Inspection on 20/09/05 for Archmoor Care Home

This inspection was carried out on 20th September 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

Archmoor Care Home 08/07/09

Archmoor Care Home 03/11/08

Archmoor Care Home 13/11/07

Archmoor Care Home 30/08/06

Archmoor Care Home 02/03/06

Archmoor Care Home 01/03/05

Archmoor Care Home 22/06/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Archmoor Care Home Archmoor Care Home 116 Sandy Lane Middleton Manchester Greater Manchester M24 2FU Lead Inspector Diane Gaunt Unannounced Inspection 20th September 2005 09:00 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 Archmoor Care Home DS0000042848.V250585.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. Archmoor Care Home DS0000042848.V250585.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Archmoor Care Home Address Archmoor Care Home 116 Sandy Lane Middleton Manchester Greater Manchester M24 2FU 0161 653 2454 0161 653 6698 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) Mrs Margaret Elizabeth Pilkington Mr Andrew Pilkington Mrs Margaret Elizabeth Pilkington Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Archmoor Care Home DS0000042848.V250585.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Within the maximum registered number 20, there can be up to : 20 Older People (OP) The service should at all times employ a suitably qualified and experienced manager, who is registered with the Commission for Social Care Inspection. 1st March 2005 Date of last inspection Brief Description of the Service: Archmoor provides personal care and accommodation for up to 20 older persons aged 65 years plus. Staff at the home do not provide nursing care. Archmoor is purpose built and accommodation is provided on two floors in 16 single and 2 double bedrooms. 7 bedrooms have the added provision of an ensuite toilet. A passenger lift services both floors. A lounge, dining area and conservatory are provided on the ground floor. A pleasant and attractive garden/patio area can be easily accessed from the rear of the home. Archmoor is situated approximately 3 miles from Middleton town centre. A regular bus service to the town centre can be accessed within several minutes walking distance of the home. A small car park is available to the front of the home, and on street parking is also available. Archmoor Care Home DS0000042848.V250585.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken over a period of 9 hours. The inspector spoke with ten residents, six relatives, two care assistants, one senior carer, the deputy and the registered manager/provider. Care practice was observed and records looked at. Comment cards asking residents and visitors what they thought about the care at Archmoor were left at the home prior to the inspection but not completed until afterwards. Eight residents and nine relatives filled the cards in and returned them to CSCI. Their opinions are also included in the report. Requirements listed at the end of the report include 3 that had not been met since the last inspection. What the service does well: What has improved since the last inspection? What they could do better: The home must provide more training for staff. Of particular importance is health and safety training, but introductory and basic training as well training in care matters and protection of residents must also be provided. The manager or deputy must watch and advise staff about their daily work, spend time helping them to write care plans and meet with them to discuss their work both on their own and in a group. Care plans and assessments of risk that say what care each person needs must be written with every resident Archmoor Care Home DS0000042848.V250585.R01.S.doc Version 5.0 Page 6 and/or their relative. Staff must then meet with residents and/or their relatives to discuss and record changes to the care. Care managers assess residents before admission but the manager or deputy occasionally do not see the person to assess them before they move. When ever they do see them before admission they should write this down. Management staff should assess residents before they move in to make sure the home can give the care they need. The manager should take a management course, hold more regular staff meetings and attend daily handovers. 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. Archmoor Care Home DS0000042848.V250585.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 Archmoor Care Home DS0000042848.V250585.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. As intermediate care is not provided standard 6 is not applicable. Not all prospective residents had a full assessment and could not therefore be assured prior to admission that all their needs would be met. EVIDENCE: Individual records were kept for each resident and four were inspected. Those who were care managed had a full assessment of needs undertaken by the residents’ care manager. Although the home had an assessment format it was not in use and internal assessments had not been undertaken in respect of some care managed and privately funded residents. In the past the manager or deputy had visited prospective residents in hospital. Whilst the manager encouraged prospective residents to look around the home prior to admission and stay for a meal if they wished, not everyone was able to do so. In some instances therefore, a representative of the home had not met with the prospective resident prior to moving in to ensure their needs could be met at the home. With regard to emergency admissions, information from placing agencies was requested but not always received prior to admission. However, assessment Archmoor Care Home DS0000042848.V250585.R01.S.doc Version 5.0 Page 9 was undertaken on admission and the manager reserved the right to request an alternative placement if Archmoor could not meet the person’s needs. Archmoor Care Home DS0000042848.V250585.R01.S.doc Version 5.0 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 the following standard(s): 7, 8, and 10. Not all resident’s health, personal and social care needs were set out in an individual plan of care. Health care needs were not always appropriately monitored. Residents were treated with respect and their right to privacy upheld. EVIDENCE: Four files were inspected, relating to residents who had lived at the home for 5 years, 1 year, 5 and 3 weeks respectively. A care plan had not been written for the resident who had lived at the home for 5 weeks, others were brief in that they did not clearly identify needs, aims, and required action. The home had