Inspection on 08/01/09 for Aspen Grange Care Home

This inspection was carried out on 8th January 2009.

CSCI found this care home to be providing an Poor service.

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 Grange Care Home 08/07/09

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

CARE HOMES FOR OLDER PEOPLE Aspen Grange Care Home 18 Wharncliffe Road Boscombe Bournemouth Dorset BH5 1AH Lead Inspector Jo Johnson Unannounced Inspection 8th January 2009 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 Aspen Grange Care Home DS0000072288.V373801.R01.S.doc Version 5.2 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. Aspen Grange Care Home DS0000072288.V373801.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Aspen Grange Care Home Address 18 Wharncliffe Road Boscombe Bournemouth Dorset BH5 1AH 01202 395435 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) Mr Kevin Gunputh Mr David Leedham Mrs Louise Tabitha Pidgeon Mrs Deborah Mary Usher Care Home 43 Category(ies) of Old age, not falling within any other category registration, with number (43) of places Aspen Grange Care Home DS0000072288.V373801.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Old Age, not falling within any other category (Code OP) The maximum number of service users who can be accommodated is 43. Date of last inspection Brief Description of the Service: Aspen Grange is a large, detached house, situated in the Boscombe area of Bournemouth. It is registered to accommodate up to 43 older people who are in need of personal care. The property has limited on-site parking for visitors. Street parking is also available in the vicinity of the home. The home has a small, sheltered garden with lawn area and a courtyard garden with summerhouse. Aspen Grange is situated within level walking distance of the amenities of Boscombe, including shops, restaurants, cafes, places of worship, library etc. The sea front and Boscombe Gardens are also within walking distance (sloping in part). There is a bus service to the centre of Bournemouth and other areas of the town from the nearby Christchurch Road. Aids and equipment are available for people with disabilities, including ramps to aid access to and from the home, (portable ramp used for two doors) and assisted bathing facilities. Accommodation is provided over two floors in 39 single and 2 double rooms. The home is centrally heated throughout and 28 bedrooms have en-suite facilities. Access between floors is by means of two passenger lifts or stairs. The home has lounges and two dining rooms. Aspen Grange Care Home DS0000072288.V373801.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is zero star. This means the people who use this service experience poor quality outcomes. The focus of inspections undertaken by us is upon outcomes for people who live at the home and their views of the service provided. This process considers the homes capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. This report uses information and evidence gathered during the key inspection process, which involves a visit to the home and looking at a range of information. This includes the service history for the home and inspection activity, notifications made by the home, information shared from other agencies and the general public and a number of case files. The proposed manager supplied the commission with an AQAA (Annual Quality Assurance Assessment). Information from this has been used to make judgements about the service, and have been included in this report. The manager distributed surveys to people who live at the home and staff. Three surveys from people and five staff surveys were returned. The findings of these surveys have been included in the report. This inspection visit was unannounced (we did not let the home know that we were coming) and took place on 8th January between 9.30 am and 3.45 pm by two inspectors. The current registered manager was present throughout the inspection; the two registered providers were also present at different times during the inspection. The inspection was conducted by two inspectors and involved observations of and talking with people who live at the home, the staff on duty, the manager and the new registered provider. Four people were identified for close examination by reading their care plan, risk assessments, daily records and other relevant information. This is part of a process known as case tracking, where evidence is matched to outcomes for people. A tour of the environment was undertaken, and home records were sampled, including staff training and recruitment, health and safety, and staff rotas. Aspen Grange Care Home DS0000072288.V373801.R01.S.doc Version 5.2 Page 6 This inspection was carried out by two inspectors, but throughout the report the term we is used, to show that the report is the view of the Commission for Social Care Inspection. What the service does well: What has improved since the last inspection? What they could do better: Since the last inspection in 2007, there has been deterioration in the quality of the service provided by the home and on the outcomes and the safety and well being of the people who live there. Accurate full assessments must be completed for people. This is to make sure that peoples needs are identified, the home can meet their needs and staff know how to care for them. The ongoing assessment process for people must identify when the home is not able to continue to safely meet their needs. This is so people whose needs have increased or changed move to a more appropriate care setting. Aspen Grange Care Home DS0000072288.V373801.R01.S.doc Version 5.2 Page 7 The home must not admit people who they are not registered to care for. They must not admit people