Inspection on 14/08/06 for Autumn House Nursing Home

This inspection was carried out on 14th August 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

Autumn House Nursing Home 18/09/07

Autumn House Nursing Home 16/12/05

Autumn House Nursing Home 12/07/05

Autumn House Nursing Home 24/01/05

Autumn House Nursing Home 21/07/04

Autumn House Nursing Home 02/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Autumn House Nursing Home 37 Stafford Road Stone Staffordshire ST15 OHG Lead Inspector Lynne Gammon Key Unannounced Inspection 14 August 2006 09:00 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 Autumn House Nursing Home DS0000022309.V308219.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. Autumn House Nursing Home DS0000022309.V308219.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Autumn House Nursing Home Address 37 Stafford Road Stone Staffordshire ST15 OHG 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) 01785 812885 01785 615506 lpowell@waverleycarehomes.co.uk Waverley Care Homes Limited Mrs Lesley Barbara Powell Care Home 67 Category(ies) of Dementia - over 65 years of age (6), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (6), Old age, not falling within any other category (31), Physical disability (31), Physical disability over 65 years of age (31) Autumn House Nursing Home DS0000022309.V308219.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 1 Physical Disability (PD) - minimum age 50 years on admission Nursing Care 31 Physical Disability (PD) - Minimum age 60 years on admission Nursing Care 4 Physical Disability (PD) - Minimum age 50 years on admission Personal Care 16th December 2005 Date of last inspection Brief Description of the Service: Autumn House is a care home providing personal care, nursing care and accommodation for up to 67 elderly service users. The home is registered with the Commission for Social Care Inspection to care for service users with the following needs: - dementia, mental disorder (excluding learning disability or dementia), old age, (not falling within any other category) and physical disability. The home is owned by Waverley Care Homes Limited who also own the other care home located on the site. The home is located on the outskirts of the town of Stone in Staffordshire. Amenities, including those in Stone town centre are situated within walking distance. The home consists of two floors, the ground floor is home to service users requiring personal care and the first floor is dedicated to those needing nursing care. There is a passenger lift installed serving both floors. Most bedrooms have en-suite facilities, with some double rooms available. There is a patio area with tables and chairs and a substantial car-parking area at the front of the home. On 6th July 2006 information from the registered care manager identified that the fees for the service ranged from £325 to £506 per week depending upon individual need and other contributions from other agencies or individuals. Additional charges were also made for hairdressing facilities, newspapers, chiropody services and some transport costs. Autumn House Nursing Home DS0000022309.V308219.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit was made on 14 August 2006 at 9.00 am. The inspection was carried out by one inspector who used the National Minimum Standards for Older People as the basis for the inspection. The total time spent for the inspection, including pre and fieldwork, amounted to 10 hours. The inspection included a tour of the home, inspection of records, observation and discussions with service users, relatives and staff. Service users and relatives confirmed they were happy with the service provided. One stated ‘For 18 months I have had good care and support by very friendly staff’. What the service does well: Care planning processes were well documented and informative to enable staff to have a clear understanding of service user’s needs. Health care needs were met very well and service users confirmed that they were treated with dignity and respect. A variety of activities were available for the benefit of the service users and they were encouraged and supported to maintain contact with family and friends. Service users were able to make their own decisions and choices about their lives and a nutritional and well balanced diet was provided for the benefit of the service users. A robust complaints procedure was in place and service users confirmed that they were listened to with their views taken into account. The home was safe and well maintained and very clean and hygienic. Staffing levels and skill mix were sufficient to meet the needs of the service users living in the home at that time. More than 50 of care staff working within the home were trained to NVQ Level 2 in care for the safety of the service users. The registered care manager was an experienced and professional nurse who was fit to be in charge and a competent and able manager. Financial processes were robust for the benefit of the service users. Autumn House Nursing Home DS0000022309.V308219.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Two requirements were raised as a result of this inspection and were as follows: • • For all staff files to contain all required elements as detailed in Schedule 2 of the Care Homes Regulations 2001. For all staff to undertake mandatory training each year. One recommendation was also raised as follows: • For a consent form to be signed by the service user or their representative as authorisation for the use of bed rails by the home and held on the individual’s care plan. 