Inspection on 29/06/07 for Aspen House

This inspection was carried out on 29th June 2007.

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 House 10/05/06

Aspen House 14/12/05

Aspen House 01/07/05

Aspen House 03/02/05

Aspen House 24/09/04

Aspen House 30/07/02

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

CARE HOMES FOR OLDER PEOPLE Aspen House 17 Wilbury Avenue Hove East Sussex BN3 6HS Lead Inspector Merle Blakeley Unannounced Inspection 29th June 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Aspen House DS0000014175.V346441.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 House DS0000014175.V346441.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Aspen House Address 17 Wilbury Avenue Hove East Sussex BN3 6HS 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) 01273 772255 01273 772255 Mrs Denise Marie Bernadette Roussel Mrs Denise Marie Bernadette Roussel Care Home 15 Category(ies) of Dementia (15) registration, with number of places Aspen House DS0000014175.V346441.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is fifteen (15) Service users must be aged sixty-five (65) years or over on admission Service users accommodated will have senile dementia type illness Date of last inspection Brief Description of the Service: Aspen House is registered to provide care and accommodation for up to fifteen older people who are in the various stages of dementia. The property consists of a large detached house with an additional two-storey purpose built extension. Resident’s bedrooms are located over two floors and there are nine single rooms and three shared rooms. Six of the bedrooms provide en suite facilities. A stair lift is available. Communal facilities include a lounge, a small quiet room, dining room, large entrance hall and a patio garden. The home is located in a quiet residential area of Hove, which is reasonably close to local transport and other amenities. The current scale of fees is from £409.00 to £441.00. Chiropody and hairdressing are extra charges. Aspen House DS0000014175.V346441.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over a period of eight hours on 29th June 2007. As well as this site visit information was also gained from a returned Annual Quality Assurance Assessment (AQAA) and feedback from staff and one professional person. During the visit the inspector spent time with some of the residents and was able to talk to three of them. The inspector was also able to speak to five staff members who were on duty during the day. Discussions with the owner/manager were carried out as was document reading and a health and safety check of the premises. Staff were also observed throughout the day interacting with residents. In February 2007 the home was subject to an Adult Protection investigation. A member of staff physically assaulted a resident. The subsequent investigation found that the home was in breach of a number of regulations, which included the home not following correct recruitment procedures when employing staff, the failure of staff to effectively report the assault under adult protection procedures, the owner/manager failing to inform the CSCI that she would be absent from the home for a period longer than 28 days. Following on from a management review meeting with the owner/manager and the CSCI the home was issued with a set of Statutory Notices. An action plan to address these issues was requested from the home and these issues have been dealt with in a timely and satisfactory manner. Aspen House has employed the services of an external Care Consultant who is working with the home to assist them with the improvement and continuing development of the service. An Annual Development Plan has been produced and it covers the areas of staffing, training, care planning, activities, policies & procedures, quality assurance, premises and health and safety. The home will be contacted in December 2007 to enquire as to how they are progressing with the Annual Development Plan. What the service does well: What has improved since the last inspection? Aspen House DS0000014175.V346441.R01.S.doc Version 5.2 Page 6 During the last inspection seven requirements and three recommendations were made. The home has addressed these and they have improved the information in care plans and they are trying to ensure that residents receive a broader range of activities. There have been some good improvements made to the environment with the lounge; dining room and hallway have been redecorated. The large pieces of furniture that were not being used in the lounge room have been removed and new chairs have been purchased. The lounge is now a much more relaxed and brighter room. Fire drills are being carried out on a more frequent basis. A recommendation was made for staff to receive dementia training and this was carried out earlier this year. Staff are now also receiving regular supervision sessions and staff meetings are being held. All new staff receive induction training. Four of the staff team now hold NVQ qualifications and a further four staff are currently completing their NVQ training. A new deputy manager has been appointed along with three other new staff members. 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. The summary of this inspection report can be made available in other formats on request. Aspen House DS0000014175.V346441.R01.S.doc Version 5.2 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 Aspen House DS0000014175.V346441.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All prospective residents are assessed prior to moving into the home. EVIDENCE: The owner/manager carries out an assessment before any new person moves into the home. The home must continue to ensure that it can meet the needs of all people who move into the home. Aspen House DS0000014175.V346441.