Inspection on 01/06/05 for Aspen Court

This inspection was carried out on 1st June 2005.

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

Aspen Court 24/03/09

Aspen Court 02/02/07

Aspen Court 29/09/05

Aspen Court 10/11/04

Aspen Court 11/05/04

Aspen Court 26/09/02

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Aspen Court Aspen Drive Spondon Derby DE21 7SG Lead Inspector Jenny Thornton Unannounced 1June 2005 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. Aspen Court C52 C02 S2137 AspenCourt V230583 010605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Aspen Court Address Aspen Drive, Spondon, Derby, DE21 7SG 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) 01332 672289 01332 669914 ricea@bupa.com BUPA Care Homes Ann Rice Care Home providing Nursing 40 Category(ies) of Older People registration, with number of places Aspen Court C52 C02 S2137 AspenCourt V230583 010605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 10 November 2004 Brief Description of the Service: Aspen Court is a care home providing nursing for 40 older people aged 65 years and over. The home is a two storey purpose built building, situated near to Sponden village and local facilities. The home has 36 single and 2 shared rooms, all rooms have ensuite facilites. The home is on two floors accessed by stairs and a passenger lift. There are a number of lounge and dining areas, as well as a separate smoking area. Residents have access to a well set out garden. Aspen Court C52 C02 S2137 AspenCourt V230583 010605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was un-announced and took place over four hours. The Inspector spoke to seven residents, one relative, three members of staff, the manager and the head of care. Several residents had difficulties in expressing themselves in words and were unable to contribute directly to the inspection, but they were observed throughout the visit as to how well their needs were being met by staff. The Inspector looked around parts of the home and examined various records. What the service does well: What has improved since the last inspection? Further improvements have been made to the environment to make it more homely. Some new bedroom furniture had been provided. Procedures for the safe keeping and handling of medicines have been strengthened. Practices within the home have been reviewed around staff and residents needs. Further improvements have been made to residents care plans to ensure their needs are met. An additional mobile hoist had been ordered in response to staff and residents needs. Residents had recently completed a satisfaction questionnaire about the laundry service. Staff have attended various training and further care staff were working to achieve a national training qualification. Aspen Court C52 C02 S2137 AspenCourt V230583 010605 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. Aspen Court C52 C02 S2137 AspenCourt V230583 010605 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 Aspen Court C52 C02 S2137 AspenCourt V230583 010605 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) 3 Arrangements are in place to ensure that residents’ needs are assessed, although staff need to ensure that all essential information is recorded prior to and following residents admission to the home. EVIDENCE: Three care plans examined contained an assessment of resident’s needs, although some information was brief and did not provide sufficient detail about individual needs and preferences. Efforts have been made to ensure that all information outlined in this standard is recorded on the assessment of need, although information relating to foot and mouth care was not always recorded. Staff had completed a life history for residents that had recently been admitted, which was well completed. Staff had completed various risk assessments for residents, which were well completed except a safe bathing assessment had not been completed for one resident. The manager agreed to address this. Records showed that a qualified nurse had visited residents prior to their admission to ensure the home is able to meet their needs. The home’s preAspen Court C52 C02 S2137 AspenCourt V230583 010605 Stage 4.doc Version 1.30 Page 9 admission assessment form had not been completed for one resident, although some information was recorded. The level of information recorded on the preadmission assessment forms tended to be brief. Resident’s current medication was listed, although this did not include the dose and frequency of all medicines. Aspen Court C52 C02 S2137 AspenCourt V230583 010605 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 10 Improvements have been made to ensure that care plans clearly show how resident’s needs are being met. EVIDENCE: Good progress has been made to ensure that care plans are updated and reviewed at least monthly. Three care plans examined were very detailed and clearly showed how resident’s needs were being met. Staff recorded that care plans had been discussed with the resident or their relative. Daily entries contained a good level of information, and qualified staff had completed a monthly progress report of residents care needs. Monthly reviews of residents care plans were generally well completed, and reported on individual’s progress and wellbeing in regards to each care plan. Some reviews recorded ‘care plan still relevant’, which did not demonstrate that residents were receiving appropriate care. It was clear from discussions with residents and staff that resident’s health and personal needs are well managed; these were set out in care plans, although aspects of personal care needs were not clearly recorded. Residents said that staff duly arranged for their G.P. to visit when they were unwell or to carry out health checks. Information relating to visits from health professionals such as Aspen Court C52 C02 S2137 AspenCourt V230583 010605 Stage 4.doc Version 1.30 Page 11 G.P, dentist, and optician was clearly recorded in resident’s files; a new form had been introduced to record chiropodist visits to aid communication. Residents spoken with said that their privacy and dignity is respected. Aspen Court C52 C02 S2137 AspenCourt V230583 010605 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) 12 Social activities are well organised and residents’ social needs and interests are met. EVIDENCE: Daily routines were generally flexible, several residents preferred to get up later and have a late breakfast, which staff respected. Some residents preferred to spend time and have their meals in their room. The home continues to provide a full time activities person, who has established a varied activities programme, which takes into account individuals interests and preferences. The activities person was leaving due to personal circumstances, and the manager said that the home was advertising for a new activities person. Residents confirmed that the home provides a planned activities programme, which includes a good range of activities and outings. Residents said they enjoyed the social activities and outings provided. On the day of this inspection, nine residents and several relatives and staff went out for lunch. Some residents preferred not to participate in the activities provided and staff respected this. Aspen Court C52 C02 S2137 AspenCourt V230583 010605 