Inspection on 25/04/06 for Autumn Leaves

This inspection was carried out on 25th April 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 Leaves 11/12/08

Autumn Leaves 03/05/07

Autumn Leaves 06/01/06

Autumn Leaves 30/08/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Autumn Leaves 502 Devonshire Road Blackpool Lancashire FY2 0JR Lead Inspector Mr Ajam Auckburally Unannounced Inspection 25th April 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Autumn Leaves DS0000064142.V286240.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. Autumn Leaves DS0000064142.V286240.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Autumn Leaves Address 502 Devonshire Road Blackpool Lancashire FY2 0JR 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) 01253 354595 Autumn Leaves UK Limited Mrs Kathleen Mary McLoughney Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Autumn Leaves DS0000064142.V286240.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service is registered for a maximum of 20 service users in the category OP (older people over the age of 65 years.) The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 30th August 2005 Date of last inspection Brief Description of the Service: Autumn Leaves is situated on Devonshire Road in Bispham, Blackpool. The home is an extended detached property and provides accommodation for a maximum of 20 residents of both sexes who are 65 years old and over. Accommodation is provided in 14 single and 3 double bedrooms. The double rooms are mainly used for single occupancy. At the time of the inspection there were 17 residents at the home. There are two lounges and a dining room. A passenger lift is also available. The inspector spoke to most of the residents and they said that they enjoy living at Autumn Leaves and that everyone is kind and helpful. Residents are encouraged to retain as much of their independence as possible and the staff said that one of their roles is to help them achieve this. For those residents who need assistance, a team of staff are there to provide it. There is a patio and garden at the rear of the home which overlooks the golf course. The current weekly fees charged by the home are between £340 and £356. Residents are responsible to pay for their hairdressing, private chiropody and newspapers. Autumn Leaves DS0000064142.V286240.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Under IBL (Inspecting for Better Lives) Autumn Leaves was assessed as requiring a statutory key inspection between April 2006 and March 2007 with a further random inspection if required. An unannounced key inspection was carried out on 25th April 2006 and it lasted for 5 hours. The inspection was carried out against the National Minimum Standards for Older People. The inspection despite being an unannounced one was carried out in a nice atmosphere and with the full cooperation of the owners, the staff and the residents. During the inspection, some records were looked at and several residents and staff were spoken to. The residents were very positive about the care they receive and the way the staff treat them. There were 17 residents living at the home at the time of the inspection and there were 1 care staff, 1 senior carer, the owners, and a cook on duty. The number of staff on duty was within the minimum level recommended. The staff were observed to be polite and attentive when talking to the residents. What the service does well: The owners said that they provide a personal service to the residents. They said that the business is a family business and that they are hands on owners. Their daughter also works in the home. The residents spoken to said that they are well cared for and that all the staff are kind. One survey card completed by a resident stated that “ the staff are brilliant” The inspector observed the residents being cared for with respect. The staff were observed to be polite. Autumn Leaves DS0000064142.V286240.R01.S.doc Version 5.1 Page 6 The residents were seen to move around the home freely and said that they can do what they want. Some residents were in the lounge and two came in the dining room to have a chat. Another resident went to the patio to have a smoke. What has improved since the last inspection? 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. Autumn Leaves DS0000064142.V286240.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 Autumn Leaves DS0000064142.V286240.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 Quality in this outcome is good. This judgment has been made using available evidence including a visit to the service. The information provided to prospective residents about the home and the information that the home gathers about the needs and preferences of the individual makes sure people are able to choose whether the home us suitable for them or not. EVIDENCE: Every resident considering coming to live at Autumn Leaves has a pre admission assessment done. This is done by different methods and the most common one is when a relative of a resident rings the home to see if there is a vacancy. If there is, then the person is asked some basic questions and given the option to visit the home. Where it is possible and practicable, one of the owners will visit the prospective resident in her own home. Autumn Leaves DS0000064142.V286240.R01.S.doc Version 