CARE HOMES FOR OLDER PEOPLE
Astley Hall Nursing Home Astley Hall Off Dunley Road Astley Stourport-on-Severn Worcestershire DY13 ORW Lead Inspector
Chris Potter Unannounced InspectionReport 13th October 2005 12:00 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 Astley Hall Nursing Home DS0000004094.V250232.R01.S.doc Version 5.0 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. Astley Hall Nursing Home DS0000004094.V250232.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Astley Hall Nursing Home Address Astley Hall Off Dunley Road Astley Stourport-on-Severn Worcestershire DY13 ORW 01299 827020 01299 827020 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Jayantilal James Bhikhabhal Patel Mrs Kakash Jayantium Patel Mrs Carol Wallington Care Home 48 Category(ies) of Dementia - over 65 years of age (29), Old age, registration, with number not falling within any other category (48), of places Physical disability over 65 years of age (48) Astley Hall Nursing Home DS0000004094.V250232.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. The Home may also accommodate a maximum of two people with a physical disability whose age is between 50 and 65 years. A registered nurse participates in the English National Board (ENB) N 11 Course for care of people suffering from dementia. Care staff attending an external course designated in providing training in the care of service users. 28/04/05 Date of last inspection Brief Description of the Service: Astley Hall Nursing Home is a three storey; Grade II listed building, set in 20 acres of parkland and situated two miles outside Stourport-on-Severn. Astley village is a short, travelling distance away. Astley Hall is registered to accommodate up to 48 residents’ who require nursing and/or personal care - including service users who have short-term memory care needs. Accommodation is provided on all three floors of the home, and access to all floors is gained via stairs or a central passenger lift. Mr and Mrs Patel are the owners and also have homes in other areas. The manager for the home is Mrs C Wallington who is a registered nurse with many years experience in the both the private and health service. Mrs Wallington has been the manager for the home for the past ten years and has the appropriate qualifications. Astley Hall Nursing Home DS0000004094.V250232.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and was carried out on the afternoon of 13th October 2005. The inspection focused on the requirements from the last inspection, a tour of the home, review of the resident’s care records and other records and registers were examined. Residents were spoken to during the inspection process to establish their views about the home and the care provision. There have been no complaints made to the CSCI about the service since the last inspection. What the service does well: What has improved since the last inspection?
The home displays the menu in the dining room for the residents and relatives to see. Areas that have been redecorated have further enhanced the appearance of these areas. Astley Hall Nursing Home DS0000004094.V250232.R01.S.doc Version 5.0 Page 6 The residents’ care records have been changed since the last inspection and these reflect the care needs and risk assessments of the residents more clearly. 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. Astley Hall Nursing Home DS0000004094.V250232.R01.S.doc Version 5.0 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 Astley Hall Nursing Home DS0000004094.V250232.R01.S.doc Version 5.0 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 and 5 The manager assesses all residents prior to admission to ensure the home can meet the assessed needs of the prospective resident. EVIDENCE: The manager completes a care needs assessments for prospective residents, prior to them being admitted to the home. This ensures the home is able to meet those needs appropriately. The care needs assessment then forms the basis of the residents care plan. A resident who had been recently admitted to the home, confirmed that the manager had been out to see her and asked lots of questions. She stated that it felt like “home from home”. Another resident confirmed he had been made most welcome and was pleased with his room and the food at Astley Hall. Astley Hall Nursing Home DS0000004094.V250232.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 8 Residents care documentation had improved since the last inspection to reflect the health care needs of all residents. EVIDENCE: The care plans for three residents were reviewed the documentation had been reviewed since the last inspection. There was guidance for staff on the tasks to be completed to meet the needs of the residents. Appropriate risk assessments had been carried out and recorded. One care plan had not been updated since May 2005, the risk assessments were however up to date. Residents have access to general practitioners and other services. The residents spoken to confirmed that they were well looked after at the home. Astley Hall Nursing Home DS0000004094.V250232.R01.S.doc Version 5.0 Page 10 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): 13, 14 and 15 Activities for the residents’ needed to be further developed and ensure details of the residents’ day and activities are included in the care records. The home provides a varied choice of meals catering for the residents’ likes and dislikes and special diets. EVIDENCE: Since the last inspection the home has employed an activities organiser, some residents have details about their social needs recorded in their care documentation. The need to develop this further and develop a formal activities program was discussed. On the day of the inspection no specific activities were being offered to the residents. There were a number of visitors at the home; some were seeing relatives in their rooms whilst others sat in the lounges. The residents’ who commented about the food available at the home, were most complimentary about the quality and quantity of food served. Staff was assisting the residents who required assistance with feeding in a dignified manner. The lunch being served looked appetising and well presented. The
