Inspection on 13/09/06 for Aspreys Nursing Home

This inspection was carried out on 13th September 2006.

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

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

Other inspections for this house

Aspreys Nursing Home 23/04/09

Aspreys Nursing Home 04/06/08

Aspreys Nursing Home 06/12/07

Aspreys Nursing Home 25/04/07

Aspreys Nursing Home 08/12/05

Aspreys Nursing Home 06/04/05

Aspreys Nursing Home 12/10/04

Aspreys Nursing Home 29/06/04

Aspreys Nursing Home 04/03/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Aspreys Nursing Home I Kents Road Torquay Devon TQ1 2NL Lead Inspector Rachel Proctor Unannounced Inspection 13th September 2006 10:30 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 Aspreys Nursing Home DS0000028780.V306878.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. Aspreys Nursing Home DS0000028780.V306878.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Aspreys Nursing Home Address I Kents Road Torquay Devon TQ1 2NL 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) 01803 201500 01803 201700 matron@aspreys.co.uk Friendly Care Homes Ltd Vacancy Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (10), Physical disability over 65 years of age of places (25) Aspreys Nursing Home DS0000028780.V306878.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Two lower ground floor rooms must not be used for Service Users who require nursing The number of Service Users who require nursing is limited to 31 A minimum staffing level that follows the previously agreed Health Authority staffing notice must be available to meet the needs/dependency of Service Users who require nursing One named Service User, named elsewhere, under 60 yrs of age (PD Category) Service Users from age 60 years and above may reside at the home. 4. 5. Date of last inspection 8th December 2005 Brief Description of the Service: Aspreys Nursing Home is located in Wellswood, approximately one mile from Torquay town centre. It has level access to the local shops, pubic house and restaurants all being within 100 yards from the home. The St Matthias Church is within 200 yards of the home. The home operates its services on all of the four floors with the dining room and rear garden area being on the lower ground level, the lounges, matrons office and some rooms on the ground floor and the remaining rooms being on each of the two upper floors. All floors can be reached by a shaft lift. The home offers both Nursing and personal care mainly to people over the age of retirement (60 years). The home is registered for 31 residents who require nursing and 2 residents who require personal care The staff group is made up of registered nurses and trained social care staff (Health Care Assistants). There is a good level of specialist equipment like a Parker bath, hoists and stand aides available to meet the needs of disabled people. The statement of purpose, inspection reports and service user guide are available on request at the home. The fee levels were stated at the time of this inspection as from £350- £540. These are dependant on the care needs of the residents and the room occupied. Additional charges include chiropody and hairdressing. Aspreys Nursing Home DS0000028780.V306878.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection. Two site visits one unannounced and one announced were undertaken as part of the inspection to ensure that key staff were available. During these visits a tour of the home was completed. Residents and staff were spoken to and some records were inspected. Two random inspections have also been completed in February and May 2006, to review progress with requirements made the last inspection. Information received from the home since the last inspection was also reviewed. Two service users, two relatives and two health professional comment cards were received. Comments made in these have been incorporated into this inspection report. What the service does well: What has improved since the last inspection? What they could do better: The requirement that all staff have the training and development plan appropriate to their work has not been met. Since the appointed manager left in August 06 the home does not have a manager to lead the staff team, the deputy manager and owner are providing leadership. However it is still unclear how staff are trained to care for the specific needs of the residents and how training is planned. The home has 7 of its care staff trained to NVQ level 2 or above, which is below 50 standard, although there was evidence that some staff were due to start NVQ training before the end of the year. Without clear training staff may not always follow best practice guidelines when delivering care for residents. Aspreys Nursing Home DS0000028780.V306878.R01.S.doc Version 5.2 Page 6 The recruitment practices in the home need to include references and CRB checks being provided for all staff to ensure the residents are protected from unsuitable staff. The home has not completed a quality audit of the services they provide since December 2003. This may mean that residents and their representatives do not have confidence that their views are taken into account. Although activities are now provided on a weekly basis not many of the residents who were able to participate were doing so. This may mean that the activities organised may not be meeting the resident’s needs. Radiators, which the residents have access to should be covered to reduce the risk of accidental scalding/burns. 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. Aspreys Nursing Home DS0000028780.V306878.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 Aspreys Nursing Home DS0000028780.V306878.