with dementia or needing nursing care. This is to make sure that the home is able to meet an individuals needs. Peoples care plans must be reviewed, kept up to date, and include all the individuals needs identified in their assessments. This is so staff know what care and support people require to make sure that all their needs are met and they are well cared for. Any areas of risk identified for an individual must assessed and these assessments must include nutrition, pressure areas, behaviour and falls. This is so that any risks are minimised and staff know what action to take to keep people safe and well. Accurate care records must be maintained for people. This is to demonstrate that people are being provided with the care and support they have been assessed as needing. Individuals’ personal information must be recorded in their records and not in a communal record. This is to maintain peoples’ confidentiality and to comply with data protection. People must be provided with suitable stimulation and have the opportunity to be occupied. This is to ensure that people have a good quality of life and well being. All allegations of abuse must be referred to the local authority and the commission. This is to make sure that any allegations are appropriately investigated and actions taken to safeguard people living at the home. Windows must be risk assessed, made safe and risks minimised where any risks are identified. Staffing levels provided at the home must be based upon the individual needs of the people who live there. Staffing levels throughout the day and night must be based on people’s needs. This is to make sure that there is sufficient staff throughout the day and night to meet the personal, physical, social and psychological care and support needs of the people at the home. The overall management of the home must improve, and develop effective ways of assessing and monitoring the quality of the service. This is so that shortfalls are identified, are improved on and the quality of the service is kept under constant review. Aspen Grange Care Home DS0000072288.V373801.R01.S.doc Version 5.2 Page 8 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. The summary of this inspection report can be made available in other formats on request. Aspen Grange Care Home DS0000072288.V373801.R01.S.doc Version 5.2 Page 9 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 Aspen Grange Care Home DS0000072288.V373801.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is poor. People’s needs are assessed before moving in but they cannot be sure the home can safely meet their needs. It is not clear whether all people’s needs are reassessed so that staff can continue to meet their changing needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One of the three surveys from people told us that they had enough information before moving into the home. One person being case tracked said that someone had visited them in hospital before they moved in. They told us that they had not looked at the home themselves but their relatives had chosen the home for them. Aspen Grange Care Home DS0000072288.V373801.R01.S.doc Version 5.2 Page 11 The registered or proposed manager undertakes a pre admission assessment before determining whether they can meet someone’s needs. A fuller assessment, risk assessments and a social history assessment are completed with people as soon as they move in. From this a care plan is developed. The assessments for four people were looked at. This included the most recent admission to the home and one person who was recently readmitted following a short stay in hospital. All four people had pre-admission assessments completed before they moved into the home. However, from these assessments it is not clear whether the home is always admitting people whose needs they can meet or updating people’s assessment and care plans as their needs change. For example: The assessment for the last person to move into the home included information that indicate that their needs are too high to be met in a care home registered for older people only. The funding authority assessment detailed that the individual has a diagnosis of dementia and requires nursing care. Both the funding authority and the proposed manager’s assessment identifies that the individual may be aggressive to other people. One person who has become much frailer and dependent following a hospital admission has not had their assessment updated to reflect their current needs. Another person who was admitted in October has a dementia, presents challenges and risks to themselves and other, and can be verbally and physically aggressive. The home is not registered to care for people with dementia but for older people only. Aspen Grange Care Home DS0000072288.V373801.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is poor. Care plans and risk assessments do not identify and or consistently describe the actions necessary to meet the identified needs of people living in the home, which puts them at risk of not having their needs met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Five people’s care records were looked at. The organisation has a standard assessment, care planning, risk assessment and daily recording system. The information gained from the initial assessments should identify needs that must be risk assessed and planned for. The shortfalls identified mean that elements of peoples lives are not up to date, risk assessed or planned for in sufficient details for staff to be able to meet their needs. For example: Aspen Grange Care Home DS0000072288.V373801.R01.S.doc Version 5.2 Page 13 One person who was readmitted into the home from hospital did not have their care plan or risk assessments