5.1 Page 9 The owners said that prospective residents are encouraged to visit the home and spend some time with the other residents. They can have a meal and participate in daily activities. However in many instances it is a member of their families who would visit. During the visit a written assessment is done to decide whether the home can meet the needs of the resident. Questions will include such things as mobility, mental state, likes and dislikes, any idiosyncrasies and other needs which will help the staff provide the right care. Autumn Leaves has a policy of not accepting people for whom they cannot provide total care. A full assessment is carried once the new resident is admitted and continues all the time. Regular reviews are carried to ensure that the level of care provided is appropriate. The written records of two residents were examined and they clearly show that pre admission assessments were done and these were followed up by full assessments and reviews. Existing residents are encouraged to be involved in helping new ones settle in. They can help by telling new residents about the routines of the home. An information pack containing the service user guide and other relevant information is available in all the rooms. Every resident has a written contract, which gives details of the services to be provided, and how much they need to pay. This document is signed by the resident or their representatives and also the owner of the home. Autumn Leaves DS0000064142.V286240.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 & 10 Quality in this outcome is good. This judgment has been made using available evidence including a visit to the service. The systems in place at the home ensure that residents health and social care needs are fully met and that services meet the persons needs and preferences. EVIDENCE: Two residents were case tracked. This means that two residents were selected by the inspector and the care they receive examined closely. Their case files were examined and they were spoken to. The case files show that detailed written information about the residents has been recorded. These include an assessment to identify the needs of the residents and also a care plan which shows how the needs were being met. One of the residents needed help with personal care, and the records clearly show how the staff were involved in providing assistance with this task. Autumn Leaves DS0000064142.V286240.R01.S.doc Version 5.1 Page 11 The two residents said that the staff and the owners speak to them everyday to find out if they are all right and also if they need anything. The staff were observed to be polite when speaking to the residents and assisting them. Their medical details were documented. They include the names and contacts of the GP’s. Other health professionals such as dentist, optician are also included if the resident has one. On the day on the inspection, one of the owners was escorting a resident to an appointment. The owner said that it is normal practice at the home for the residents to be taken in the car by her to medical appointments and other appointments such hairdresser. A brief medical history is recorded as well as any medications the resident may be taking. If the district nurse is treating someone, this information is also written down. The district nurse was treating one resident and she keeps her own notes on the treatments she provides to the residents. The residents said that if they needed a doctor, then one would be sent for. They said that they prefer the doctor to visit them at the home as they are not fit enough to go to the surgery. The pharmacist inspector visited the home following a request from the inspector after the inspection on 6th January 2006. There were issues around the storing and secondary dispensing (this is when medications are transferred from one container to another before being given). These areas have been improved following the recommendations by the pharmacist inspector. The medication policy states that residents who are able and willing can keep and administer their own medications. None of the residents currently in the home was self-medicating. The residents spoken to said that they prefer the staff to manage their medications. The staff spoken to said that they respect the privacy and rights of all the residents. They said that they always knock before entering a resident’s bedroom. The residents said that as far as they are concerned all their rights as people are respected. One resident said “ I can do what I want, my visitors can come when they want and the staff treat me well.” Some residents were in their rooms when the inspector went round the home. One said that she spends most of her time in her room. She said that she Autumn Leaves DS0000064142.V286240.R01.S.doc Version 5.1 Page 12 prefers it this way and that the staff respect her choice to stay in her room. She added that the staff look after all her needs without infringing on her privacy. The owners said that all staff are given in house training to ensure that they care for the residents with dignity. Policies regarding residents’ rights, privacy and dignity are available in the home’s policy manual. The care plans are reviewed monthly and more frequently if required. This is to ensure that the changing needs of the