a format including this information but it was not in use. For example, a care manager’s assessment identified the need to accommodate a culturally led diet but this information was not transferred to the care plan; in another instance there was no record of a resident’s confusion, disturbed sleep pattern, wandering and agitation. Monthly reviews had been completed by care staff but only in one instance had this been undertaken with a resident or relative. There was little evidence on care plans of residents’ or relatives’ involvement and those interviewed were not familiar with the concept of a care plan. Staff interviewed said they relied on verbal handovers for information about residents. These were supported by daily report notes but these were brief Archmoor Care Home DS0000042848.V250585.R01.S.doc Version 5.0 Page 11 and recorded little about the day/night’s occurrences. Relevant information was not always transferred to care plans or the manager informed of its occurrence. To assist staff in understanding the care needs of a resident who spoke little English, an interpreter had been invited to the home. Staff were using a written sheet of key phrases to aid in communication to positive effect. Observation showed that personal care and hygiene needs were met at the home. This was supported by discussion with residents and relatives. Those interviewed said staff generally responded quickly to call bells. Relatives interviewed said they were informed of important issues pertaining to residents’ health but sometimes had to ask for progress reports regarding ongoing health issues. Those returning comment cards considered they were sufficiently consulted and informed. Residents and relatives interviewed considered staff assisted with moving and handling in an appropriate manner ensuring residents’ well being. Care plans recorded GP, District Nurse and other professional healthcare involvement. None of the residents had pressure sores. Pressure relieving equipment was available if necessary. Continence needs were appropriately assessed and addressed. Residents said the home called their GP when they needed them and the services of opticians, dentists, chiropodist and audiologist were accessed either at the home or in the community as and when necessary. Risk assessments were held with care plans. There was no planned review date and they were not signed by the resident and/or their relative. Risk assessments with regard to nutrition and skin care were not routinely completed, and in one instance had not been put in place for a resident who had suffered weight loss at their previous placement. Residents were not regularly weighed and their weights recorded for monitoring purposes. Residents were offered the opportunity for regular exercise in the form of dancing, armchair exercises, walking in the garden in the summer months, and a fortnightly visit by a physiotherapist. Residents interviewed considered their privacy and dignity was respected at the home. Staff interviewed were able to describe good practice in this area. Relatives commented that observation during their regular visits to the home indicated staff treated residents with respect and upheld their dignity. Safety locks were provided to bedroom doors and new suites of keys had been ordered for the locks. Lockable space was provided in some but not all rooms – the manager agreed to address this matter. Residents and relatives returning comment cards were satisfied with the overall care. Archmoor Care Home DS0000042848.V250585.R01.S.doc Version 5.0 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 the following standard(s): None of these standards were assessed. EVIDENCE: Archmoor Care Home DS0000042848.V250585.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): 16 and 18 Residents and their relatives were confident that their complaints would be listened to, taken seriously and acted upon. Whilst appropriate systems were in place to protect residents from abuse, staff were in need of further training to ensure their full understanding. EVIDENCE: The complaints procedure was included in the Residents Agreement, which they or relatives signed. It was also in the Service User Guide – a copy of which was provided in each bedroom. All but one relative returning comment cards were familiar with the complaints procedure. Complaints forms were available in the office but residents and relatives spoken with said they raised issues before they became complaints and they were resolved at this stage. Complaints were appropriately recorded in the office. The CSCI had not been involved in the investigation of any complaints since the last inspection. Both an internal abuse procedure and the Rochdale Inter-agency Protection of Vulnerable Adults (POVA) procedure were held at the home. Staff spoken with understood the importance of reporting malpractice but had not received training in this area. Neither had the manager and deputy. A POVA investigation, led by Rochdale Social Services Department staff, had been undertaken since the last inspection but allegations were unsubstantiated. Residents said they felt safe living at the home. Archmoor Care Home DS0000042848.V250585.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): None of these standards were assessed. EVIDENCE: Archmoor Care Home DS0000042848.V250585.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): 27, 29 and 30. Sufficient numbers of staff were provided to meet the needs of residents. Whilst recruitment and selection policies supported and protected residents, the home’s practice didn’t always do so. Sufficient training was not provided to ensure the competence of all staff. EVIDENCE: Inspection of three weeks rotas showed that sufficient staff were provided to meet the needs of residents. Feedback from staff, residents and relatives supported the view that there were enough staff on duty each shift to meet residents’ needs. Observation on the day of inspection provided further evidence. Residents spoke well of staff. One resident commented that the quality of the staff was important and made all the difference to the care given. Relatives considered staff to be friendly and welcoming. Inspection of three staff files showed that Criminal Records Bureau (CRB) or Protection of Vulnerable Adults (POVA) checks were taken up, but that the home’s recruitment and selection policy of taking two written references prior to appointment was not always followed. Recent photographs of staff were not held at the home. With these exceptions satisfactory recruitment procedures were