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents and their supporters are given information about the home and the services it provides, which enables them to make informed choice. The residents are assessed by staff who have their best interests at heart. EVIDENCE: Six residents had their care followed as part of this inspection. All the residents whose care was followed had an assessment of their care needs completed, which included risk assessments. Risk assessment appeared to be an integral part of the assessment process and risk assessments included manual handling, pressure sore prevention and nutrition. The residents who spoke to the inspector said staff are friendly and helpful and they come to assist them when the call bell is used. Others commented that staff are always polite and listen to what they say. Two residents who had been assessed as needing bed guards for their safety had a consent form completed, which had been signed by the resident or their representative. The assessments completed in the six residents care plans whose care had been followed had been reviewed where the care needs of the individual residents have changed. Where individuals Aspreys Nursing Home DS0000028780.V306878.R01.S.doc Version 5.2 Page 9 had been referred to the care management process a summary of their care plan had been provided for the home. The registered nurses responsible for the resident’s care had developed their care plan from their assessment of need. The deputy manager confirmed that each of the residents who required nursing care had had their NHS assessment completed by an NHS registered nurse. Reference to an NHS assessment dated August 06 was seen in one of the residents care plans whose care was followed. Aspreys Nursing Home DS0000028780.V306878.R01.S.doc Version 5.2 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, 10 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Where there have been shortfalls in the standard of care provided these are being or have been addressed by the interim management team through training and review of working practices. The residents are cared for by a staff team who are friendly and have their best interests at heart. EVIDENCE: One complaint regarding the way healthcare was provided for one resident has been received since the last inspection. This complaint was partially upheld. The inspector discussed this complaint with the owner and deputy manager to establish what actions had been taken to address the concerns raised by the complainant. The concerns included the availability of a call bell in an en suite facility, the staff teams ability to carry out manual handling safely and the way staff address/speak to residents. The owner confirmed that a call bell had been fitted to the en suite facility highlighted by the complaint. And as a result of the complaint all staff had received practical training for manual handling, which included the use of hoists. Records of this training were provided for inspection. The deputy manager confirmed that the induction training Aspreys Nursing Home DS0000028780.V306878.R01.S.doc Version 5.2 Page 11 provided for new staff guided them how to address residents and treat them with respect. The deputy manger also advised that some staff had also completed further adult protection training. Policies were also provided for staff regarding their expected conduct and copies of the General social Care Councils code were available in the office. Residents spoken to during the inspection told the inspector that the staff who cared for them were friendly and understood them. The staff observed speaking to the residents were doing so in a friendly supportive way. Call bells were being answered in a timely manor during the inspection and residents spoken to said staff usually respond when they use their call bell. One commented that “they sometimes take a bit longer at meal times and weekends”, although this did not cause them concern. Two relatives comment cards were received one commented that “ I have always been happy with the treatment and care--- received”. One health professional comment card received indicated that they were satisfied with the over all care provided for the residents and that the home communicates clearly and works in partnership with them. The six residents whose care was followed as part of this inspection had plans of care in place which reflected their personal health and social care needs. The plans had been reviewed monthly or sooner if the resident’s care needs have changed. When the GP had seen a resident this had been documented separately in their care plan. Treatments recommended by the GP for one resident who had been seen recently had been incorporated into the plan of care. The deputy manager advised that the resident’s care is reviewed regularly and at least monthly by a registered nurse. During this inspection it was noted that one resident whose care was followed who had been identified as at risk of pressure sore development had pressure relieving mattress in place to reduce this risk. A pressure sore risk assessment had been completed and updated regularly for this resident. This resident had a high dependency airflow mattress fitted to their bed, which provided intermittent relief from pressure. The deputy manager advised that this resident also had their position changed regularly to reduce the risk of pressure damage to their skin. While the inspector was with this resident two staff came into the room to turn the resident. The staff confirmed that they turn the resident while they are in bed to reduce the risk of pressure sore development. Nutritional assessments had also been completed in each of the six residents plans whose care was followed. The deputy manager confirmed that these continue to be reviewed. A health professionals comment card stated that “ the home have been taking many steps to improve --- nutritional intake”, Very pleasant and helpful staff.” Staff observed assisting residents to eat their food were doing so in a supportive discrete way, talking to the residents as they assisted them. Residents who were being cared for in their own rooms had drinks placed to enable them to reach these easily. A variety of manual handling aids were provided to assist staff to move residents safely. The deputy manager confirmed that all staff had recently received practical manual handling training from a recognised training agency. Copies of certificates awarded were available for inspection. This should Aspreys Nursing Home DS0000028780.V306878.R01.S.doc Version 5.2 Page 12 ensure that residents who require staff to use manual handling equipment do so in a way that reduces the risk of discomfort for the residents. The controlled drug record was checked against the stock held for one resident as correct. A drug fridge is provided for storage of medication such as insulin and eye drops that need to be stored at low temperatures. A record of the fridge temperature was being kept. The records of medication disposed of