Inspection on 11/01/06 for Amblecote House

This inspection was carried out on 11th January 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Amblecote House 07/01/09

Amblecote House 27/02/07

Amblecote House 15/06/05

Amblecote House 20/01/05

Amblecote House 26/08/04

Amblecote House 15/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Amblecote House King William Street Amblecote Nr Stourbridge West Midlands DY8 4ES Lead Inspector Mr Keith Salmon Unannounced Inspection 11th January 2006 09:30 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 Amblecote House DS0000041946.V275467.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 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. Amblecote House DS0000041946.V275467.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Amblecote House Address King William Street Amblecote Nr Stourbridge West Midlands DY8 4ES 01384 813515 01384 813516 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) N/K Dudley Metropolitan Borough Council Mercedes Holness Care Home 36 Category(ies) of Dementia (11), Old age, not falling within any registration, with number other category (25) of places Amblecote House DS0000041946.V275467.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Daycare provision must not encroach on the facilities, staffing and services, provided to residential service users By the 30 September 2003, all radiators and exposed pipe work in bathrooms and within areas accessed by service users shall not exceed 43 deg C in the interim following risk assessments, strategies are implemented to safeguard service users. All requirements contained within the registration report of 6,9, and 12 December 2002 are met within the timescales contained within the action plan agreed between Dudley Metropolitan Borough Council and the National Care Standards Commission. All recommendations made by the West Midlands Fire Services detailed in their report dated 2 April 2003 to be met by the 30 September 2003. 15th June 2005 3. 4. Date of last inspection Brief Description of the Service: Amblecote House is owned by Dudley Local Authority and managed by their Social Services Department. Registered to provide residential care services for 36 people over the age of 65, it is situated within the local community, close to the Brierley Hill and Stourbridge shopping centres and is accessible by public transport. The building provides single bedroom accommodation, on one floor, and is shaped in a square providing two small inner garden areas, one of which is lain to lawn, the other with shrubs and flowerbeds. The Home also provides a day care facility used by Residents and non-Residents. Amblecote House DS0000041946.V275467.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Unannounced Inspection, undertaken by one Inspector, commenced at 09.30 and lasted 5 hours. This Report is a product of observations made during a tour of the Home, through discussions with the Registered Manager, several members of Staff, 8 Residents and 3 Relatives. In addition, a review was undertaken of care related documentation, staff recruitment/deployment records, and a range of documents/records reflecting the general operation of the Home. The overall ambience of the Home presents a very friendly and open atmosphere with Residents enabled to conduct their ‘day’ as they wish, which was strongly reflected in ‘one to one’ discussions with Residents and Relatives. Comments made to the Inspector included: - “My Mother has been here for many years and the Staff have always been wonderful – nothing is too much trouble. Their attention to the finer details is excellent”… “I’m very happy with the standard of care and attention at the Home”…, “The Staff are very friendly and do everything they can for us…”, “They organise lots of trips and entertainments for us”… The Home has responded positively, and effectively, in meeting most of the Requirements identified at the previous Unannounced Inspection in June 2005 (the majority of which were outstanding from previous Inspections). What the service does well: What has improved since the last inspection? What they could do better: The Home is well managed and provides a good quality of care in accordance with national Minimum Standards/Statutory Regulations. However, an issue relating to security of Residents and Staff was noted. The detail of this matter was brought to the attention of the Registered manager by way of the issuing of an ‘Immediate Requirement’. Amblecote House DS0000041946.V275467.R01.S.doc Version 5.1 Page 6 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. Amblecote House DS0000041946.V275467.R01.S.doc Version 5.1 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 Amblecote House DS0000041946.V275467.R01.S.doc Version 5.1 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 Pre-admission information is sufficient to enable prospective Residents to make an informed decision regarding entering the Home, and their rights are protected by a written Contract setting out Terms and Conditions of Residency. EVIDENCE: The Home has a Statement of Purpose and User Guide, both of which are concise, easy to read and contain content, which meets the requirements of the Standard. A random review of a sample of Residents’ Personal Files (10) Residents’ showed evidence of Terms and Conditions documentation, complete with signature of agreement either by the Resident or his/her Agent. Amblecote House DS0000041946.V275467.R01.S.doc Version 5.1 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. The model of Care Plan utilised by the Home is of good design, easy to read and comprehensive. The care provided by the Home meets the Residents’ assessed care needs, and is delivered considerately and effectively. The storage, administration, and disposal of medicines are in accordance with accepted good practice. EVIDENCE: A review of 10 Residents’ Care Plans showed them to be well organised, current, clearly written and comprehensively encompassed the range of ‘care areas’ necessary to ensure the delivery of care appropriate to the needs of each Resident (They now include coverage of all relevant ‘risk assessments). Inspection of the medicine storage provision and medicine administration records demonstrated the Home’s practices meet the guidelines of the Royal Pharmaceutical Society. Amblecote House DS0000041946.V275467.R01.S.doc Version 5.1 Page 10 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): 13 &15. Where Residents’ capabilities permit, the Home works with Residents to enable good contact with family and friends and continuation of religious practices. The Home provides nutritionally balanced meals based on the type of food preferred by the Residents. EVIDENCE: Visitors spoken with confirmed they are always welcome at the Home and that they are kept well informed regarding the wellbeing of their Relative/friend. The Home provides a printed menu, the contents of which appeared well-balanced, nutritious and varied. Residents spoken with all commented the food was plentiful and to their liking. Amblecote House DS0000041946.V275467.R01.S.doc Version 5.1 Page 11 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 & 18. The interests of Residents are protected through ready access to the Home’s Complaints Procedure and information relating to advocacy services. Staff are clearly aware of their role in protecting Residents from abuse. EVIDENCE: There are policies and procedures in place to facilitate protection of vulnerable people and which meet the requirements of this Standard. Evidence was observed in Staff files confirming this topic is covered both at induction and through on-going staff training. Amblecote House DS0000041946.V275467.R01.S.doc Version 5.1 Page 12 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): 19,20,22, 23,25 & 26. With the exception of an issue identified below (see Standard 38) Residents live in a safe, well-maintained environment. The Home’s lounge/sitting and dining areas offer a good variety of size and outlook, with furnishings and decoration being of good order and presenting a ‘domestic’ ambience. Generally, bedrooms meet the requirements of Residents’ individual needs. However, some Residents are not able to directly control the ambient temperature in their room. Specialist equipment is available to facilitate provision of care, e.g. hoists, wheelchairs, stand-aids and consistent with the needs of Service Users. EVIDENCE: A tour of the Home demonstrated that Statutory Requirements relating to the correct closing of fire safety doors, and the effective ‘boxing’ of previously exposed water pipes, have been met. The Home has an on-going programme for the installation of replacement radiators in all bedrooms, which provide Residents with a hand adjustable thermostat. The laundry is well organised with large washing capacity provided by ‘industrial’ size machines and has benefited from replacement wall tiling. The cleanliness in all areas of the Home is a credit to the Housekeeping Staff. Amblecote House DS0000041946.V275467.R01.S.doc Version 5.1 Page 13 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): 27,28,29 & 30 Staff numbers and skill-mix on duty were consistent with that shown on the rota, and were sufficient to meet the assessed care needs of current Residents. Recruitment and employment practices are consistent with the safeguarding of Residents. EVIDENCE: The current staffing rota, and those from the immediately preceding weeks, were examined. Staffing numbers and skill-mix enable a service provision, which meets the care needs of the Service Users. Staff Personnel Files demonstrated evidence of full compliance with the Standard and Schedule 2 of the Regulations. Staff files further confirmed they undertake relevant orientation/induction programmes, followed by comprehensive ‘foundation’ training, e.g. ‘manual handling and lifting’, ‘fire safety’, ‘simple infection control’. Amblecote House DS0000041946.V275467.R01.S.doc Version 5.1 Page 14 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 & 38. The Home has excellent leadership from the Manager, who is very well supported by longstanding and experienced Staff. Operationally, the Home is very well organised, with the central purpose being ‘the best interests of Residents’. Lines of accountability are clearly defined and observed. Staff are subject to effective support, with regular supervision, and appeared involved and happy in their work. Accounting and financial procedures are conducted and recorded efficiently. The security of Residents and Staff is at risk. EVIDENCE: The Registered Manager has many years experience as a Care Manager, and is clearly closely involved in day-to-day ‘hands-on’ management. In addition, the senior support staff showed they are very capable in acting in the Manager’s absence (the Manager was away from the Home attending an ‘off-site’ meeting for a considerable period of the Inspection.) The Home conducts financial management of personal monies for a number of Residents. Due to the ‘impressed’ system in use (as determined by the Local Authority Finance Practices) amounts for individual Residents are ‘pooled’, which is contrary to Amblecote House DS0000041946.V275467.R01.S.doc Version 5.1 Page 15 the Standard (i.e. individual Residents’ personal monies should be kept as separate amounts). However, it should be reported the system in use by the Home to record transactions, and to keep receipts, is properly implemented and is backed by evidence of regular audit. The Home’s operational practices, in the context of health, safety and welfare of Residents, Visitors, and Staff, were seen to be in accordance with the Regulations. An issue relating to security of Residents and Staff was noted by the Inspector and bought to the attention of the Registered Manager. The detail of this was set out in an ‘Immediate Requirement’, and directly following this Inspection the Registered Manager brought the matter to the attention of the Registered Responsible Individual. It is expected that related remedial action will be undertaken both in the short and long term. Amblecote House DS0000041946.V275467.R01.S.doc Version 5.1 Page 16 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 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 X 3 2 X 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Amblecote House DS0000041946.V275467.R01.S.doc Version 5.1 Page 17 Are there any outstanding requirements from the last inspection? NO Amblecote House DS0000041946.V275467.R01.S.doc Version 5.1 Page 18 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 OP25OP23 Regulation 13,16 & 23 Requirement To complete the radiator replacement programme, to provide each Resident with the means to control the heating in their bedrooms. This is an outstanding requirement from the last two Inspections. To submit to the CSCI (Halesowen Office) written proposals, for agreement, detailing remedial action to be taken by the Home in response to the ‘Immediate Requirement’, as issued to the Registered Manager, relating to security of Residents and Staff. Timescale for action 31/07/06 2. OP38 13.-(4)(c) 31/01/06 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 Amblecote House DS0000041946.V275467.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Amblecote House DS0000041946.V275467.R01.S.doc Version 5.1 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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