Inspection on 30/08/05 for Autumn Leaves

This inspection was carried out on 30th August 2005.

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 25/04/06

Autumn Leaves 06/01/06

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 Ajam Auckburally Unannounced 30 August 2005 th 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 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 F57 F09 S64142 Autumn Leaves V232986 140705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Autumn Leaves Address 502 Devonshire Road, Blackpool, Lancashire, FY2 0JR Telephone number Fax number Email 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 CRH Care Home 20 Category(ies) of OP Old Age 20 registration, with number of places Autumn Leaves F57 F09 S64142 Autumn Leaves V232986 140705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service is registered for a maximum of 20 service users in the category OP (Older People over the age of 65). 2. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection 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. There is a patio and garden at the rear of the home which overlooks the golf course. 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. The inspector spoke to most of them 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. Autumn Leaves F57 F09 S64142 Autumn Leaves V232986 140705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first of two statutory inspections to be carried out this year. The inspection was an unannounced one and took place on the 30th August 2005 and 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. One resident said “I am very well looked after here and all the staff are good.” 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 by being available to them. The owners work in the home and they provide help and support to the residents and the staff. The residents said that they can speak to the owners and that they listen and help. The admission process involves new residents meeting existing ones to help them settle in the home. One of the owners said that she would try where possible to take a new resident out in the car for an outing alongside an existing resident. She said that she has found this method works, as new and existing residents talk and become friends. Autumn Leaves F57 F09 S64142 Autumn Leaves V232986 140705 Stage 4.doc Version 1.40 Page 6 All residents are accompanied to hospital appointments and such like by either the family or one of the owners. The owners said that unless residents are insistent and able to go alone, they are always given an escort. The owners take residents out for short trips several times a week. The care provided is based on individual assessments and residents are given choices in their daily living. The residents said that they can do what they want. 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 F57 F09 S64142 Autumn Leaves V232986 140705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Autumn Leaves F57 F09 S64142 Autumn Leaves V232986 140705 Stage 4.doc Version 1.40 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 standard(s) 3 There are good pre admission assessments to meet the needs of new residents. New residents are provided with good care by having all their needs met. 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. The owners said that prospective residents are encouraged to visit the home prior to admission; 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, Autumn Leaves F57 F09 S64142 Autumn Leaves V232986 140705 Stage 4.doc Version 1.40 Page 9 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. Autumn Leaves F57 F09 S64142 Autumn Leaves V232986 140705 Stage 4.doc Version 1.40 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 standard(s) 7 & 10 There is a good system in place to meet the health needs of the residents. Policies and training to care for the residents with respect are in place. Residents’ health needs are met and they are treated with respect. EVIDENCE: The case files of two residents were examined and they clearly show that 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. 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 two residents and she keeps her own notes on the treatments she provides to the residents. Autumn Leaves F57 F09 S64142 Autumn Leaves V232986 140705 Stage 4.doc Version 1.40 Page 11 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 owners said that they would happily take any residents who would like to visit doctors’ surgeries. They said they already take residents to opticians, dentists and to other appointments. 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 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 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. Autumn Leaves F57 F09 S64142 Autumn Leaves V232986 140705 Stage 4.doc Version 1.40 Page 12 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 standard(s) 12 & 13 Policies and procedures to help residents maintain their social, cultural and religious needs are in place. Residents are able to practice their religious beliefs and maintain their cultural and social needs. EVIDENCE: 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. 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 Autumn Leaves F57 F09 S64142 Autumn Leaves V232986 140705 Stage 4.doc Version 1.40 Page 13 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 the residents can practice their religions freely and priest and other religious leaders visit the home regularly. 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. The residents said that the owners and the staff will help them do what they want. Autumn Leaves F57 F09 S64142 Autumn Leaves V232986 140705 Stage 4.doc Version 1.40 Page 14 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 standard(s) 16 Policies and procedures to deal with complaints have been produced. Residents live in a safe environment and are able to speak their minds without fear of reprisals. 