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) EVIDENCE: The above standards were not assessed on this inspection. Residents and a relative spoken with said that they found staff approachable and felt that concerns are listened to and acted upon. Aspen Court C52 C02 S2137 AspenCourt V230583 010605 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) 19, 24 and 26 The environment is safe and well maintained to ensure residents comfort. EVIDENCE: All residents spoken with considered that the environment is well maintained, very clean and free of odours. Areas of the environment seen on inspection were well maintained and clean. Rain was leaking through a section of the conservatory roof; the manager was aware of this and was taking action to address the problem. The Inspector noted a slight odour in the main lounge and dining area. The manager confirmed that the lounge carpets had recently been cleaned, and queried if the cleaning products used had left an odour. The manager agreed to follow up this issue. The manager confirmed that further work had been carried out to make the environment more homely, which was apparent on this inspection. The manager planned to carry out further work and create a homely setting throughout all areas. Resident’s bedrooms contained personal belongings and reflected individual’s preferences. New bedroom furniture had been provided Aspen Court C52 C02 S2137 AspenCourt V230583 010605 Stage 4.doc Version 1.30 Page 15 in one bedroom, and the manager reported plans to replace further bedroom furniture. Locks are not fitted to bedroom doors; the manager had consulted with the fire officer about fitting suitable locks. The head of care said that all residents had been informed that they could have a bedroom door lock fitted for privacy, although no resident had requested this facility. The head of care was looking where best to record this information in resident’s care plan. Residents spoken with said that personal clothes were well laundered by the home, and that they had recently completed a satisfaction questionnaire as to their views on the laundry service. Observations and discussions with staff showed that a high percentage of residents required a hoist to transfer. The home currently had three mobile hoists, which were appropriately used. Staff had identified the need for a ‘stand aid’ hoist and the manager said that this had been ordered. The garden was attractively set out, well maintained and contained seating and a covered area for resident’s comfort. Residents were able to access the garden. Several residents commented that they enjoyed spending time in the garden. Aspen Court C52 C02 S2137 AspenCourt V230583 010605 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) 27 and 30 The home is sufficiently staffed to meet residents’ needs. Staff receive a good level of training to ensure they have the skills to care for residents. EVIDENCE: Staff and residents spoken with considered that sufficient staff are generally provided to meet residents needs. The home has a large team of staff, and the manager is supernumerary to the required staffing levels. The head of care also receives 3 days supernumerary time, which enables her to supervise the care and services in the home. The home experienced a considerable turnover of staff last year. Discussions with staff and records showed that the number of staff changes within the team and the need for agency staff support had reduced over the last six months, resulting in residents receiving care from staff they know. The home had recruited additional staff to replace staff that had left. Staff felt that morale had improved and that they were working together as a team; which was evident on this inspection. Residents said that they had formed good relationships with the majority of staff. The home has an annual training and development plan to ensure staff receives appropriate training. Staff spoken with said that the home provides good training opportunities and that they had attended recent trained. Records showed that staff had attended various training, and that further care staff were undertaking a national approved qualification (N.V.Q), to ensure they are trained and competent to do their job. Records showed that a new member of staff who started work in December 04 had completed the home’s Aspen Court C52 C02 S2137 AspenCourt V230583 010605 Stage 4.doc Version 1.30 Page 17 induction programme to a good standard. The member of staff had yet to commence the home’s foundation-training programme. Not all staff had attended training on protecting residents; the manager reported that further training was planned. Aspen Court C52 C02 S2137 AspenCourt V230583 010605 Stage 4.doc Version 1.30 Page 18 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) 36 Arrangements are in place to ensure that staff are closely supervised in their work and receive regular supervision meetings. EVIDENCE: The home is well managed. The manager and head of care work in the home most days and closely supervise staff in their work. Discussions with staff and records showed that staff are appropriately supervised. Good progress has been made to establish regular one to one supervision meetings with all staff. Records of supervision meetings did not routinely include staff’s development needs; the managers said that this was covered in their annual appraisal. Aspen Court C52 C02 S2137 AspenCourt V230583 010605 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 x x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x x 3 x x Aspen Court C52 C02 S2137 AspenCourt V230583 010605 Stage 4.doc Version 1.30 Page 20 No 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 3 Regulation 14 Requirement Staff must complete a full assessment of residients needs and preferences to enable them to meet identified needs. A phased programme must be carried out to fit suitable locks to bedroom doors. This requirement is carried forward from the inspection reports dated May and November 2004. All staff must receive training on the vulnerable adults procedure. Timescale for action 31 July 2005 31 December 2005 2. 24 12 3. 4. 30 13 30 October 2005 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. 3. 4. Refer to Standard 7 19 19 24 Good Practice Recommendations Care plan reviews should clearly show that residents are receiving appropriate care. The manager should monitor the presence of odours in the day areas The manager should continue to create a homely enviroment throughout all areas of the home. Residents care plans should clearly show that they have been given the opprtunity to have a door lock fitted to C52 C02 S2137 AspenCourt V230583 010605 Stage 4.doc Version 1.30 Page 21 Aspen Court 5. 6. 30 36 their bedroom. All staff should complete the home’s foundation-training programme within the first six months. All care staff should receive formal supervision at least six times a year. Records of staff supervision should cover all areas listed in standard 36.3 Aspen Court C52 C02 S2137 AspenCourt V230583 010605 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Cardinal Square Nottingham Road Derby DE1 3QT 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 Aspen Court C52 C02 S2137 AspenCourt V230583 010605 Stage 4.doc Version 1.30 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!