Inspection on 22/02/06 for Aspray House

This inspection was carried out on 22nd February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Aspray House 10/12/07

Aspray House 25/06/07

Aspray House 29/03/07

Aspray House 25/08/05

Aspray House 17/03/05

Aspray House 19/11/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Aspray House 481 Leabridge Road Leyton London E10 7EB Lead Inspector Harun Rashid Unannounced Inspection 22nd February 2006 09:55 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 Aspray House DS0000044296.V306346.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Aspray House DS0000044296.V306346.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Aspray House Address 481 Leabridge Road Leyton London E10 7EB 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) 020 8558 9579 0208 558 9052 Twinglobe Care Homes Ltd Ms Julie Burton Care Home 64 Category(ies) of Dementia - over 65 years of age (44), Old age, registration, with number not falling within any other category (20), of places Physical disability over 65 years of age (20) Aspray House DS0000044296.V306346.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The `DE` and `PE` Categories specified relate to service users who are 55 years old and over. 25th August 2005 Date of last inspection Brief Description of the Service: Aspray House is a registered care home for 64 older people. The home is registered to provide dementia care for 44 people and nursing care for 20 people including care for people with physical disabilities. The home was first registered as Twinglobe Care Home and subsequently changed the name to Aspray House. The home is part of Twinglobe Care Homes Limited. The home is situated at the heart of Leyton in the London Borough of Waltham Forest. The home is within easy access to public transport, shops and other community amenities. The home was registered with the Commission for Social Care Inspection (CSCI) on 13.8.04, providing 64 beds with en-suite facilities in four suites: Emerald and Opal with 20 beds each, and Sapphire and Topaz, each with 12 beds. Aspray house is a purpose built care home, which provides all modern equipment and facilities for service users. The bedrooms are spacious, light and airy. All have en-suite facilities, and assisted bath and shower rooms are close by. Aspray House DS0000044296.V306346.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on a weekday morning on 22/02/06. The Inspector spoke to 12 service users, three relatives and interviewed seven members of staff including the senior nurse practitioner and the administrator. They all expressed their satisfaction with the standards of care provided in the home. The registered manager was on annual leave. The senior nurse practitioner and the administrator assisted with the inspection process. The Inspector carried out a tour of the premises with the senior nurse practitioner and the administrator of the home. What the service does well: What has improved since the last inspection? What they could do better: The registered manager must ensure that all staff (clinical staff/care workers) receive one to one recorded supervision at least six times a year. The management to ensure that each service user’s photograph is inserted on the care file in order to identify a service user easily. This is required by regulation. The home should encourage service users relatives to attend review meetings so they can advocate for their relatives and contribute to the development of care plans. Aspray House DS0000044296.V306346.R01.S.doc Version 5.1 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Aspray House DS0000044296.V306346.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Aspray House DS0000044296.V306346.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4,5 and 6 The home ensures that prospective service users’ needs are assessed prior to admission to the home. Staff are provided training to meet assessed needs of the service users. However, the management to ensure that each service user’s photograph is added to the care file. EVIDENCE: The newly admitted service users are assessed before they are admitted to the home. Service users’ needs assessments are carried out by the registered manager or the senior nurse practitioner. Both have several years of experience of carrying out needs assessments. From the examination of care files it was clear that the assessment of needs tool is comprehensive and detailed with information. However, it was evident that a service user’s photograph was not added to the care file. The management to ensure that each service user’s photograph is added to the care file in order to identify a service user easily. This is required by regulation. The Inspector spoke to 12 service users, three relatives and seven members of staff. They all expressed their satisfaction with the standard of care provided in Aspray House DS0000044296.V306346.R01.S.doc Version 5.1 Page 9 the home. Care files examined suggested that service users assessed needs were met. Staff are provided training and they seek specialist advice as and when required. Evidence of referral letters was available in the files. Service users and their family members spoken to informed that service users were invited to visit the home prior to moving into the home. In some cases their relatives and social workers visited the home prior to admission. Service users who had opportunities to visit the home were introduced to members of staff, other service users and were shown their bedrooms. Standard six is not applicable to this service, as the home does not provide intermediate care. Aspray House DS0000044296.V306346.