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans were informative and were being updated. People’s healthcare needs are being met. Medication is suitably administered and recorded. Staff were seen to treat people in a caring manner. EVIDENCE: A number of care plans were viewed during this visit and the quality of these documents has improved. During the last inspection a requirement was made for the home to include more in-depth information about residents histories, likes, dislikes hobbies etc. The plans are now much more informative and provide comprehensive information about each resident. Staff complete daily record books. Care plans are reviewed regularly and there is now a key worker system in place. Resident’s current healthcare needs were discussed with the owner/manager and records revealed that people had access to a good variety of healthcare Aspen House DS0000014175.V346441.R01.S.doc Version 5.2 Page 10 professionals. A query was raised as to whether the home was keeping the healthcare records up to date, as one person’s eye care needs had changed and there was no indication of this in her care plan. The owner/manager stated that a separate sheet about this person’s new health care needs was to be written up and would go in her care plan. Medication records were checked and they were found to be in order. The home has recently changed it medicines supplier. During the day the inspector noted that several residents appeared to spend a lot of time asleep and it was queried as to what types of medication these people were being administered. The owner/manager stated that none of the residents were sedated during the day only at night. During the day the inspector was able to observe staff interacting with residents and overall people were seen to be treated in a caring and friendly manner. Aspen House DS0000014175.V346441.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are currently making improvements to the level of activities that are offered. People maintain contact with relatives and friends. The home offers residents a reasonably good diet. EVIDENCE: A requirement was made during the last inspection for the home to improve the level of activities that were being offered to people. This was discussed with the owner/manager who stated that she has allocated the roles of activities co-ordinator to two members of staff. They will be responsible for setting up an activity rota and so far they have organised walks out for some residents, arts & crafts classes, reminiscing, reading and bingo. Exercise to music and singing is always available during the week. The home needs to ensure that these two staff members are given adequate time during the day to organise these activities. Aspen House DS0000014175.V346441.R01.S.doc Version 5.2 Page 12 Visitors are welcome in the home at most times of the day. Two visitors were seen in the home, however the inspector did not get a chance to speak to them. A large majority of the people who live at Aspen House lack the capacity to exercise choice and control over their daily lives, however there was some evidence to show that where possible people can make certain choices and the home must remember to record these choices in people’s care plans. Currently the owner/manager is cooking and preparing all the meals. The owner/manager stated that she is intending to employ a part-time cook. The home has advertised in the local newspaper, however the position has not yet been filled. A whiteboard is displayed in the dining room, which informs people of the daily menu. A recommendation was made during the last inspection for the home to ensure that adequate fresh fruit and vegetables were being offered to people. The owner/manager said that fresh meat and vegetables were delivered to the home twice a week. Overall, residents that were spoken to appeared quite happy with the meals that were being offered. Following a visit from Environmental Health the home has purchased a new boiler. The flooring in the kitchen is also due to be replaced in August 2007. Aspen House DS0000014175.V346441.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints policy and procedure. The home has responded positively to a serious adult protection alert. EVIDENCE: The home has produced a complaints policy and procedure, which is displayed in the hallway of the home. The complaints book was viewed and there were no entries. In February 2007 the Older People’s Community Assessment Team received an Adult Protection Alert from a member of staff who stated that a resident had been physically assaulted by someone who worked at the home. The alert was passed onto the Community Mental Health Team in Hove who carried out an Adult Protection investigation. The CSCI also carried out a Management Review Meeting with the owner/manager on her return to the UK. The CSCI’s meeting with the owner/manager identified that the home was in breach of several regulations • The registered person had failed to ensure that staff carried out their legal responsibilities regarding keeping vulnerable service users safe. • The home had failed to carry out the correct procedures in the employment of staff. The person who committed the assault had no Aspen House DS0000014175.V346441.R01.S.doc Version 5.2 Page 14 • • record of employment in the home. No reference checks or CRB check had been undertaken. The owner/manager stated that at the time this person had not been employed because he was only carrying out ‘casual work’ in the garden, however whilst the owner was away the deputy manager brought this person into the home to work with vulnerable people who have dementia type illnesses. The owner/manager also breached regulations by not informing the CSCI that she would be out of the country for a period of over 28 days. The failure of staff, particularly the person that was left in charge of the care home in the owner/managers absence, to report this assault under adult protection procedures. As a result of these breaches of regulation Aspen House was issued with a set of Statutory Notices. The home has responded to the Notices in a timely fashion and an action plan was received from the service outlining how they will address all the issues that have been raised. 1. The owner/manager and all of the staff team have attended training in the protection of vulnerable adults. Adult Protection discussions have also been held with staff at meetings and one-toone supervisions. A whistleblowing policy has been displayed on the staff notice board. 2. Staff recruitment procedures have been fully reviewed and new forms developed. All staffing files have been updated. All staff have a current CRB check and photos on their file. The home is ensuring that all new staff provide two satisfactory referees. 