Inspection on 03/05/07 for Autumn Leaves

This inspection was carried out on 3rd May 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Autumn Leaves 11/12/08

Autumn Leaves 25/04/06

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 3rd May 2007 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.V335238.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 Leaves DS0000064142.V335238.R01.S.doc Version 5.2 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.V335238.R01.S.doc Version 5.2 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. 25th April 2006 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 16 residents living at the home. Communal facilities include two lounges and a dining room which the residents can use freely. 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. There is a patio and garden at the rear of the home which overlooks the golf course. 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. The current weekly fee charged by the home is £370. Residents are responsible to pay for their own hairdressing, private chiropody and newspapers. Autumn Leaves DS0000064142.V335238.R01.S.doc Version 5.2 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 visit (inspection) between April 2007 and March 2008. An unannounced key site visit was carried out on 3rd May 2007, followed by another visit on 11th May to complete the inspection. The second visit was to examine records not available on the first day. The inspection lasted a total of 7.5 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 friendly 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. Evidence about the inspection was gathered firstly by sending out a questionnaire for the manager of the home to complete and return. The completed questionnaire gave information about several areas such as staffing, checks that the home has made about the safety and maintenance of the building, information about residents and other useful information. Questionnaires sent to residents, the families and other professionals such as district nurses and doctors were not received back. There were 16 residents living at the home at the time of the inspection and there was an adequate number of care staff on duty. One of the owners and a cook were also on duty. The number of staff on duty was well within the minimum level recommended. The staff were observed to be polite and attentive when talking and dealing with the residents. Autumn Leaves DS0000064142.V335238.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Several areas of the home are in need of decorating. Wallpaper is peeling off the walls and some of the paintwork is looking tired. The kitchen floor and work surfaces are in poor conditions. The owners said that the kitchen is being refitted soon. 50 of the care staff needs to achieve their NVQ (National Vocational Qualification) level 2 as recommended by CSCI so that there is a good mixed of staff to provide appropriate care to the residents. The current level of staff with this qualification is a poor 11 . One of the management team should achieve NVQ level 4 or equivalent as soon as possible. Autumn Leaves DS0000064142.V335238.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Autumn Leaves DS0000064142.V335238.R01.S.doc Version 5.2 Page 8 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.V335238.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The procedures and practices to admit new residents are good. Prospective residents are given adequate written and verbal information to make an informed choice about the home. EVIDENCE: The records of admission of the last resident admitted to the home were examined and they showed that a full assessment was carried out prior to admission. 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. Autumn Leaves DS0000064142.V335238.R01.S.doc Version 5.2 Page 10 However in most instances, it is a member of the family of prospective residents who would visit on their behalf. 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. This policy also extends to existing residents whose needs become too great for the home to manage. The owner said that this is explained to prospective residents and their families. 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. 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. Intermediate care is not provided at Autumn Leaves. Autumn Leaves DS0000064142.V335238.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The practices to meet the health and personal care needs of the residents are good. Residents benefit from having their needs assessed and met by a team of dedicated staff. EVIDENCE: Two residents, one of whom being the last one admitted to the home were case tracked. This means that two residents were selected by the inspector and the care they receive examined closely. Their assessments and care plans were examined and they were spoken to. Autumn Leaves DS0000064142.V335238.R01.S.doc Version 5.2 Page 12 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. The physical assessment covers; personal hygiene, mobility, hearing, vision and other areas. The care plans give details of how the assessed needs are met. For example, if someone needed help with personal hygiene, the record will show that this person needs staff to wash and dress her. The care plans are reviewed monthly or as required to meet their changing needs. The residents and their families can be involved in this exercise. The residents said that they are very well looked after by a team of very good staff. They were very positive about the staff and the management of the home. They described the home as being very good. The inspector observed a very relaxed and friendly atmosphere in the home. There were good interactions between the staff and the residents. To meet the needs of residents who need support when walking along the corridors, handrails have been fitted on the walls. Some of the toilets have been fitted with grab rails to help those residents with poor balance and mobility. A passenger lift is available to access the first floor. All the residents are white British, but the owner said if a resident from a minority group was to be admitted to the home, she will obtain as much information as possible by researching this group to meet care, cultural and dietary needs. Resident’s health care needs are met by involving health care professionals. GP’s, district nurses and chiropodist visit when required. The home is sensitive to the needs of all the residents and does everything to help them remain as independent as possible. The staff said that their job is to work with the residents and meet all their needs. They said that they have very good relationships with all the residents. They were observed talking and helping the residents with respect and dignity. 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. Autumn Leaves DS0000064142.V335238.R01.S.doc Version 5.2 Page 13 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. Autumn Leaves DS0000064142.V335238.