CARE HOMES FOR OLDER PEOPLE
Alicia Nursing Home 109 -115 Marsh Road Luton Bedfordshire LU3 2QG Lead Inspector
Katrina Derbyshire Announced 4 April 2005
th 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. Alicia Nursing Home I51 17661 Alicia V213103 04.04.05 - Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Alicia Nursing Home Address 109 - 115 Marsh Road Luton Bedfordshire LU3 2QG 01582 560500 01582 561574 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) Apex Care Homes Ltd Vacant Care Home 61 Category(ies) of (N) Care Home with Nursing registration, with number of places Alicia Nursing Home I51 17661 Alicia V213103 04.04.05 - Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 2nd September 2004 Brief Description of the Service: Alicia Nursing home is situated on the Marsh Road in Luton close to a variety of local amenities such as shops, places of worship and public houses. The home provides accommodation over three floors. For operational purposes each floor provides its own style of care for a particular group of service users. Attached to the home is a day centre that is staffed to provide activities for any of the service users who wish to attend Monday to Friday. The care staff can open this centre at weekends or in the evenings. The home has a small-enclosed garden with parking space for staff and visitors. The home is close to the M1 and the A6 and is on a bus route. Leagrave railway station is easily accessible. Alicia Nursing Home I51 17661 Alicia V213103 04.04.05 - Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This announced inspection was carried out on 4th April 2005. The Acting Manager, Mrs Mary Tengenesha was present throughout. During the inspection several areas of the home were visited and the inspector spent time with many of the residents in the lounges and their own individual rooms. The care of six residents was examined in depth by looking at their records and interviewing the residents and the staff who look after them. Comments from relatives of two residents were also received. What the service does well: What has improved since the last inspection?
There has been a change to the person who is in charge of running the home on a day-to-day basis. The new Manager has several years experience gained though working in other homes. Residents and staff were pleased with the changes she had made in the home, and many spoke of improvements in communication. One resident said “ l have confidence in her and she puts us first”.
Alicia Nursing Home I51 17661 Alicia V213103 04.04.05 - Stage 4.doc Version 1.30 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. Alicia Nursing Home I51 17661 Alicia V213103 04.04.05 - Stage 4.doc Version 1.30 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 Alicia Nursing Home I51 17661 Alicia V213103 04.04.05 - Stage 4.doc Version 1.30 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) 1,3,5 and 6. The way new admissions to the home are managed means; residents are made to feel welcome from their first visit to the home. EVIDENCE: The homes admission procedure was very clear and residents had received an assessment, before a decision was taken to move into the home. The home had made sure that they could meet all the residents’ needs before agreeing to an admission, a detailed assessment by a senior member of staff was always undertaken, these were then kept in the care files of each resident. Residents had also been given the opportunity to visit the home when making a decision on where to live, and meet other residents and staff. The statement of purpose had improved recently and contained all the information needed, so that residents would know about all the services offered in the home, and about the staff and building. Residents had all been given copies of the statement of purpose, and there was also a copy on display in the home. Intermediate care was not offered at the home.
Alicia Nursing Home I51 17661 Alicia V213103 04.04.05 - Stage 4.doc Version 1.30 Page 9 Alicia Nursing Home I51 17661 Alicia V213103 04.04.05 - Stage 4.doc Version 1.30 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 11. Care plans were not clear enough and this placed the residents at risk, of not receiving the care that they need. EVIDENCE: Changes had been made to the care planning system in the home, under the new management. However further development is required as the care plans still did not make clear how staff were to support the residents, in meeting all their needs. For one particular resident who was unable to communicate verbally, their care plan did not indicate how they did communicate, or if staff should use any sign language or communication equipment although discussion with staff did suggest that some needs were being addressed even though there was a lack of clear plans and guidance. Healthcare needs were being met through the use of specialist medical staff at the local hospital, and resident’s files contained medical correspondence to support this. Residents described their attendance at hospital appointments and that their General Practitioner visited them in the home when they needed them, and that the home arranged all this. Alicia Nursing Home I51 17661 Alicia V213103 04.04.05 - Stage 4.doc Version 1.30 Page 11 Although the wishes of some residents had been sought, concerning how they wished to be cared for when dying some had not. This is needed so that everyone is very clear about the individual beliefs and custom of all residents. Alicia Nursing Home I51 17661 Alicia V213103 04.04.05 - Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13 and 15. Dietary needs of residents are well catered for with a balanced and varied selection of food available that meets residents’ tastes and choices. EVIDENCE: The home undertakes menu planning throughout the year, choices at mealtimes are detailed in the homes menus, which are on display in the home for residents to view. These menus show that a nutritionally balanced diet is available and is prepared by the homes catering team. The kitchens were clean and well organised, with temperature checks being undertaken on prepared food, storage fridge/freezers and cleaning schedules were also in place. Several residents commented on how they enjoyed the food and they said it was of a good standard. Visiting times in the home are flexible and residents are able to receive visitors in their own room, if they so wish. Information on the residents’ family or advocate is kept in the residents’ individual file to assist in keeping contact with people who are important to the residents. One relative stated “ l am always made to feel welcome, l have been visiting my relative for over two years and have never had any problems”. Residents’ also spoke of the contact that the home assisted them in maintaining with their families and friends. Alicia Nursing Home I51 17661 Alicia V213103 04.04.05 - Stage 4.doc Version 1.30 