3. In future the owner/manager will inform the CSCI in writing if she intends to be away from the home for a continuous period of 28 days. The deputy manager was suspended immediately and a referral was made to the Protection of Vulnerable Adults List (POVA). The person who committed the assault was not seen again and the Police have been unable to trace him. Aspen House DS0000014175.V346441.R01.S.doc Version 5.2 Page 15 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 good. This judgement has been made using available evidence including a visit to this service. Positive improvements have been made to the environment. EVIDENCE: At the last inspection two requirements were made for the home to make improvements to the lounge room and the dining area. Since then the dining room has been redecorated, as has the lounge room. The lounge was previously very cluttered with large pieces of furniture that were not used and the home has now cleared the room of this furniture. This has resulted in the room being much more relaxed and brighter. The window area is now also clear so that residents are able to see out of the windows. The hallway has also benefited from being repainted and overall the communal areas now look brighter and more homely. Generally the home was found to be clean and tidy on the day. Aspen House DS0000014175.V346441.R01.S.doc Version 5.2 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 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 good. This judgement has been made using available evidence including a visit to this service. Three new staff have recently been employed. Several staff have obtained NVQ qualifications. The home must continue to follow strict recruitment guidelines. Staff are receiving adequate training. EVIDENCE: The home has a varied staff team, which includes both male and female workers. The home is continuing to provide four carers in the morning and three in the afternoon. One waking and one sleeping night staff are employed. Three new staff members have joined the team recently and two of them were spoken to during the inspection. The third new recruit to the home is a parttime ancillary worker. So far the new staff were enjoying the job and one was still completing the Skills for Care induction programme. A new deputy manager has also been employed and she has several years experience of working with people who have dementia type illnesses, she also holds an NVQ Level 3 qualification and she will commence studying for NVQ Level 4 in September 2007. In discussions with staff there was one issue that was brought up and this was that sometimes staff tend to ‘rush too much’ and do not spend enough time talking to residents. Two other staff were spoken to and they have worked at Aspen House DS0000014175.V346441.R01.S.doc Version 5.2 Page 17 the home for some time now. They felt that there had been some positive changes made in the home, particularly following the adult protection incident. Overall staff said they felt supported in their work. There are currently four staff that hold NVQ qualifications and a further four who are undertaking this qualification. The majority of staff have attended training in dementia now, as this was a recommendation made during the last inspection. Other training staff have received include Adult Protection training and food hygiene. Staff supervision and staff meetings are occurring on a regular basis. A thorough check of all staffing files was carried out, as this had been an issue during the adult protection investigation. All the files were found to have the correct records and documentation. The home must continue to ensure that all new staff are subject to strict recruitment procedures and that no staff member enters the home to work unless they have a returned CRB check and the required references. Aspen House DS0000014175.V346441.R01.S.doc Version 5.2 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 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 good. This judgement has been made using available evidence including a visit to this service. The home is run and managed by a qualified owner/manager. The home has produced a quality assurance programme. There were no health and safety issues identified at this inspection. EVIDENCE: The owner/manager has run Aspen House for a number of years and she holds the Registered Managers Award and a psychiatric nursing qualification. The owner/manager is now aware that she must inform the CSCI in writing if she intends to be away from the home for a period longer then 28 days. During the adult protection investigation it was discovered that the owner had been out of the country for approximately five weeks and the CSCI had not been informed. Aspen House DS0000014175.V346441.R01.S.doc Version 5.2 Page 19 As part of the homes improvement plan, the owner /manager was required to attend training in the Protection Of Vulnerable Adults. This training was attended in May 2007. Staff who were spoken to during the inspection said that they felt the owner/manager was approachable and supportive. The home has produced an Annual Development Plan for the period up to the end of March 2008. The plan covers staffing, training, care planning, activities, policies & procedures, quality assurance, premises and health and safety. The plan states that the home intends to employ an independent consultant to assist with the quality assurance programme. At present the home sends out feedback surveys to relatives once a year. The home is aware that more work is required to produce a more comprehensive quality assurance system. The service also needs to seek feedback from visiting professionals who come into the home on a fairly regular basis. The home will be contacted in December 2007 to see how they are progressing with the Annual Development Plan. The finances of five residents were checked and they were found to be in order. A fire risk assessment has been carried out on the home and in May 2007 all staff attended fire safety training. A requirement was made during the last inspection for the home to carry out more frequent fire drills. Fire drills are now carried out monthly and records of these drills are maintained. The home has now introduced a maintenance book so that staff can record any minor repairs etc that need attention. Staff are now wearing disposable gloves and aprons and more health & safety notices have been displayed within the home. All hall doors and fire doors that remain open have magnetic closures fitted to them. Aspen House DS0000014175.V346441.R01.S.doc Version 5.2 Page 20 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Aspen House DS0000014175.V346441.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Aspen House DS0000014175.V346441.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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. Extracts may not be used or reproduced without the express permission of CSCI Aspen House DS0000014175.V346441.R01.S.doc Version 5.2 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. 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