were completed dated and signed as required. The home has a lockable medication trolley for storage of medication the residents are using, which can be moved to the individual residents rooms. The deputy manager advised of the stock control system in place for resident’s medication. The medication stored checked by the inspector was for the current residents and with in date. Aspreys Nursing Home DS0000028780.V306878.R01.S.doc Version 5.2 Page 13 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): 12,13,14,15 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Although there are activities provided for the residents at Aspreys on a weekly basis not many of the residents who were able were choosing to take part. This may mean that the activities provided don’t always meet the resident’s expectations. EVIDENCE: The deputy manager advised that Antics and Activities and Brixham Activities visit the home alternate weeks. A record of the activities provided and the residents who took part was being kept. This was in place at the last inspection. Three residents who would have been able to take part in the activities provided told the inspector that they preferred to stay in their own rooms and didnt wish to take part in the activities the home had provided. The list of activities provided with the pre- inspection questionnaire indicated that there had been no change in the activities provided since the last inspection. At the last inspection the manager had advised that the home has close links with the local St Matthias Church. The residents were using both of the ground floor lounges during this inspection. The deputy manager advised that at present the dining room on the lower ground floor and the lounge on the lower ground floor were not being Aspreys Nursing Home DS0000028780.V306878.R01.S.doc Version 5.2 Page 14 used. The residents who had chosen to stay in the lounge were eating their meals from height adjustable tables. Some residents seen in their own rooms told the inspector that they preferred to eat their meals in their own room. The staff were facilitating this for them. Visitors were coming and going throughout the inspection days, they were seeing their relatives either in one of the communal lounges or in their own rooms. One relative spoken to during the inspection said they were always made to feel welcome at the home and felt that the home staff were very friendly. At the time of this inspection one resident was managing their own affairs and five residents were subject to power of attorney. Records of money held on behalf of the residents were being kept. One resident told the inspector “staff help them with their money and will get some items from the shops for them if they ask them to” The residents rooms entered during the inspection had been personalised with items of their choice. One resident told the inspector that staff had put their pictures on the walls for them. The residents asked said they enjoyed the meals provided for them. The lunchtime meals observed during the inspection were attractively presented and nutritionally the balance. The residents who required help to eat their meals were being given this by staff in a supportive discreet way. Staff were seen sitting next to residents, talking to them as they help them meet their meal. One resident told the inspector that when they didnt like what was on offer for the lunchtime meal they were “offered an alternative”; they also said that “staff had got to know what they like to eat”. Drinks are being served to the residents throughout the inspection. Residents who were in their own rooms and unable to mobilise independently had drinks placed within easy reach. Aspreys Nursing Home DS0000028780.V306878.R01.S.doc Version 5.2 Page 15 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, 18 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The caring attitude of the staff towards the residents enables them to express their concerns and wishes. However the failure to complete all pre-employment checks for new staff may put the residents at risk from unsuitable staff. EVIDENCE: Two complaints about the quality of the care provided at Aspreys had been received since the last inspection. These related to the availability and the time staff took to answer call bells. Since this complaint one en suite facility that didnt have a working call bell has been fitted with one. The way staff carried out manual handling tasks with residents was also raised. The previous inspection indicated that although staff had been given information about best practice for manual handling they had not received practical training from a recognised training agency. At this inspection the deputy manager provided information about a manual handling course, which included practical training for staff. A record of the staff who had completed this training was provided for inspection. The commission is satisfied that the homes owner and deputy manager have taken appropriate action to address the concerns raised by the complaints. The deputy manager confirmed that she regularly talks to the residents and their representatives. One relatives comment card confirmed that they were satisfied with the way the deputy manager was managing the home. The complaints procedure and policy is easily available for staff and residents. The residents spoken to during the inspection and the two comment cards received from residents indicated that they knew who to complain to if they had any Aspreys Nursing Home DS0000028780.V306878.R01.S.doc Version 5.2 Page 16 concerns and had confidence that any concerns they raised would be dealt with sensitively by the staff team. Four staff files were viewed during the inspection. Not all of these contained the information required. (See staffing) The home has a recruitment policy, however this did not seem to have been followed in every instance. A record of training received and copies of certificates were provided in the staff files. These included fire training and manual handling. A training pack was also available for the staff regarding adult protection. Policies and procedures are in place to guide staff regard prevention, recognition and handling of incidents of abuse. Aspreys Nursing Home DS0000028780.V306878.R01.S.doc Version 5.2 Page 17 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): 19,25,26 