reviewed and updated to reflect their changed needs. This individual’s health deteriorated again four days later and they were seen by the GP. The care plan was again not updated to reflect the care needed and the pressure area and moving and handling risk assessment had not been reviewed since before their hospital admission. The daily care records were very sparse for an individual who is receiving palliative or end of life care. The care plan referred to turn charts but these were not being used. This means that it is not clear whether the individual is being turned at night. Another person had a number of falls in October 2008 and their falls risk assessment was not reviewed to reflect this change. A pressure mat, that sounds an alarm when it is stood on, was placed by the bedroom door. However, it is not clear what benefit this would have been for the individual, as they were seated in their armchair in the middle of the bedroom. The personal profile section in the care plans seen had very little or no information about the individuals. Two of the people have dementia and one of them has very complex behaviours, the staff spoken knew very little about them as individuals and about their lives. The daily care records were seen. There were a number of gaps in these records for some people. For one person with complex needs and dementia who moved into the home on 29th December 2008 there was no recording from 31st December to 4th January. This is a matter of serious concern as there are a number of people with high and complex needs and there is not any record of the care and support provided to them. The manager told us that this issue has been raised with the staff. There were body maps for one person included in the daily care records. That showed an injury that had been inflicted by another person living at the home. There had been no follow up of this incident nor had it been reported under adult protection safeguarding procedures. There were separate records of people’s fluid and nutritional intake and people’s weight was being recorded. There were also turn charts kept in people’s bedrooms. However, there was not any clear way of collating or monitoring the information for each individual to ensure that people are getting the care and support that they need. The staff communication book included personal care and health information about people. This is a communal record and means that people’s information is not kept private and confidential. The care plan for one person with dementia did not include their photo or risk assessments for them leaving the home or going missing. This person is at risk of injuring themselves and there have been incidents where they have Aspen Grange Care Home DS0000072288.V373801.R01.S.doc Version 5.2 Page 14 harmed other people living at the home. From the daily records, we established that this person routinely become distressed in the evening and during the night and attempts to leave the home by any means. This included attempting to climb out of a second floor window. Advice and assessments have been sought from the appropriate health professionals. Accurate records of this individual’s behaviours should be kept that include the circumstances, the behaviour and consequences. This will assist the health and social care professionals working with the person to understand when they are getting unsettled or upset. There was evidence in people’s care records that they have good access to health care and relevant health care professionals such as GP, dietician, dentist and specialist consultants and chiropodist. People spoken with and three surveys told us that they ‘always’ or ‘usually’ receive the medical support and care that they need. The medication records for four people were looked at. The medication records were completed correctly and medications were stored safely. One person takes Warfarin and their routine blood test was overdue by a week. The manager had contacted the GP surgery to arrange this and explained that this was an oversight as the system had changed. People were generally well groomed and cared for. People spoken with said that staff always take care to make sure people are well dressed and their appearance is cared for. Staff spoken with had a good understanding of recognising people as individuals and respecting their privacy and dignity. They were observed respecting people’s privacy and dignity, by knocking on their doors and offering personal care discreetly and in private. People spoken with and surveys told us that staff treat them well and that staff listen to and act on what they say. People said “staff are all very good and treat me well” and “staff are all lovely and I get on well with them”. Aspen Grange Care Home DS0000072288.V373801.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. People who live at the home that are able to participate in social activities and are given choices to maintain their quality of life. People with dementia who live at the home have very little opportunity to participate in daily living or stimulating activities. This means that there are long periods of time when people are unoccupied and become unsettled and or upset. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People spoken with said that their visitors were made to feel welcome whenever they visited. People spoken with and observed got up and spent their time how and where they chose if they could walk independently. Some people chose to spend time in their bedrooms. Aspen Grange Care Home DS0000072288.V373801.R01.S.doc Version 5.2 Page 16 The manager told us that they have arranged for people to be able to worship if they choose to. An activities schedule is in place, which shows that there is an activity being provided most weekdays. This is usually in the main lounge. One the day of inspection we did not observe any organised activities. One person with dementia was sat in their wheelchair in the main lounge. They had nothing to stimulate them and they eventually pulled the electric fire away from the fireplace. Another person was sat in their bedroom for the whole of the inspection with no stimulation at all and another person sat in a recliner chair in a small alcove off the dining room with no stimulation or very little staff interaction for a majority of the morning. One person’s care records reflected that they had been unsettled and anxious in the evenings and during the night. There were times when staff were occupied with other people that this person was at risk themselves and placed other people at risk of harm or injury. People’s surveys told us that there are ‘sometimes’ activities that they can take part in. One person told us that they have their daily paper delivered and that keeps them occupied. Menus showed that the people who live there have a choice of meals through the day. The menu was varied and meals appeared nutritious. People spoken with said they enjoy the meals and stated that they are always offered choices. One person said “ there’s always plenty to eat and if we don’t like anything there is a choice”, another said, “the food is good, we choose every morning for the rest of the day”. The surveys from people tell us that they ‘usually’ or ‘sometimes’ like the meals. Staff were observed to sit with people and assist them to eat where needed. The support given was relaxed, sensitive and discreet. Staff spoke to people through out the meal about what they were eating and offering choices. Aspen Grange Care Home DS0000072288.V373801.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is poor. People living in the home can be confident that their concerns will be listened to and acted upon. The staff and manager’s failure to recognise what constitutes abuse and not making adult protection referrals puts people living in the home at risk of not being protected from potential harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a formal complaints policy which is accessible to people and their families. People are encouraged to raise their concerns with the manager. People who live at the home spoken with and surveys tell us that they know how to make a complaint. Staff spoken with told us that they know what to do if a person living at the home or relative or friend has concerns about the home. The staff surveys tells us that do not know what to do if a person at the home, relative, or friend has concerns about the home. There have been no complaints made to the home since March 2008. Aspen Grange Care Home DS0000072288.V373801.R01.S.doc Version 5.2 Page 18 There have been two adult protection safeguarding referrals made to the local authority since the last key inspection. The local authority has investigated these allegations and the manager told us that they are waiting for the written outcome. The home co-operated fully with the investigations. As identified throughout the report, a number of serious concerns and incidents where identified that placed people at risk of harm to either themselves or others. There were incomplete records of an incident whereby one person injured another person leaving them with marks on their arm. One person attempted to climb out of a first floor window when they were in a distressed state of mind. The daily care records refer to other incidents where one individual may have been into other people’s rooms during the evening or night and being verbally and physically aggressive. However, the daily and accident or incidents records are incomplete so we were not able to establish what had happened. The new registered provider acknowledged the seriousness of these issues and that they had not been reported to either the commission or the local authority. He took immediate action to ensure that the new acting manager referred the incidents to both the local authority and us. Aspen Grange Care Home DS0000072288.V373801.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is adequate. The home is maintained and furnished so that people live or stay in a homely, clean, comfortable environment. Parts of the home have not been risk assessed or made safe, this may put people at risk of injury. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a warm and relaxed atmosphere. The home is well decorated and generally well maintained throughout. The three lounges and two dining areas are comfortably furnished. Ramped access is provided from these rooms to the courtyard garden with seating and a summerhouse for residents to enjoy. There is a garden area, laid mainly to lawn. Aspen Grange Care Home DS0000072288.V373801.R01.S.doc Version 5.2 Page 20 There are five communal bathrooms at Aspen Grange, one being a wet room. Assisted baths are available. There are sufficient communal WCs, including some situated close to the lounges and dining areas. A number of bedrooms also have their own en-suite facilities. Twenty-eight of the 41 bedrooms have en-suite facilities, including both of the shared rooms. The windows on the first floor are not restricted. We were told by the registered manager that there were no identified risks associated with the windows. However, we later identified that one person had attempted to climb out of a window whilst they were in a distressed state. We looked at some of the bedrooms of the people involved in case tracking. They were clean and well furnished. The rooms were personalised with their own belongings. However, for one person who has dementia and is partially sighted their bedroom was very sparse. We observed that during the inspection this individual had no form of stimulation provided to them such as a radio or music or any other sensory environment. There is an oxygen cylinder in one person’s bedroom that is not securely stored and there is not suitable signage to show that oxygen is stored there. There are some radiators and exposed heating pipes that may pose a risk to people. These should either be risk assessed or covered to reduce to risks to individuals. Systems are in place to reduce the risk of infection. Disposable gloves, aprons and hand scrub were available and were used by staff when handling soiled linen and when supporting people with personal care. Aspen Grange Care Home DS0000072288.V373801.