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Staff review care plans on a monthly basis. The home can demonstrate that service users’ health and personal care needs are met. However the home should ensure that all service users relatives are invited to attend review meetings. EVIDENCE: Service users care plans were generated from comprehensive assessment by the care managers, who were referred by the local authorities. For service users who are self funded their care plans were developed from comprehensive assessments carried out by the home. The assessment covers all aspects of health, personal, social, cultural and religious needs. The service involved service users; their family and professionals in drawing up individual care plans. Staff review care plans on a monthly basis. However, during the conversation with service users family members, a relative informed that he was not aware of the review meeting and he was not invited either. The senior nurse practitioner informed that it is the placing authority social worker’s responsibility to invite relatives in the review meeting. The inspector’s view is that the home should develop a system to remind service users’ relatives that a review meeting is taking place so they can advocate for their relatives and contribute to the development of care plans. Aspray House DS0000044296.V306346.R01.S.doc Version 5.1 Page 11 Staff escort service users to all medical appointments. The G.P. also visits service users in the home as and when required. The home has access to ‘Waltham Forest On Call Doctors’ should this service be needed. Staff carry out nutritional screening for service users on admission. The psycho-geriatric consultant and community/district nurses also visit service users in order to carry out assessments and provide medical support to service users and advice to members of staff. Care files suggest that staff seek medical assistance to meet service users health needs. Medications are provided in blister packs from the chemist. Records of all medication received and disposed of were available for inspection. Qualified nurses carry out medication administration. Following the requirement of the previous inspection report staff record all medication administration immediate after medications were administered. At the time of the inspection none of the service users was prescribed a controlled drug, however, there is a system in place for administering controlled drugs if required. Service users spoken to informed that they are treated with respect by the members of staff. All service users are provided with a single bedroom with ensuite facilities. Service users family members informed that their relatives are treated with respect. At the time of the inspection the inspector observed that service users bedrooms were locked when personal care was given. Aspray House DS0000044296.V306346.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and15 Social activities for service users are well arranged. Staff welcome and encourage service users relatives and friends to visit them. Staff respect service users privacy at all times. EVIDENCE: The home employs one full-time and one part-time activity co-ordinator for service users who co-ordinate and organise individual and group activities. Service users are encouraged to visit local parks, pubs and seasides during summer. They are also encouraged to join Dial-a-Ride. Staff encourage service users friends and family to visit at any time. There is a room on the first floor available for service users to receive visitors in private. Service users are registered on the electoral register. Some of the service users were encouraged to vote in the last May general election. Family members and local authorities (placing authorities) are handling service users finances. However, service users have lockable drawers to keep their personal money in the bedrooms. Service users were able to bring some of their personal belongings with them during the move to the home. Service users have access to their records according to the home’s policy. Staff provide information to service users and their relatives how to access advocacy services. Aspray House DS0000044296.V306346.R01.S.doc Version 5.1 Page 13 The inspector examined weekly menus, which confirmed that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements. The weekly menu offers choices of at least two main meals at each time. Service users spoken to were satisfied with the meals provided in the home. Aspray House DS0000044296.V306346.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The complaint policy and procedure of Twinglobe Care Homes Ltd. is simple, clear and was made available to all relevant parties. The Adult protection policy and procedure contain sufficient guidance for staff to enable them to protect service users from abuse. EVIDENCE: Twinglobe Care Homes Ltd. provides a simple, clear policy and procedures for service users, their family members and for other relevant parties. A record of complaints was kept in a complaint book including details of investigation and action taken by staff. All members of staff attended adult protection training following the requirement of the previous inspection report. The adult protection policy and procedure of Twinglobe Care Homes Ltd. contains sufficient guidance for staff to protect service users from abuse. The registered manager/management understand her/their responsibility to refer staff who harm service users in their care to the POVA list. Aspray House DS0000044296.V306346.