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. Complaints are handled in a way that the residents are confident that they will be listened to, and that the home will act upon their concerns. EVIDENCE: The home has a clear complaints policy, which details how to complain, who to complain to and how long you wait until you receive a response to your concerns. Staff through discussion were able to demonstrate that they knew how to respond to residents concerns or complaints, and their description matched the details in the home policy. Records of complaints received are kept by the home; they show how the complaint was investigated and how they responded to the complainant. Residents also spoke of their awareness of their right to complain, and were very clear that they would ask to speak to the manager if they wanted to. Alicia Nursing Home I51 17661 Alicia V213103 04.04.05 - Stage 4.doc Version 1.30 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) 20 and 26. There has been a slight change to the décor in certain parts of the home in the past 6 months; the appearance has improved these areas creating a comfortable environment. Cleaning was not sufficient in all areas of the home; the odour of urine in resident’s rooms is unpleasant and unsatisfactory, for a resident to sleep in. EVIDENCE: The home writes out a maintenance plan each year, this identifies where and when replacement of furnishings and redecoration has and will take place and identified recent redecoration in the home. In the main part of the home each floor has been decorated in its own designated colour and the sitting and dining areas are made to feel homely through the use of pictures and ornaments. Paintwork in this section was clean and unmarked, and furnishings were of a good standard. Alicia Nursing Home I51 17661 Alicia V213103 04.04.05 - Stage 4.doc Version 1.30 Page 15 One residents’ individual room had a very strong odour of urine, the strength of the odour indicated that this was a long term issue, and the home must address this. Alicia Nursing Home I51 17661 Alicia V213103 04.04.05 - Stage 4.doc Version 1.30 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) 29 and 30. Staff are trained and recruitment procedures are robust enough to safeguard residents. EVIDENCE: All staff had training plans in place, these made clear all training received to date alongside the identification of future training needs. Staff confirmed that they had several opportunities to attend training workshops, and certificates of attendance were in place to support this. Several staff had already achieved their National Vocational Qualification at level 2 and 3. Qualified nurses were also employed and had attended courses to support their continuing professional development. Recruitment practices in the home had improved and were sufficient to safeguard the residents in the home. Staff recently employed had been checked against the register designed to protect vulnerable adults, and the remaining required checks and documents were also in place. The qualifications of staff had been checked by the home, references taken up and identification checked before a person was employed in the home. Alicia Nursing Home I51 17661 Alicia V213103 04.04.05 - Stage 4.doc Version 1.30 Page 17 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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 manager has a clear development plan and vision for the home, which she has effectively communicated to the residents’ and staff. EVIDENCE: The home has had a change in its Home Manager since the last inspection. The new manager has already been registered to run another home in the county, and is waiting for her application for this home, to be processed by the Commission for Social Care Inspection. Staff and residents spoke of the improvement in communication in the home since she arrived, and that standard in the home had improved. Staff are clear on the managers expectations concerning their performance, and staff meetings and individual meetings take place with staff to discuss performance and improving the service in the home. Alicia Nursing Home I51 17661 Alicia V213103 04.04.05 - Stage 4.doc Version 1.30 Page 18 A very detailed plan has been written by the manager describing all the areas in the home that she would like to develop and improve, these plans have taken into account the views of residents and staff. Generally health and safety was being managed to a satisfactory level, fire, moving and handling and electrical equipment is checked to make sure it is safe and records of these checks are kept to evidence this. Staff had received training in several areas of health and safety and these included food hygiene, first aid and risk assessment. However the home is not always recording when they check the temperature of water in the bathrooms of the home. This is required to make sure the risk of scalding is reduced for residents and the home must start this practice. Alicia Nursing Home I51 17661 Alicia V213103 04.04.05 - Stage 4.doc Version 1.30 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 x 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3
COMPLAINTS AND PROTECTION x 3 x x x x x 2 STAFFING Standard No Score 27 x 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 x x x x x x 2 Alicia Nursing Home I51 17661 Alicia V213103 04.04.05 - Stage 4.doc Version 1.30 Page 20 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 OP7 Regulation 12(1)(a) & 15 Timescale for action Care plans must contain sufficent 30/06/05 detail for the needs of residents to be met and carried out. (Previous requirement timescale of 01/01/05 not met.) The home must ensure the 30/06/05 wishes of residents for the time of death and funeral arrangements are documented.(Previous requirement timescale of 01/01/05 not met) The registered person must 01/01/05 ensure that all residents who want a key to their room have the opportunity to hold one. (Previous requirement, not assessed at this inspection. All areas of the home must be 30/06/05 kept clean and free from odours. The registered person must ensure that the needs of staff members who work nights are taken into account when planning training or meetings. (Previous requirement, not assessed at this inspection.) Evidence must be available to show that temperature checks have been undertaken in 01/01/05 Requirement 2. OP12 8 3. OP24 12 4. 5. OP26 OP32 16(2)(k) & 23(2)(d) 12 6. OP38 13,16 & 23. 30/06/05 Alicia Nursing Home I51 17661 Alicia V213103 04.04.05 - Stage 4.doc Version 1.30 Page 21 bathrooms to prevent scalding. 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. Refer to Standard Good Practice Recommendations Alicia Nursing Home I51 17661 Alicia V213103 04.04.05 - Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Clifton House Goldington Road Bedford MK40 3NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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