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. There are insufficient staff on duty to fully meet the needs of the people living there. Staff present as competent and caring. However, due to the high dependency levels of some people who live there, people are not receiving the best possible care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff rotas were seen for a one-month period. The manager told us that the staffing at the home is as follows: From 7.30am to 2.00 pm there are 8 care staff. From 2.00 pm to 7.30 pm there are 5 care staff. From 7.30 pm to 7.30 am there are 3 care staff. In addition to this there are management, catering and domestic staff. We raised concerns about the reduction in staffing at 7.30 pm and how 3 care staff could safely care for 40 people when there are 8 carers in the morning and 5 in the afternoons. This staffing has not been based on people’s needs Aspen Grange Care Home DS0000072288.V373801.R01.S.doc Version 5.2 Page 22 and has promoted institutional practices in the home. The manager told us that everyone ‘likes’ to go to bed before 7.30pm. However, this may just be reaction that there is a greatly reduced staff presence during the evening and night. We had further concerns that staffing had recently been increased to make sure that there were sufficient staff to assist people with eating at breakfast and lunch. No consideration had been given to the support needed for the evening meal and supporting the ongoing incidents with at least one person and others during the evenings and at night. The new registered provider took immediate action to increase the staffing in the afternoons by one and in the evenings with an extra 4.00 pm to 10.00pm shift. He also increased the night shift to finish at 8.00 am to make sure that there was enough time for staff to have a detailed handover. He gave a commitment to ensuring that there are enough staff to meet peoples’ identified needs. People spoken with and surveys told us that staff are ‘always’ or ‘usually’ available when they need them. People’s surveys show that staff listen and act on what people say. Two staff files were seen including the most recently recruited staff. One file included evidence of CRB (Criminal Records Bureau) checks and PoVA (Protection of Vulnerable Adults) checks. However, one staff member had started after a PoVA check. It was not clear from the staff file whether an experienced member of staff had been identified to supervise them whilst waiting for their CRB check to be returned. One file did not include a copy of the staff member’s birth certificate. This is needed to verify their identity. Aspen Grange Care Home DS0000072288.V373801.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is poor. People who live at the home do not benefit from or live in a home that is consistently managed or that has effective monitoring systems. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was re registered with the commission in July 2008 as there was a change in ownership and registered providers. The previous registered provider remains registered as a partner and continues to visit the home on a daily basis. The new registered provider is part of an organisation that operates a number of other care homes. Aspen Grange Care Home DS0000072288.V373801.R01.S.doc Version 5.2 Page 24 Following the change in ownership there has also been a change in the management structure as there is a long term plan to care for older people with dementia. The current registered manager is not experienced in dementia care and a new manager has been recruited and is applying to be registered with the commission. There are a number of serious shortfalls in the assessment of risks and care plans for new people who have been admitted or readmitted in to the home. The care plans and monitoring of the care provided to people already living at the home, poor record keeping and the staffing levels are all having an impact on the quality of care that people at the home receive. There has not been any way of determining whether the current staffing levels could safely meet the increasing needs of the people at the home. The impact of then admitting people with high and or challenging needs has meant that there has been insufficient staff to meet the needs of people and to keep people safe. The non reporting of adult protection issues is also a matter of serious concern and again highlights shortfalls in the management of the home. The new registered provider contacted us immediately following the inspection to confirm that he was taking immediate action to ensure the safety of the people at the home and to raise the shortfalls with the management team at the home. As identified throughout the report the record keeping is poor and it is not clear whether all accidents and incidents are recorded or reported. This means that the management cannot sure whether they are capturing and monitoring everything that is happening at the home. There is not any