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. Autumn House Nursing Home DS0000022309.V308219.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 Autumn House Nursing Home DS0000022309.V308219.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 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users received written confirmation that their needs could be met following in-depth pre-admission assessments. Intermediate care provision within the home was due to end in August 2006. EVIDENCE: Service users and documentation evidenced that in depth pre-admission assessments of service user needs took place. Following the assessment, a letter to confirm that their needs could be met was provided to the service user prior to moving into the home. Intermediate care had been provided in the home but this service was due to end in August 2006. Autumn House Nursing Home DS0000022309.V308219.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 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 detailed and informative to enable staff to have a clear understanding of service user’s needs. Health care needs were met well and there was a safe system for the receipt, storage, and administration of medicines. Service users confirmed that they were treated respectfully and their privacy supported. EVIDENCE: Five service user care plans were examined and found to be well documented and detailed. All aspects of daily living had been reviewed monthly to ensure that service user needs were being met at all times. Risk assessments were in place and had been reviewed monthly. Bed rails were used within the home for some service users and it is a recommendation of this report that a consent form is signed by the service user or their representative as authorisation for the use of bed rails by the home and held on the individual’s care plan Autumn House Nursing Home DS0000022309.V308219.R01.S.doc Version 5.2 Page 10 Health care needs were met very well and recorded accordingly. Service users had access to a range of other health professionals such as a GP, chiropodist, speech therapist etc. Medication Administration Records and the Controlled Drugs Register were examined in conjunction with medication stock levels. All medication was stored appropriately and safely and all records and stock levels were accurate. Records also showed that a thorough medication review had taken place in April 2006 by the local Chemist on behalf of the home. One service user, in a completed questionnaire sent directly to the Commission commented as follows: ‘I spent 2 weeks in respite care before finally choosing the home, the staff are very helpful and there is good co-operation between the home, the medical services and myself’. Throughout the inspection it was observed that service users were treated with respect, privacy and dignity. Autumn House Nursing Home DS0000022309.V308219.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of activities were provided for the benefit of the service users and they were supported and encouraged to maintain contacts with family and friends and make their own choices over their lives. A well balanced and nutritional menu was provided to meet the needs of the service users. EVIDENCE: Records and service users confirmed that a variety of activities and events were provided by the home and an open visiting policy was in place for relatives and friends. Some service users were in the process of designing a comment slip to be used by all service users living in the home. It was anticipated that service users would use the comment slip to write their thoughts about any aspect of the service, and whether any changes or improvements could be made, and then ‘post’ the slips in a box in reception. Some service users in the home were also making the box to contain the slips. Autumn House Nursing Home DS0000022309.V308219.R01.S.doc Version 5.2 Page 12 Service users spoken to stated that they were treated very well by the staff and in a respectful and dignified manner. One service user said ‘I see my daughter twice per week and I like living here – they are very good to me’. During a tour of the home, the kitchen was visited and menus and catering records were examined. These provided evidence that food probe, fridge and freezer temperatures were within recommended guidelines and recorded daily, and a cleaning schedule was in place and adhered to accordingly. Menus showed a variety of meals were provided and choices offered. Food appeared to be well presented and nutritious. Autumn House Nursing Home DS0000022309.V308219.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had a satisfactory complaints procedure and service users confirmed that their views were listened to and acted upon. Service users were protected from abuse by the home’s Adult Protection procedure, however this needs to be strengthened with further training for staff on abuse awareness and protection of vulnerable adults procedures. EVIDENCE: The home had a comprehensive complaints procedure, however neither the Commission nor the home had received any complaints since the last inspection. Service users confirmed that they could talk to the Matron or the staff if they had any problems. The Matron of Autumn House had recently reported an allegation of abuse, which was investigated prior to the inspection via the Protection of Vulnerable Adults procedure. All key agencies had been involved in this