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The home is very much suitable for its stated purpose. It is safe and well maintained. The home provides modern equipment and facilities for service users accommodated. EVIDENCE: Aspray House is a purpose built care home, which provides modern equipment and facilities for service users accommodated in its four suites. En-suite facilities are provided in all four suites: Emerald and Opal with 20 beds each, and Sapphire and Topaz, each with 12 beds. The bedrooms are spacious, light and airy. In addition to these there are sufficient numbers of toilets, 6 assisted Apollo baths, 4 assisted shower rooms and 4 sluice rooms in the home. Bathrooms are clearly marked with blue colours. The use of the CCTV cameras is restricted to entrance areas for security purposes only and does not intrude on the daily life of the service users. At the time of the unannounced inspection the premises were clean, fresh and bright with no offensive odour. There was sluice facility incorporated in the Aspray House DS0000044296.V306346.R01.S.doc Version 5.1 Page 16 communal washing machines. The kitchen was clean and tidy with wellorganised storage areas. Aspray House DS0000044296.V306346.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 The deployment and current number of staff was sufficient to meet service users current needs. The service provides training for staff development. EVIDENCE: At the time of the inspection the home was accommodating 60 service users. The home employs 76 part-time and full time staff, which include ancillary staff for example 2 full-time administrators, 2 activity co-ordinators, 2 cooks, 2 handy men and 6 domestic workers. The home employs 11 qualified nurses and in addition to this 12 adaptation nurses were provided placements in the home at the time of the inspection (six of the adaptation nurses are completing their three months placements at the end of February 2006). Ten care staff have completed their NVQ level 2/3 qualifications in care and the inspector was advised that another group of staff will commence NVQ training in March 2006. The home operates a thorough recruitment procedure based on equal opportunity policies. Staff recruitment reflects the policy of the home. The management carry out all relevant checks including the CRB disclosures prior to staff appointments. Aspray House developed their training programme from the programmes of BVS (a consultancy service) training programme. There is an induction programme for staff, which was developed to TOPPS specifications. This is completed within the first six weeks of employment. Foundation training has Aspray House DS0000044296.V306346.R01.S.doc Version 5.1 Page 18 also been developed to TOPPS specifications and delivered within the first six months of the appointment of staff. A training programme had been drawn up to take account of this requirement. The staffing review takes account of individual staff members training needs. Aspray House DS0000044296.V306346.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,36 and 38 There is effective guidance and direction to staff to ensure service users assessed needs are met. However, the manager must ensure that all members of staff including clinical staff receive one-to-one recorded supervision at least six times a year. The service ensures service users health, safety and welfare. EVIDENCE: Service users’/relatives satisfaction survey questionnaire are obtained on a quarterly basis. The management ensures that there is an effective quality assurance and a quality monitoring system in place to measure success in meeting the stated aims, objectives and Statement of Purpose of the home including the views of service users and their representatives. The service sends Regulation 26 visit reports to the Commission on a monthly basis. Aspray House DS0000044296.V306346.R01.S.doc Version 5.1 Page 20 Care staff and adaptation nurses interviewed confirmed that they are receiving minimum of six individual supervisions in a year. Form the examination of supervision notes it was clear that staff are receiving supervision with their line managers. However, the evidence suggests that all qualified nursing staff are not receiving six one to one supervision in a year. The manager must ensure that all members of staff including clinical staff receive one-to-one recorded supervision at least six times a year. The service ensures safe working practice for health, safety and welfare of both staff and service users. Staff receive training in areas such as moving and handling, food hygiene, fire safety and infection control. There is a written statement of policy and arrangements for maintaining safe working practices. The management has completed a fire safety risk assessment for the premises and identified risk areas and how to eliminate/reduce the risks. The home carry out safety checks for all electrical and gas appliances. Fire alarms are tested on a weekly basis. A valid insurance certificate against loss or damage to the business was available. Aspray House DS0000044296.V306346.R01.S.doc Version 5.1 Page 21 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 x x 3 x x 2 x 3 Aspray House DS0000044296.V306346.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? YES 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 17 Requirement The registered manager to ensure that each service user’s photograph is inserted in the care file in order to identify the service user. The registered manager must ensure that all staff (clinical staff/care workers) receive one to one supervision at least six times a year. Timescale for action 28/02/06 2. OP36 18 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations The management to develop a system for inviting service users relatives to attend review meetings in order to advocate for their relatives and contribute in service users care plans. Aspray House DS0000044296.V306346.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ 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 Aspray House DS0000044296.V306346.R01.S.doc Version 5.1 Page 24 - 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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