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has a pleasant and homely environment for the residents live in, which is kept clean and fresh. EVIDENCE: The redecoration and refurbishment of the home has continued since the last inspection. The owner confirmed that when rooms become vacant they are usually decorated before a new resident is admitted. A tour of the home revealed that several rooms had been re-decorated and new carpet fitted. The hair salon, which was almost completed, will be available for the residents on the lower ground floor of the home. The owner advised that it was his intention to make this look, as much like an external hair salon as possible. Some furnishings had been added to the hair salon and the disabled access toilet had been installed in the same area. The home does not currently employ a maintenance person. The owner advised that until one is appointed he was taking responsibility for minor maintenance tasks as and when required. The residents seen in their own Aspreys Nursing Home DS0000028780.V306878.R01.S.doc Version 5.2 Page 18 rooms had call bells easily accessible to them. Three of these residents who were asked about their call bell, told the inspector “staff responded when they called although sometimes they took a little bit longer at mealtimes and weekends”. During the inspection the call bells were being answered in a timely manner by the staff. The systems in place at the last inspection to assess the resident’s ability to benefit from a lockable door to their room has continued. The deputy manager advised that none of the residents were able to benefit from a lockable door to their room. The tour of the home revealed that the residents who needed to be cared for in bed, had been provided with height adjustable beds. Not all the radiators in the home being guarded. However the owner confirmed that the radiators were continuing to be covered on a risk assessment basis. Heating can be adjusted in individual’s rooms to suit the resident’s tastes. The inspector noted that individual residents rooms were of differing temperatures, which suited the residents in those rooms. Each of the resident’s rooms entered during the inspection and the communal areas residents were using during the inspection were fresh and clean and free from odour. Two of the residents asked told the inspector “the cleaners keep their room is fresh and clean for them”. One of the domestic staff spoken to during inspection said that they liked to ensure that the home looks clean and fresh for the residents. The owner confirmed that two new domestic staff had been appointed since the last inspection and they were planning to have a designated laundry person to manage the laundry. Infection control policies and procedures were available for staff. Staff observe providing care for residents were using gloves and aprons when providing personal care for residents. Disposable gloves and aprons were easily available for the staff. A yellow bag clinical waste disposal system was in place and a clinical waste disposal contract had been arranged. Aspreys Nursing Home DS0000028780.V306878.R01.S.doc Version 5.2 Page 19 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): 27,28,29,30 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The staff team continue to be friendly and supportive towards the residents. However, the way staff are trained and their skills developed needs to continue improve to ensure the residents are cared for by a staff team who understand their care needs. EVIDENCE: Two relatives comment cards received both commented on staffing at the home one said “ when there is a staff shortage it is always because staff fail to turn up for duty” The other commenting they felt “standards had dropped because not enough staff were available on duty particularly at Weekends.” The duty rota provided showed the number of staff on duty in the home. A team of registered nurse cover duty over a 24-hour period supported by Health Care Assistants. At the time of the visit to the home there appeared to have sufficient staff on duty to meet the needs of the residents. One member of staff advised that if the staff who were due to be on duty reported for duty then they had sufficient staff to care for the residents. However they did say that when staff go off sick at short notice it is sometimes difficult to get their shift covered, which increases the work and some times makes it difficult to care for the residents, as they would like. The deputy manager confirmed that it had not always been possible to get staff to cover shift shortfalls particularly at weekend and there had been occasions when the agency had been unable to help. The deputy manager said she kept the staffing number under review and if the needs of the residents increased the number of staff on duty would be changed to reflect this. One residents comment card received commented that Aspreys Nursing Home DS0000028780.V306878.R01.S.doc Version 5.2 Page 20 I get plenty of care and support from the good staff, always coming in to see me. The pre inspection information indicated that 2 of the 14 care staff employed had completed an NVQ in Care. One senior carer spoken to during the inspection said it had been agreed that they could complete an NVQ training course and they were awaiting confirmation. Documentation in the office supported that this was the case. The owner confirmed that he would be accessing training for staff that improved their skills and knowledge to care for the residents. And at present he was exploring suitable training providers. The manager had resigned just prior to this inspection and the deputy manager with the support of the owner was managing the home. The inspector looked at four staff files during the inspection. All had application forms and records indicated references had been sought. The deputy manager advised that it has been the homes practice to get verbal references from previous employers, although this was not recorded in the staff files seen. Not all for staff files viewed had to written references on file. Three of the staff files had evidence of their CRB check. One member of staff had a letter from CRB requesting more information; this member of staff didnt have a completed CRB on file. The owner and deputy manager confirmed that they were working towards ensuring all information required is contained in the