investigation, including CSCI and appropriate action was agreed to ensure the on-going protection of the service users which included refresher training for staff in abuse awareness and protection of vulnerable adults procedures. The Matron confirmed that key staff would be undertaking this training in the near future. Autumn House Nursing Home DS0000022309.V308219.R01.S.doc Version 5.2 Page 14 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was safe and well maintained and very clean and hygienic. EVIDENCE: A tour of the home identified that the home was safe and overall, well maintained. The upstairs of the home was in the process of being redecorated at the time of the inspection and a new patio area was nearing completion at the front of the home for the benefit of the service users. The home was very clean throughout and free from any offensive odours. Autumn House Nursing Home DS0000022309.V308219.R01.S.doc Version 5.2 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, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels and skill mix were sufficient to meet the needs of the service users living in the home at that time. Over 50 of care staff within the home at the time of the inspection had achieved NVQ Level 2 in care or equivalent for the safety of the service users. However, recruitment and selection practices were not robust enough for the protection of the service users and not all staff had received mandatory training in order to meet the needs of the service users. EVIDENCE: Staffing rotas were examined and evidenced that sufficient numbers of trained staff were on duty at all times to meet the needs of the service users. The registered care manager confirmed that the home had 48 care staff working in the home with 26 care staff having achieved NVQ Level 2 in care. Therefore at the time of the inspection the home had more than 50 of its care staff qualified to NVQ Level 2 in care or equivalent. Five staff files were examined and each contained the following: an application form, two references, and evidence of satisfactory criminal record bureau checks. However, no photographs of the individual staff member or proof of Autumn House Nursing Home DS0000022309.V308219.R01.S.doc Version 5.2 Page 16 their identity were contained within the file and therefore, it is a requirement of this report that these are obtained for all staff as required in Schedule 2 of the Care Homes Regulations 2001. Staff training records were inspected and evidenced that not all staff had received mandatory training, in particular manual handling and it is a further requirement of this report that mandatory training is provided for all staff. It was noted that other training had been undertaken and included: fire safety awareness, feeding and swallowing, food hygiene and induction training, which was particularly detailed. Autumn House Nursing Home DS0000022309.V308219.R01.S.doc Version 5.2 Page 17 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 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered care manager was an experienced and professional nurse who was fit to be in charge and a competent and able manager. Informal meetings for service users and relatives took place to enable feedback about the service in a relaxed setting. Financial processes were robust for the benefit of the service users. EVIDENCE: The registered care manager for the home had worked at Autumn House Nursing Home for a number of years and was a qualified nurse and an experienced manager. She was very experienced in managing her Autumn House Nursing Home DS0000022309.V308219.R01.S.doc Version 5.2 Page 18 responsibilities and staff to meet the needs of the service users in the home and service users benefited from her open approach. Service users and staff confirmed that cheese and wine evenings were provided for service users and relatives to raise any issues of concern or to make recommendations for improvements, in a relaxed setting. The comments slips referred to earlier within the report will provide on-going quality assurance for the providers and manager of the home and enable them to assess the success of the service in meeting the needs of the service users. Records of service user’s finances were examined and found to balance with monies held. A robust system was in place to ensure the protection of their personal allowances. Autumn House Nursing Home DS0000022309.V308219.R01.S.doc Version 5.2 Page 19 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 4 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 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X X Autumn House Nursing Home DS0000022309.V308219.R01.S.doc Version 5.2 Page 20 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 OP29 Regulation 19 (1)(b) (i) 18 (1)(c) Requirement For all staff files to contain all required elements as detailed in Schedule 2 of the Care Homes Regulations 2001. For all staff to undertake mandatory training each year. Timescale for action 30/09/06 2. OP30 30/09/06 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 For a consent form to be signed by the service user or their representative as authorisation for the use of bed rails by the home and held on the individual’s care plan. Autumn House Nursing Home DS0000022309.V308219.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Autumn House Nursing Home DS0000022309.V308219.R01.S.doc Version 5.2 Page 22 - 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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