followed. In- house induction was provided on appointment and staff said they shadowed other workers until they felt confident enough to work alone. Induction training in line with Skills for Care standards was also provided for care staff but not within 6 weeks of employment. Skills for Care foundation training was not routinely provided. Three care staff had achieved NVQ level Archmoor Care Home DS0000042848.V250585.R01.S.doc Version 5.0 Page 16 2, and 3 were on the course. A matrix to monitor frequency and need for training was not available on the day of inspection but was forwarded to CSCI later. This showed considerable gaps in staff training, particularly with regard to health and safety training. The matrix further showed that staff did not all receive 3 paid days training per annum. Evidence was available that the home was in the process of purchasing training videos to extend the existing provision with regard to resident care as well as health and safety matters. Archmoor Care Home DS0000042848.V250585.R01.S.doc Version 5.0 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 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): 36 and 38 Staff were not sufficiently supervised and considered they lacked guidance. The health, safety and welfare of service users and staff was mostly promoted and protected but staff did not have sufficient training in this area. EVIDENCE: Discussion with staff and inspection of staff files showed that staff were not formally supervised by the registered manager or deputy on a regular basis. Only one of three staff files contained an appraisal completed within the last 12 months. An outstanding requirement is in place. Staff said that the manager and deputy were available to answer queries each weekday and by telephone at other times. However, they did not receive day to day supervision of their work from either the manager or deputy on an ongoing basis. A senior carer was on duty each shift but those interviewed considered they would benefit from regular guidance and oversight of their work by the home’s deputy or manager. Evidence recorded in the Health and Personal Care section above supports this view. Archmoor Care Home DS0000042848.V250585.R01.S.doc Version 5.0 Page 18 Staff meetings for all staff were not held regularly. Records and discussion with care staff showed that health and safety training had been provided but not all carers had attended: 4 staff had current moving and handling training; 1 had a valid 1st Aid certificate, 2 had attended infection control training, and 2 had attended health and safety training. When staff had not attended planned courses. An outstanding requirement is in place. No health and safety hazards were noted during the inspection. Residents and staff considered it a safe place to live and work. Regular maintenance checks were undertaken in line with legislation and building/COSHH risk assessments were written as required. Records and observation showed that the building and equipment were well maintained. Fire precaution checks were undertaken on a regular basis in keeping with GM Fire Officer’s recommendations. Induction included fire training but an annual lecture was not provided. Fourteen staff had not had a fire practice within the last 12 months. A relative raised a health and safety issue regarding a resident smoking in the conservatory – which is a non-smoking area. The smoking policy states that residents should either smoke outside or in their rooms, accompanied by staff. This is included in the residents’ agreement, which is signed on admission and in the service user guide. The inspector was informed the home had already investigated this matter and established that the resident had sat by the open conservatory door. The manager will continue to monitor the situation, and encourage the resident to use her room. Archmoor Care Home DS0000042848.V250585.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 x x x x x x x x STAFFING Standard No Score 27 3 28 x 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x x 1 x 2 Archmoor Care Home DS0000042848.V250585.R01.S.doc Version 5.0 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 15 Requirement That accurate care plans are written and reviewed with all residents and/or their representatives and include needs, aims and required action. That appropriate risk assessments are completed in respect of all residents, agreed with residents and/or their representatives and regularly reviewed. That a record is kept of all belongings brought into the home by a resident, including furniture. (Original timescale: 15/04/05) That staff receive training in the Protection of Vulnerable Adults. That 2 written references and a recent photograph are obtained for each staff member. That staff receive induction and foundation training within 6 weeks and 6 months of employment respectively. That staff are appropriately supervised. (Original timescale 15/05/05) That staff receive training in all DS0000042848.V250585.R01.S.doc Timescale for action 31/10/05 2. OP8 12 30/11/05 3. OP14 17 20/10/05 4. 5. 6. OP18 OP29 OP30 18 17 18 31/12/05 31/10/05 31/12/05 7. 8. OP36 OP38 18 18 30/11/05 31/12/05 Page 21 Archmoor Care Home Version 5.0 9. OP38 23 aspects of health and safety. (Original timescale: 30/04/05) That all staff attend a fire lecture and fire practice every 12 months. 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP3 OP7 Good Practice Recommendations Prospective residents should be assessed by staff prior to admission, and the assessment recorded and agreed by the potential resident and/or their representative. The manager and deputy should work with care staff to complete accurate care plans and reviews, and introduce a monitoring system to ensure they are maintained to a satisfactory standard. Staff should be more pro-active in keeping relatives informed of progress with regard to health issues. The manager or deputy should have formal feedback from the senior on duty at least once per day and observe and supervise their work on a day to day basis. All care staff should receive 3 paid days training per year. The registered manager should undertake the Registered Manager’s Award or equivalent. Staff meetings for all staff should be held more regularly. 3. 4. 5. 6. 7. OP8 OP8OP36 OP30 OP31 OP36 Archmoor Care Home DS0000042848.V250585.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Archmoor Care Home DS0000042848.V250585.R01.S.doc Version 5.0 Page 23 - 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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