staff files. However they were aware that at the time of the inspection not all staff files contained all the information required. None of the staff had an up to date development plan, which was linked to an appraisal. The owner advised the inspector that he had thought the previous manager had completed these and was trying to assess what else needed to be done in relation to the information for staff files. The owner was aware that this had been noted at the previous inspection, although the inspector found more information and documentation required were available in the four staff files viewed on this occasion. Because of this the time scales for providing training and development plans for all staff has been extended. A record of training received and copies of certificates were also provided in the staff files. These included fire training and manual handling. Aspreys Nursing Home DS0000028780.V306878.R01.S.doc Version 5.2 Page 21 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): 31,33,35,38 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home needs a suitably qualified manager to lead the staff team to ensure residents continue to have their health, safety and welfare promoted and protected. EVIDENCE: The appointed manager had resigned just prior to this inspection; she had not registered with the Commission. The owner advised that he was in the process of advertising for a replacement but had not found a suitable candidate as yet. He confirmed that the deputy manager would be managing the care of the residents and he would continue to provide support until a new manager had been appointed. The staff team appeared to be working well together during the inspection. The deputy manager said that the staff team had rallied together to ensure the residents received the care they needed and were covering shift short falls when they were able. Aspreys Nursing Home DS0000028780.V306878.R01.S.doc Version 5.2 Page 22 There was an open positive atmosphere in the home despite the recent changes in leadership. Staff spoken to said they felt able to suggest different things that they felt would improve resident’s experience of care at Aspreys. The residents were complimentary about the staff team who were providing their care. The home does not have a quality assurance system, which is fully developed. The inspector was told that they were in the process of sending out questionnaires to residents and their representatives to ask their opinion about the care they received. Some letters received from previous residents families had been received and they commented on their satisfaction with the care their relative received. The pre inspection questionnaire indicated that one resident managed their own affairs. The money held for this resident was checked against the records as correct; recites of expenditure on behalf of the resident were also kept. However a giro payment slip dated more than 12 months ago, which had not been cashed formed part of the money held for this resident. The owner agreed to follow this up. The deputy manager and owner advised that they had not been able to complete appraisals for all the staff this year but were hoping to complete these with staff with in the next three months. They also confirmed that none of the staff had a training and development plan, which identified their training needs. Although the staff spoken said they felt supported to do their work and felt they could speak to the deputy manager about issues that concerned them. The pre-inspection questionnaire provided showed that the fire equipment tests and hoists services had been completed as required. The fire extinguishers had the date of the last service recorded on them. Temperature checks are completed and the owner confirmed that a water heating check for prevention of legionella had been undertaken on 5th October 06, this information was received after the visit to the home. There is a written statement of policy for maintaining safe working practices in place. An environmental risk assessment has been completed and individual residents have risk assessments completed for manual handling, pressure sore risk, risk of falls and nutritional risk. The accidents and injuries are recorded and include the actions taken by staff following the incident. There were instructions provided for staff regarding RIDDOR reportable incidents and how to report them. Aspreys Nursing Home DS0000028780.V306878.R01.S.doc Version 5.2 Page 23 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 3 X 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 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X 2 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X X 2 Aspreys Nursing Home DS0000028780.V306878.R01.S.doc Version 5.2 Page 24 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 OP18 Regulation 19(1)(c) Requirement The recruitment practices used must be followed to ensure the residents are protected from unsuitable staff The recruitment practices used must be followed to ensure the residents are protected from unsuitable staff Staff must have training and development plans appropriate to the work they perform Extended from 08.06.06 Timescale for action 13/09/06 2 OP29 19(1)(c) 13/09/06 3. OP30 18(1)(c)(i ) 08/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP19 OP25 Good Practice Recommendations A routine programme of maintenance should be available for inspection The covering of all radiators in residents areas should continue using the risk assessment process in place DS0000028780.V306878.R01.S.doc Version 5.2 Page 25 Aspreys Nursing Home 3. 4 5. 6. 6. OP28 OP31 OP33 OP35 OP38 The induction process for new staff should link to best practice. 50 of the care staff should be trained to N.V.Q level 2 or above. There should be a manager to lead the staff team who is registered with the commission. Continuous self monitoring internal audit should take place at least annually How the money held on behalf of residents is kept should be clearer The manager/Owner should ensure that all staff continue to receive training, which ensures they understand safe working practices. Aspreys Nursing Home DS0000028780.V306878.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Aspreys Nursing Home DS0000028780.V306878.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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