Astley Hall Nursing Home DS0000004094.V250232.R01.S.doc Version 5.0 Page 11 home displays the menus in the dining room so residents and visitors can see the choices available for that day. Astley Hall Nursing Home DS0000004094.V250232.R01.S.doc Version 5.0 Page 12 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 Complaints are handled appropriately. The home has a procedure for responding to any potential allegations of abuse. EVIDENCE: The home maintains detailed records of any complaint made, these records were available and showed that the homes complaints procedure had been followed. The home and the CSCI had received no complaints since the last inspection. One member of staff had been referred to the POVA (Protection of Vulnerable Adults) list since the last inspection. This followed reports that the member of staff’s attitude was not appropriate to care for vulnerable residents’. The home has referred the member of staff to the appropriate authorities and maintained detailed records of the incident. Astley Hall Nursing Home DS0000004094.V250232.R01.S.doc Version 5.0 Page 13 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): 19,21,23, and 26 The homes appearance in some areas would be further improved by a redecoration program. EVIDENCE: Since the last inspection there has been some limited improvement to the standard of the environment. At the time of the inspection three vacant bedrooms were in the process of being redecorated. The manager confirmed that this is normal practice when a room is vacated it is redecorated. The lounge/Dining room on the first floor remains in need of an upgrade its appearance is poor and lets the home down. Some floor coverings had been replaced since the last inspection and staff commented that this had assisted in managing residents with incontinence problems. The home has a passenger lift and the service records were available for this.
Astley Hall Nursing Home DS0000004094.V250232.R01.S.doc Version 5.0 Page 14 Some of the bedrooms used by residents were observed, the residents in these rooms commented on how pleased they were with their bedrooms and one said, “It was home from home”. The use of safety gates on resident’s bedroom doors was discussed; all residents’ relatives consent to their use and appreciate the rationale for their use. It was recommended that an alternative to safety gates be reviewed. Given the size of the home and dependency of the residents the management of odours was good. Astley Hall Nursing Home DS0000004094.V250232.R01.S.doc Version 5.0 Page 15 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 and 30 Staff have received dementia training to further assist them in meeting the needs of the residents. EVIDENCE: The staff training records were available and showed that all staff are up to date with mandatory training courses. Since the last inspection sixteen staff have attended a training course on dementia. This will further assist them in meeting the care needs of the residents on the first floor. Several care staff are in the process of completing NVQ level 2 and 3 and the home has exceeded the 50 as required by the standard. Staffing levels were appropriate for the number of residents at the home. The home is looking to recruit to cover for maternity leave. The home uses a small amount of agency staff to maintain the staffing levels, they tend to request the same staff to ensure consistency for the residents. The manager completes regular staff supervision and appraisals with the staff. This ensures that the home is meeting the staff’s expectations, and deal with any staff issues on a one to one basis. Residents complimented the staff and how good they are. Astley Hall Nursing Home DS0000004094.V250232.R01.S.doc Version 5.0 Page 16 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): 31,33,37 and 38. The manager is competent to ensure the needs of the residents are met. EVIDENCE: The manager is a first level registered nurse with many years experience in managing a care home. The manager is appropriately qualified to be the registered manager. The home has a formal quality assurance process and the results are available at the home. Meetings are also held with the relatives and residents, the minutes for these meetings are available for reference. Records reviewed indicated that regular health and safety checks are completed including fire safety tests.
Astley Hall Nursing Home DS0000004094.V250232.R01.S.doc Version 5.0 Page 17 The home provides monthly statutory reports to the CSCI. Astley Hall Nursing Home DS0000004094.V250232.R01.S.doc Version 5.0 Page 18 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 N/A 3 X 3 x X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X X 3 3 3 Astley Hall Nursing Home DS0000004094.V250232.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard 12 Regulation 15 Requirement The home must ensure a more formalised activities program is available for the residents, and included in the care records. Resident’s care plans must be reviewed at least once a month. The home must keep all parts of the home in good decorative order, the lounge/ dining room on the first floor is to be prioritised.
REMAINS OUSTANDING FROM PREVIOUS INSPECION. Timescale for action 31/12/05 2 3 7 19 15 23 30/11/05 31/12/05 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 38 Good Practice Recommendations The use of safety gates on residents’ bedroom doors should be reviewed for an alternative. Astley Hall Nursing Home DS0000004094.V250232.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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