formal quality assurance system in place. The new provider told us that Regulation 26 visits will be undertaken by another person within the organisation. The current monitoring and quality assurance systems management team and organisation have not identified all of the shortfalls we have reported and these must be improved. Information provided before the inspection, by the acting manager in the AQAA (Annual Quality Assurance Assessment) shows that relevant Health and Safety checks and maintenance are being carried out at the home. We acknowledge that the manager and new provider took action to address shortfalls once we had identified them. Aspen Grange Care Home DS0000072288.V373801.R01.S.doc Version 5.2 Page 25 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 x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 1 2 x x x x x x 3 STAFFING Standard No Score 27 1 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x 1 x 3 x 2 3 Aspen Grange Care Home DS0000072288.V373801.R01.S.doc Version 5.2 Page 26 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 OP3 Regulation 14 Requirement Accurate full assessments must be completed for people. This is to make sure that peoples needs are identified and staff know how to care for them. The ongoing assessment process for people must identify when the home is not able to continue to safely meet their needs. This is so people whose needs have increased or changed move to a more appropriate care setting. The home must not admit people who they are not registered to care for. This is to make sure that the home is able to meet an individuals assessed needs. Peoples care plans must be reviewed, kept up to date, and include all the individuals needs identified in their assessments. This is so staff know what care and support people require to Aspen Grange Care Home DS0000072288.V373801.R01.S.doc Version 5.2 Page 27 Timescale for action 01/04/09 2 OP3 14 01/04/09 3 OP3 14 01/03/09 4 OP7 12 01/04/09 5 OP7 13 make sure that all their needs are met and they are well cared for. Any areas of risk identified for an 01/04/09 individual must assessed and these assessments must include nutrition, pressure areas, behaviour and falls. This is so that any risks are minimised and staff know what action to take to keep people safe 6 OP7 17 Accurate care records must be maintained for people. This is to demonstrate that people are being provided with the care and support they have been assessed as needing. Individuals’ personal information must be recorded in their records and not in a communal record. 01/03/09 7 OP7 17 01/04/09 8 OP12 12 This is to maintain peoples’ confidentiality and to comply with data protection. People must be provided with 01/05/09 suitable stimulation and have the opportunity to be occupied. This is to ensure that people have a good quality of life and well being All allegations of abuse must be 01/03/09 referred to the local authority and the commission. This is to make sure that any allegations are appropriately investigated and actions taken to safeguard people living at the home. 9 OP18 12 Aspen Grange Care Home DS0000072288.V373801.R01.S.doc Version 5.2 Page 28 10 11 OP19 OP27 13 12, 18 Windows must be risk assessed, made safe and risks minimised where any risks are identified. Staffing levels provided at the home must be based upon the individual needs of the people who live there. Staffing levels throughout the day and night must be based on people’s needs. This is to make sure that there is sufficient staff throughout the day and night to meet the personal, physical, social and psychological care and support needs of the people at the home. 01/03/09 01/05/09 12 OP33 24 The overall management of the home must improve, and develop effective ways of assessing and monitoring the quality of the service. 01/07/09 13 OP37 37 This is so that shortfalls are identified, are improved on and the quality of the service is kept under constant review. Regulation 37 notifications must 01/04/09 be made for all events that effect the well being of people living at the home. This is to ensure that the home is effectively monitoring and reporting incidents in the home. 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 Good Practice Recommendations DS0000072288.V373801.R01.S.doc Version 5.2 Page 29 Aspen Grange Care Home 1 Standard OP7 2 3 OP19 OP19 4 OP19 5 OP29 6 OP29 Personal profiles in care plans and or Life History books should be developed that include details and photographs of their history such as family, friends, where they have lived, pets, work etc. These profiles or life history books will assist staff to have a greater understanding of them as an individual. More stimulating and tactile environments should be developed both in peoples bedrooms and in the communal areas for people with dementia. Oxygen cylinders should be stored securely and rooms where oxygen is stored must be labelled. This is to make sure that it is stored safely and people and the fire service know where it is stored. Radiators and exposed heating pipes should either be risk assessed or covered to reduce to risks to individuals. This is to make sure people are protected from being scalded or burnt. An experienced member of staff should be identified to supervise staff who start work on a PoVA check whilst waiting for their CRB check to be returned. This is to make sure that staff are supervised until it has been established that they are suitable and safe to work with vulnerable people. Copies of staff birth certificates should be kept in staff files. This is needed to verify their identity. Aspen Grange Care Home DS0000072288.V373801.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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