relative meetings. Staff said they received training on adult protection and those who spoke to the inspector displayed an understanding of this and how they would manage such a situation. Aldington House DS0000006853.V259345.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None. The environment continued to be maintained to a high standard with attention given to hygiene and safety. EVIDENCE: The environmental standards were all assessed at the last inspection and were met or exceeded. No environmental issues were identified during a tour of the premises on this occasion and residents confirmed their satisfaction with both communal and personal space. One recommendation made in relation to standard 23 at the last inspection had been appropriately addressed. Aldington House DS0000006853.V259345.R01.S.doc Version 5.0 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 and 30. The home must obtain all the information on employees as required by regulation. EVIDENCE: The home benefited from having a stable staff team. The staff team comprised of a full time manager, deputy manager, team leaders, care assistants, domestic and ancillary staff. From observation staff interacted in a friendly yet professional manner with residents. Residents seemed relaxed in their interactions with staff. From the staff rotas seen for a three-week period, including the week of the inspection it was evident that adequate staffing levels were maintained. The manager said that care staff no longer covered the kitchen. Two employee files were viewed. Neither of these included proof of the person’s identity, a recent photograph and both had only one reference. Both had a POVA first check, one had a CRB check and the other had evidence that a CRB application had been submitted. Staff said they got adequate support and training to fulfil their roles. No training had been provided since the last inspection but there was evidence to show training session were planned to take place in the near future. Requirement 6. Aldington House DS0000006853.V259345.R01.S.doc Version 5.0 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38. Since the last inspection the manager has been registered with the Commission. From the evidence provided attention was given to ensuring a safe environment was provided for residents and others. EVIDENCE: Since the last inspection the manager had registered with the Commission. From comments made to the inspector by residents, relatives and staff the manager had a positive effect on running the service. The manager was currently studying for the registered managers award. The provider completed a quality audit annually. The outcome of this was made available to residents and relatives. From briefly looking at this it was evident that there was a high level of satisfaction with the service. The manager sent a copy of this to the Commission following the inspection. The provider must ensure reports continue to be sent to the Commission as required by regulation 26. Aldington House DS0000006853.V259345.R01.S.doc Version 5.0 Page 16 The home looked after a small amount of personal money for some residents. The money was provided by relatives or resident representatives and used for personal items such as toiletries and hairdressing. Records were kept to show amounts of money received and receipts kept for money spent. The money held for two residents was checked and found to be correct. Formal supervision was not being provided for staff. The staff designated to provide supervision were currently being trained on how to do this. Records were kept as required by regulation and those seen were up to date and safely stored. A sample of safety records seen showed attention was given to safety. Up to date service records were seen for the lift, assisted baths, mobile hoists and electricity. The fire alarm and emergency lighting were serviced in May 2005 and the last fire drill for day staff was held on 16/11/05 and for night staff on 28/9/05. The home had a fire risk assessment and an evacuation policy. The landlord’s gas safety certificate was out of date. Requirements 7, 8 and 9. Aldington House DS0000006853.V259345.R01.S.doc Version 5.0 Page 17 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 3 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 X X X X X X X X STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 1 3 2 Aldington House DS0000006853.V259345.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP2 Regulation 5 Requirement The Registered Person must ensure the contract for service reflects the service provided, is signed and states what the fees are and who pays these. (Timescale of 30/09/05 was not met.) The Registered Person must ensure residents have care plans prepared to show how all their assessed needs will be met. The Registered Person must ensure risks to the health of residents are identified and as far as possible eliminated. Residents at risk of developing pressure sores must have care plans in place showing how the risk will be managed. (Timescale of 29/07/05 was not met). The Registered Person must make arrangements for the safe management of medicines received into the home. The medicine room temperature must be controlled to ensure medicines are stored safely and according to manufacturers instructions. (Timescale of DS0000006853.V259345.R01.S.doc Timescale for action 30/12/05 2 OP7 15 16/12/05 3 OP8 13 16/12/05 4 OP9 13 16/12/05 Aldington House Version 5.0 Page 19 5 OP9 13 6 OP29 19 7 OP33 26 8 OP36 18 9 OP38 13 29/07/05 was not met). The Registered Person must ensue staff sign for medicines at the time of administration and record why a medicine has not been administered. The Commission must be informed in writing when the air conditioning unit has been fitted into the medicine room. The Registered Person must ensure compliance with regulation and obtain the information required for all staff employed. The Registered Person must ensure reports are sent to the Commission monthly in line with regulation. The Registered Person must ensure that staff employed in the home receive appropriate supervision. The Registered Person must ensure the home had an up to date landlord’s gas safety certificate. A copy of this must be sent to the Commission when available. 16/12/05 30/12/05 30/12/05 30/12/05 16/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Aldington House DS0000006853.V259345.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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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