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 had received two complaints via CSCI since the last inspection. Two additional inspection visits were carried out following two anonymous complaints received at the Commission for Social Care Inspection on 14/07/05 & 28/07/05. The complaints received were in relation to staffing levels, turnover of staff, environmental issues and residents getting up very early in the morning. There was also concern about an injury a resident had sustained. However, it was not suggested that this injury was non -accidental. Autumn Leaves F57 F09 S64142 Autumn Leaves V232986 140705 Stage 4.doc Version 1.40 Page 15 Element of complaint Outcome i.e. upheld, not upheld, unresolved Not upheld. The staffing levels at the home are not adequate. Some areas in the home require decorative improvement. There is a very high turnover of staff at the home. Some bedrooms at the home are mal-odorous. A resident injured herself on a carer’s belt buckle. One resident is regularly being made to get up at 5am in the mornings. Partially upheld. Not upheld. Not upheld. Not upheld. Not upheld. The owners said that the decorating of some areas of the home is being planned. 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. Autumn Leaves F57 F09 S64142 Autumn Leaves V232986 140705 Stage 4.doc Version 1.40 Page 16 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 standard(s) 19 There are policies and procedures for the safety of residents. Some areas of the home are in need of decorating and repair. Residents live in a safe environment although some cosmetic works are needed in some areas of the home. EVIDENCE: All of the central heating radiators need to have low heat covers fitted to them. The owners said that this work will be carried out by the end of this year. In the meantime, they said that all residents are risk assessed to ensure that they are not in danger from falling against hot radiators. Several areas of the home are in need of decorating and the ceiling in one of the lounges is in need of repair. The owners said that they are having a new kitchen fitted soon and that the painting and decorating of the rest of the home will follow this. Autumn Leaves F57 F09 S64142 Autumn Leaves V232986 140705 Stage 4.doc Version 1.40 Page 17 The central heating radiators need to be fitted with low surface covers in order to prevent residents from being burnt if they fall and become immobile against them. The owners said that the residents are assessed to ensure they are safe. The work to fit radiator covers will be completed by the end of 2005. Autumn Leaves F57 F09 S64142 Autumn Leaves V232986 140705 Stage 4.doc Version 1.40 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 30 The training of staff plays an important part in the home’s policy. Residents are cared for by a team of well trained staff. EVIDENCE: The owners said that all new staff are given an induction training programme when they start work at the home. The induction training includes basic practices such as Moving and Handling, Food Hygiene and First Aid. The staff the inspector spoke to said that they have attended several training courses and found them beneficial. The person in charge said that it is a contractual requirement for new staff to attend training courses. Training records confirmed that staff have attended the following courses: Abuse Awareness Health and Safety Medications First Aid NVQ Autumn Leaves F57 F09 S64142 Autumn Leaves V232986 140705 Stage 4.doc Version 1.40 Page 19 The Commission for Social Care Inspection (CSCI) has recommended that 50 of care staff achieved the National Vocational Qualification (NVQ) level 2 this year. The staff at Autumn Leaves have achieved 30 . The residents said that the staff are very good and caring and they seem to know what they are doing. They said that all of them are kind and helpful and treat them with respect and dignity. Autumn Leaves F57 F09 S64142 Autumn Leaves V232986 140705 Stage 4.doc Version 1.40 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 & 35 The policy and procedures to protect the finances of the residents are good. The home is run to serve the best interests of the residents. The residents’ finances are safeguarded and they feel that the home is run for their benefits. EVIDENCE: The home has good policies and procedures to protect the finances of the residents. The records of monies held on their behalf were examined and they were found to be accurate and current. The owners said that residents and their families are encouraged to deal with their own finances if possible, and this seemed to be the preferred way for most of them. Fees due to the home are mostly paid by direct debit arrangements. Autumn Leaves F57 F09 S64142 Autumn Leaves V232986 140705 Stage 4.doc Version 1.40 Page 21 The monies held by the home on behalf of some of the residents are for those whose families live far away or for those who have no families. Those residents who are able to deal with their finances said that they are free to use their money as they like and if they need help, the staff will provide assistance. The staff said that the residents have complete freedom in their daily activities. They said that residents can do what they want and that they are available to speak or advice them when they want. The residents said that they are happy living at the home and that everyone has their best interest at heart. Autumn Leaves F57 F09 S64142 Autumn Leaves V232986 140705 Stage 4.doc Version 1.40 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x 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 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 2 x x x x x 2 x STAFFING Standard No Score 27 3 28 2 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 2 x 3 x 3 x x x Autumn Leaves F57 F09 S64142 Autumn Leaves V232986 140705 Stage 4.doc Version 1.40 Page 23 yes 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. 2. Standard 19 25 Regulation 23 13 Requirement Timescale for action 31.12.05 Several areas of the home are in need of decorating. Radiator guards must be fitted to 31.12.05 all radiators. Risk assessments must be undertaken and used to determine the priority for undertaking this work. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 28 31 Good Practice Recommendations A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005 One of the providers must achieve NVQ Level 4 or equivalent by 2005. 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