CARE HOMES FOR OLDER PEOPLE
Ambassador Care Home 670/672 Lytham Road Blackpool Lancashire FY4 1RG Lead Inspector
Mr Kevan Royston Unannounced Inspection 26th October 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 Ambassador Care Home DS0000061568.V250517.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. Ambassador Care Home DS0000061568.V250517.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Ambassador Care Home Address 670/672 Lytham Road Blackpool Lancashire FY4 1RG 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) 01253 406371 01253 400990 D M Care Limited Mrs Lesley Anne Holbrook Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Ambassador Care Home DS0000061568.V250517.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. A suitably qualified and experienced manager, who is registered with the Commission for Social Care Inspection must be employed at all times. The home may accommodate up to 31 service users in the Older Person (OP) category. 25th May 2005 Date of last inspection Brief Description of the Service: The Ambassador Care Home provides accommodation for 28 older people of both sexes. The home is a large detached property situated in the south area of Blackpool close to the airport and Highfield Road shopping centre. Local bus and tram routes are accessible and close by. The accommodation comprises of two lounges, a large dining area and a recently built conservatory. The front and rear garden areas provide seating for the residents and at the rear of the property there is a lawned garden area. The bedrooms are en-suite with aids and adaptations to the communal bathrooms and toilets situated on the three floors of the premises. There is a passenger lift to all three floors. Ambassador Care Home DS0000061568.V250517.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place on the 25/10/05 over 5 hours and was unannounced. The Inspector spoke to the registered manager, a visitor to the home, staff and six residents. As part of the inspection process the inspector used case tracking as a means of assessing some of the National Minimum Standards. The process allows the inspector to focus on a small number of people living at the home. All records relating to these people are examined and the rooms they occupy are looked at. Other residents are invited to pass their opinions to the inspector if they wish. A tour of the premises was undertaken. Examination of the homes documentation, policies and procedures formed the basis of the inspection. What the service does well: What has improved since the last inspection?
Ambassador Care Home DS0000061568.V250517.R01.S.doc Version 5.0 Page 6 A requirement from the last inspection to provide covers for all radiators has now been completed ensuring the safety of the residents is maintained. Also the homes application form has been updated to make sure the right checks are in place when employing new members of staff in order to protect the residents. The exterior and interior of the building has been partly redecorated ensuring the home looks clean therefore providing a pleasant environment for the residents. One resident said, “They are always trying to improve the building.” 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. Ambassador Care Home DS0000061568.V250517.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 Ambassador Care Home DS0000061568.V250517.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): 3 The admission and assessment procedures were clear to ensure the care needs of residents are met. EVIDENCE: The records of three residents examined, one recently admitted, had full assessment information. Staff members confirmed they had access to this information and could describe in detail the care needs of residents. Social worker assessments examined had been obtained prior to admission. The registered manager confirmed only trained senior staff carries out assessments and all residents are invited to visit the home prior to moving in. One resident spoken to said, “I had visited the home a few times before deciding to move here.” Ambassador Care Home DS0000061568.V250517.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 and 10. Promotion of health is taken seriously. Residents welfare is closely monitored and health needs are identified and met. EVIDENCE: Individual records are kept for each resident with a plan of care setting out in detail the action that needed to be taken by care staff to ensure all aspects of health, personal and social care needs of the residents were met. Three residents records were examined. A resident spoken to was not aware of his care plan but knew his health and daily needs were discussed regularly and said, “The staff are always enquiring about my health they do care they are always checking up on me.” Significant events had been recorded and daily entries made explaining the care given. Examination of the records show risk assessments, care plans, activities preferences, reviews and other personal information are up to date and reviewed with the involvement of the resident. One resident said, “A very caring home with lovely staff.” Discussion with the registered manager and examination of records show risk assessments are constantly reviewed and updated reflecting any changes that have occurred individually and the environment.
Ambassador Care Home DS0000061568.V250517.R01.S.doc Version 5.0 Page 10 Medication practices observed were safe and good records had been kept ensuring residents health is maintained. However further checks in relation to staff recording of administering medication could be put in place to ensure the safety and protection of the residents. Ambassador Care Home DS0000061568.V250517.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): 12, 13, 14 and 15. Contact with families is encouraged and supported by staff to maintain relationships. Activities and meals are varied and well managed and choice is provided for people living at the home. EVIDENCE: Lunchtime meals served were seen to be wholesome, and varied. Menus examined are balanced and interesting. Meal times are set although flexible enough to accommodate preferences. Residents spoken to commented on the high quality of food at the home. Comments included, “There is always a choice. “ “If you don’t like something they will give you something you like.” “The food is very good and plenty of it.” There was evidence of structured activity programmes with daily events taking place and outside entertainers visiting the home. On the notice board it confirmed events taking place over the month, such as a party for Halloween, a fireworks and buffet evening and an organist visiting the home. A resident said, “I do enjoy some of the social events and wish there was more.” Records of residents examined identified personal interests and hobbies. The registered manager said, “We try to identify residents interests and try to accommodate them.” Ambassador Care Home DS0000061568.V250517.R01.S.doc Version 5.0 Page 12 Residents spoken to confirmed visitors are allowed at any time of the day or night. One resident said, “I can see friends or family at any time wherever I want in the home. Staff bring my visitors a cup of tea every time.” Resident rooms seen had evidence of personal belongings, and provided residents with a homely and comfortable environment. Ambassador Care Home DS0000061568.V250517.R01.S.doc Version 5.0 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 the following standard(s): This section of standards was not assessed. EVIDENCE: Ambassador Care Home DS0000061568.V250517.R01.S.doc Version 5.0 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 the following standard(s): 25 and 26 The home was clean and tidy and maintained to a high standard ensuring the residents comfort and safety in pleasant surroundings. EVIDENCE: Walking around the home it was found to be clean and well maintained to a high standard. A visitor to the home commented, “The home is spotless” The requirement from the previous inspection to cover all radiators has now been addressed ensuring the residents safety. Hot water temperatures were regulated and recorded providing protection for residents and ensuring appliances are in working order. Ambassador Care Home DS0000061568.V250517.R01.S.doc Version 5.0 Page 15 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): 29 The policies and procedures for the recruitment of staff are robust and provide safeguards for the protection of residents. EVIDENCE: Examination of the application form for new staff required updating to request any gaps in employment. This has now been addressed, to ensure proper checks on potential staff are carried out prior to employment and provide safeguards for the residents. Ambassador Care Home DS0000061568.V250517.R01.S.doc Version 5.0 Page 16 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): This section of standards was not assessed. EVIDENCE: Ambassador Care Home DS0000061568.V250517.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 x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x x x x x x x 3 3 STAFFING Standard No Score 27 x 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x x x x x Ambassador Care Home DS0000061568.V250517.R01.S.doc Version 5.0 Page 18 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. Standard Regulation Requirement Timescale for action 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 Ambassador Care Home DS0000061568.V250517.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1 Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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