residents are met Autumn Leaves DS0000064142.V286240.R01.S.doc Version 5.1 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 Quality in this outcome is good. This judgment has been made using available evidence including a visit to the service. Residents’ social lives and daily activities indicate that their choices and preferences are met and that they enjoy a fulfilling lifestyle. EVIDENCE: Some of the residents spoken to said that although they miss their own homes, they are happy living at Autumn Leaves. The residents spoken to said that they are free to do what they want. They said that they can follow their religions and that priests and vicars visit the home on a regular basis. The owners said that if any resident wanted to attend church or other social event, then they would take them. The residents said that the staff are good and that they would take them shopping and for walks if they wanted to. Autumn Leaves DS0000064142.V286240.R01.S.doc Version 5.1 Page 14 Some of the residents said that they prefer to spend part of the day in their rooms. Some of them were seen in their rooms when the inspector looked around the home. They said that they like the privacy of their rooms and that all the staff respect their wishes. They added that the staff will bring them a cup of tea to their rooms if they want The owners said that they try and arrange as many activities as possible. Bingo is played weekly or as residents want. Staff were seen manicuring residents nails and doing make up. The staff said they will try and accommodate any reasonable activity the residents may wish to do. One of the owners said that she takes two or three residents out several times a week for shopping, a drive round, lunch or whatever they want to do. Other activities include entertainers coming to the home, quizzes, dominoes etc. The residents said that the owners and the staff will help them do what they want. The residents said that they enjoy the food served at the home. They said that they get plenty to eat and drink. A cook is employed to do the catering. She said that she tries and provides meals to the residents’ taste and preferences. Lunch is a set menu with alternatives available. A wide choice of food is available for breakfast and teatime. Residents may have their meals in their rooms if they prefer, although they are encouraged to eat with the others as a social gathering. Family and friends of the residents are welcome to visit at any reasonable time. During the inspection, the inspector spoke to two visitors. They said that they were satisfied with the services provided to their relatives. They said that they are made very welcome and that all the staff are kind and helpful. Autumn Leaves DS0000064142.V286240.R01.S.doc Version 5.1 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 Quality in this outcome is good. This judgment has been made using available evidence including a visit to the service. Residents feel protected and safe and the policies and procedures make sure this continues. EVIDENCE: The home has a detailed complaint procedure which explains what people should do if they have a complaint. It says that in the first instance, people should complain to a member of staff unless the complaint is about staff. The next step is to speak to the owners. If this does not resolve the complaint, then the complaint can be passed to the Commission for Social Care Inspection (CSCI). The home has received no complaints since the last inspection. The owners said that they talk to the residents everyday to help them sort any problems out. A copy of the complaint’s procedure is available in all the bedrooms. The residents said that if they have any complaints, they would not hesitate to speak to someone about it. They said all the staff and the owners are very approachable and easy to speak to. A policy and procedure on abuse published by Blackpool Borough Council is available. The policy has details of what the owners and staff should do in the event of an abuse taking place and also how to prevent it. Autumn Leaves DS0000064142.V286240.R01.S.doc Version 5.1 Page 16 Although the staff are aware of the steps to take in the event of an abuse taking place, some formal training on this subject should be made available to them. They would benefit from learning about different types of abuse and learn about what to do. The residents were observed to be free from neglect and abuse. They all appear to be well cared for. Autumn Leaves DS0000064142.V286240.R01.S.doc Version 5.1 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 Quality in this outcome is poor. This judgment has been made using available evidence including a visit to the service. Residents live in a home that is poorly maintained. EVIDENCE: Requirements made last year for the owners to fit low heat surface covers to all the central heating radiators have not been met. The requirement was made to protect resident from the danger of being burnt against very hot radiators. The owners have failed to do this work as required. They were informed of their obligations to meet this requirement. The requirement made for the decorating of some areas of the home is still not done. A new date of 30th June 2006 has been set for the owners to meet the above requirements. They were informed of their obligations