Inspection on 06/01/06 for Autumn Leaves

This inspection was carried out on 6th January 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 25/04/06

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 6th January 2006 11:00 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.V276106.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.V276106.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.V276106.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. 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 area 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 19 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 DS0000064142.V276106.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This statutory inspection was the second of two to be carried out this year. The inspection took place on 6th January 2006 and was an unannounced one. It lasted for 3.5 hours. The inspection was carried out against the National Minimum Standards for Older People. The inspection was carried out in a relaxed atmosphere with the full cooperation of the owners, the staff and all the residents. The inspection took the form of looking at some of the records, talking to the residents and the staff and checking the building. There were 19 residents living at the home and they said that they were well cared for and that all the staff were kind and helpful. What the service does well: What has improved since the last inspection? There has not been any improvement made to the building as recommended during the previous inspection. Autumn Leaves DS0000064142.V276106.R01.S.doc Version 5.1 Page 6 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.V276106.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.V276106.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): EVIDENCE: The home does not provide intermediate care. The other core standard was assessed during the previous inspection and was met. Autumn Leaves DS0000064142.V276106.R01.S.doc Version 5.1 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): 8&9 The arrangements for meeting residents’ health needs are good. The policies and procedures on medications are adequate. Residents have good care plans. The procedure for administering and recording of medications although safe, needs tightening. EVIDENCE: The personal records of two residents were examined and they show that details of health care needs were recorded. Residents’ GPs and contact numbers were recorded. A brief medical history as well as any medications the residents are taking is included in the notes. Residents have access to other health professional such as dentist, optician and chiropodist of their own choice. The owners said that they take the residents to their appointments. The residents said that they are well looked after and that if they need to see the doctor or other health professionals, the staff would arrange it for them. Autumn Leaves DS0000064142.V276106.R01.S.doc Version 5.1 Page 10 They said that they can keep their own GP unless he refuses to visit because of the distance involved. The surgery used by the home is across the road and sometimes residents will see the doctor there. The district nurse visits those residents who have been referred to her by the doctors. The inspector observed the senior staff dispensing medications to the residents. The care staff was seen to take tablets out of the blister packs and put them in small plastic containers to give to the residents when they were due. The records of medications were examined and they were found to have some discrepancies in them. A visit by the pharmacist inspector has been arranged to advise the owners on medications. An audit trail of the medications of three residents was done and they were found to be accurate. The providers were aware that following the death of a resident, medications should be kept for a week in the event that a post mortem is carried out. Autumn Leaves DS0000064142.V276106.R01.S.doc Version 5.1 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): 14 & 15 Independence is encouraged. Food and nutrition play an important part in the home’s daily routines. Residents are given choices in their daily activity and have good food. EVIDENCE: The residents said that they can have as much independence as they want and that the staff help them when they need assistance. The owners said that the residents are consulted on a daily basis about what they want to do. The owners said that the policy of the home is to encourage residents to remain as independent as they want. Residents were observed doing their own things. Some were in the lounge and others were in their rooms. They said that they are able to remain as independent as they want or able to. They said that staff are helpful and will provide assistance when required. Staff were overheard asking the residents what they wanted to do later in the day. Autumn Leaves DS0000064142.V276106.R01.S.doc Version 5.1 Page 12 The staff spoken to said that although residents are encouraged to retain their independence, they are not forced to do anything. They can choose when to go to bed and when to get up. The records of meals served were examined and they show that a variety of food is provided. A choice of food is not provided at lunchtime when the main meal of the day is served. However, the owners said that if a resident does not like something, a substantial alternative is provided. They said that all the staff are aware of the likes and dislikes of the residents. A wide choice of food is provided for breakfast and teatime. The resident said that the food is good and that they get plenty to eat and drink. The staff were observed assisting the residents at lunch time with patience and politeness. Autumn Leaves DS0000064142.V276106.R01.S.doc Version 5.1 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): 18 Policies and procedures on abuse are thorough. Residents feel safe and protected. EVIDENCE: The owners have produced a detailed written policy and procedure on adult abuse. There is also a procedure on abuse published by Blackpool Borough Council available at the home. The owners and some of the staff have had training on adult abuse. The owners were able to describe accurately the steps they would follow in the event of an abuse to a resident. The staff spoken to said that they would never abuse any resident in their care and that they would report if they saw any form of abuse. The residents said that they feel safe and secure living at the home and that everyone treats them well. Autumn Leaves DS0000064142.V276106.R01.S.doc Version 5.1 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): 26 The standard of cleanliness is good. Residents live in a clean environment. EVIDENCE: The home was found to be clean and in a good hygienic condition. Residents’ rooms and the communal areas were clean. 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 March 2006. 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 DS0000064142.V276106.R01.S.doc Version 5.1 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): 28 & 29 The recruitment policy and procedures are stringent. Staff training plays an important part in staff development. Residents are cared for by a team of well chosen and trained staff. EVIDENCE: The written recruitment policy gives detail of the way a member of staff is employed. When there is a vacancy for a job, it is advertised locally and interested parties are given application forms to complete. From information received, prospective staff are selected for interviews. Once a new staff has been selected, two written references are taken and POVA (Protection Of Vulnerable Adults) and CRB (Criminal Records Bureau) checks are done. No staff starts work until satisfactory checks have been done. Once a new member of staff starts work at the home, she undertakes an induction training programme involving orientation of the home, meeting residents and staff. Training also include, Fire Procedures, Moving and Handling and many other relevant courses Five of the thirteen care staff employed have completed their NVQ (National Vocational Qualification) at level 2 and above. Autumn Leaves DS0000064142.V276106.R01.S.doc Version 5.1 Page 16 The home has 38 of its care staff with this qualification. The recommendation by CSCI (Commission for Social Care Inspection) is that 50 of staff should gain this qualification. The residents spoken to said that the staff team is good and everyone is caring and helpful. They added that nothing is too much trouble and that they feel safe and well cared for. Autumn Leaves DS0000064142.V276106.R01.S.doc Version 5.1 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 & 38 The policies on health and safety issues are good. Residents live in a safe environment where their welfare is protected. EVIDENCE: There are policies and procedures on all aspects of Health and Safety issues. These are kept in a folder which is available to all staff. There are also policies on COSHH (Control of Substances Hazardous to Health). These policies give staff instructions on how to use cleaning chemicals safely. All visitors have to sign in and out, in order to comply with Fire Safety Regulations. The residents said that they feel safe living at the home. Autumn Leaves DS0000064142.V276106.R01.S.doc Version 5.1 Page 18 The owners have many years experience in the running of the home. However one of them needs to complete NVQ level 4 and the Registered Manager’s Award as recommended by CSCI. Autumn Leaves DS0000064142.V276106.R01.S.doc Version 5.1 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X 2 2 STAFFING Standard No Score 27 X 28 2 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X X X 3 Autumn Leaves DS0000064142.V276106.R01.S.doc Version 5.1 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 OP25 Regulation 13 Timescale for action Radiator guards must be fitted to 31/03/06 all radiators. Risk assessments must be undertaken and used to determine the priority for undertaking this work. Repairs to the ceiling in one 31/03/06 lounge must be done. Several areas of the home are in 31/03/06 need of decorating. Requirement 2 3 OP19 OP19 23 23 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 OP31 OP28 Good Practice Recommendations 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.V276106.R01.S.doc Version 5.1 Page 21 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.V276106.R01.S.doc Version 5.1 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. 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