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good arrangements to meet the social and recreational needs of the residents The home provides a variety of activities to keep the residents stimulated and active. 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 events, then they would take them. Autumn Leaves DS0000064142.V335238.R01.S.doc Version 5.2 Page 15 The residents said that the staff are good and that they would take them shopping and for walks if they wanted to. 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. The residents do not currently favour bingo which was popular at one time. An entertainer comes to the home regularly to entertain the residents. The staff said they will try and accommodate any reasonable activity the residents may wish to do. The owner 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. 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. Autumn Leaves DS0000064142.V335238.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are well written policies and procedures to safeguard and keep residents safe. EVIDENCE: The home has a detailed complaint procedure which explains what people should do if they have a complaint. Allegations from an anonymous source were received by CSCI last month. The allegations were about some of the physical aspects of the home and poor practices by the owners. The owners said that they are aware that several areas of the home are in need of decorating. The kitchen which is in a poor condition is being refurbished very soon. Satisfactory explanations were given by the owners about other allegations made. 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. Autumn Leaves DS0000064142.V335238.R01.S.doc Version 5.2 Page 17 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. 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. The residents were observed to be free from neglect and abuse. They all appear to be well cared for. Autumn Leaves DS0000064142.V335238.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is kept to a good hygienic standard. Maintenance in some areas is poor. Residents live in a clean home. EVIDENCE: There are several areas in the home requiring decorating. These include some of the bedrooms, the dining room, lounge, stairway and other areas. The kitchen, which is in a poor state, is being refurbished within the next few weeks. The carpet between the dining room and the corridor is in a poor state and needs replacing or repairing. Autumn Leaves DS0000064142.V335238.R01.S.doc Version 5.2 Page 19 All the central heating radiators have now been fitted with low heat surfaces to prevent anyone from being burnt. The bedrooms visited were found to be clean and adequately furnished. The residents said that they were happy with their rooms. They may bring their own furniture and other personal belongings. The residents said that they feel safe living at the home and that the staff respect their privacy. There are policies and procedures regarding the handling of cleaning materials and infection control. Some staff have attended courses on the control of infections. The residents’ general comments were that the home is nice, clean and homely. Handrails have been fitted alongside the corridors to help residents with mobility. There are grab rails fitted to some of the toilets to help residents who are disabled. A passenger lift is available to access the first floor and residents can use it independently if they wish. The home was found to be free from hazards and the residents said that they can get around the home safely. 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.V335238.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a robust recruiting procedure to ensure that staff employed are fit to care for the residents. A team of well-motivated staff ensures good care practices for the residents. EVIDENCE: The number of staff on duty has been maintained to a good level to meet the needs of the residents. At the time of the inspection, there were 2 care staff, the owner and a cook on duty. Staff rotas examined show that the staffing level is well within the recommended level for the number of residents at the home. The owner demonstrated a good understanding of the procedures to be followed when selecting and recruiting staff. The staff files examined show that appropriate checks have been carried out before offers of employment were made. Such checks included CRB (Criminal Records Bureau) and a POVA (Protection Of Vulnerable Adults). Autumn Leaves DS0000064142.V335238.R01.S.doc Version 5.2 Page 21 The staff spoken to said that they enjoy working at the home very much. They said that the management is very supportive and listens to what they have to say. The residents said that the staff are marvellous and will do anything for them. There were good interactions between the residents and the staff. They all appeared to be happy and content Seventeen care staff are employed at the home and only 2 of them have completed their NVQ level 2. The recommendation is that 50 of them should achieve this qualification. There is also a need for the home to provide other relevant courses for the staff. This could include courses on Dementia, Moving and Handling, Medications, Nutrition and others. 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.V335238.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a good management team. The residents and staff benefit from living and working in a well managed home EVIDENCE: The owners have owned and managed Autumn Leaves for many years. They said that the home is a family run 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. Autumn Leaves DS0000064142.V335238.R01.S.doc Version 5.2 Page 23 The residents said that the owners are around everyday and that they can speak to them when they want. The staff said that they receive support and guidance from the owners. One of the owners should complete the Registered Manager’s Award or equivalent as soon as possible. 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. Autumn Leaves DS0000064142.V335238.R01.S.doc Version 5.2 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 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Autumn Leaves DS0000064142.V335238.R01.S.doc Version 5.2 Page 25 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 OP19 Regulation 23 Requirement Repairs to the ceiling in one lounge must be done. Several areas of the home are looking tired and are in need of decorating. Timescale for action 30/09/07 2. OP19 23 30/09/07 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. Refer to Standard OP31 Good Practice Recommendations One of the providers must achieve NVQ Level 4 or equivalent. 50 of the care staff should achieve NVQ Level 2. 2. OP28 Autumn Leaves DS0000064142.V335238.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V335238.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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