to meet those requirements and that CSCI could take actions if they are not met. Autumn Leaves DS0000064142.V286240.R01.S.doc Version 5.1 Page 18 The other areas of the home not affected by the requirements are well maintained and in good conditions. The bedrooms visited were well maintained and adequately furnished. The residents said that they were happy with their rooms. The home was found to be clean and in good hygienic order. The residents said that the staff clean their rooms daily and that if they wanted to they could help. Autumn Leaves DS0000064142.V286240.R01.S.doc Version 5.1 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 Quality in this outcome is poor. This judgment has been made using available evidence including a visit to the service. The recruitment procedure for new staff is poor. Staff training needs to be more robust and relevant to care practices. Residents may put at risk if staff recruited are not fully checked and do not have appropriate training. EVIDENCE: When the staff records were examined, the inspector found that one member of staff employed by the owners had not had her police check through. This member of staff has started work without the home having received her POVA (Protection Of Vulnerable Adult) first. The owners were reminded of the seriousness of employing staff without having a police check done. Seventeen care staff are employed at the home and only 4 of them have completed their NVQ level 2. The recommendation is that 50 of them should achieve this qualification. The owners said that an additional 4 members of staff have been enrolled to attend this course. There is also a need for the home to provide other relevant course for the staff. This could include courses on Dementia, Moving and Handling, Medications, Nutrition and others. Autumn Leaves DS0000064142.V286240.R01.S.doc Version 5.1 Page 20 The owners said that that they are in the process of sorting this out with a company which provides training to care homes. Autumn Leaves DS0000064142.V286240.R01.S.doc Version 5.1 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 Quality in this outcome is good. This judgment has been made using available evidence including a visit to the service. There is a good management at the home. There are good practices to safeguard residents’ financial interest. EVIDENCE: The owners have owned and managed Autumn Leaves for many years. They said that the home is a family business and that they and their daughter work in the home. This was evident on the day of the inspection when the owners and their daughter were on duty. The residents said that the owners are around everyday and that they can speak to them when they want. Autumn Leaves DS0000064142.V286240.R01.S.doc Version 5.1 Page 22 The staff said that they receive support and guidance from the owners. One of the owners is to start her Registered Manager’s Award as recommended by CSCI. The home has a policy of not handling residents’ finances. All fees due to the home are paid by direct debit arrangements. The only money handled by the home is small amount left by families for residents who cannot handle their own money. The money is used to pay hairdresser and buy small items. The records of money held were checked and found to be accurate. Equality And Diversity Autumn Leaves DS0000064142.V286240.R01.S.doc Version 5.1 Page 23 How aware of equality and diversity issues are management, staff and others involved in the service delivery? This was found to be adequate. Within the service there is evidence of reasonable awareness and understanding of equalities and diversity. The owners were aware of different religions and how to meet the belief of residents. The service shows a lack of awareness of new legislation, guidance and best practice and does not provide staff with necessary information. The owners were advised to access information on CSCI web site at www.csci.org.uk Autumn Leaves DS0000064142.V286240.R01.S.doc Version 5.1 Page 24 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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 x 2 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 3 X 3 X X 2 Autumn Leaves DS0000064142.V286240.R01.S.doc Version 5.1 Page 25 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 OP25 Regulation 13 Timescale for action Radiator guards must be fitted to 30/06/06 all radiators. Risk assessments must be undertaken and used to determine the priority for undertaking this work. Repairs to the ceiling in one lounge must be done. Several areas of the home are in need of decorating. 30/06/06 30/06/06 Requirement 2. 3. 4 5 OP19 OP19 OP38 OP29 23 23 37 19 The providers must inform CSCI 25/04/06 of all death and serious accidents of residents. The provider must not start new 25/04/06 staff unless they have been police checked. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Autumn Leaves DS0000064142.V286240.R01.S.doc Version 5.1 Page 26 1. 2. OP31 OP28 One of the providers must achieve NVQ Level 4 or equivalent by 2005. A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005 Autumn Leaves DS0000064142.V286240.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ 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 Leaves DS0000064142.V286240.R01.S.doc Version 5.1 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!