Inspection on 23/06/05 for Ayletts House

This inspection was carried out on 23rd June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Ayletts House 13/02/09

Ayletts House 06/02/07

Ayletts House 14/12/05

Ayletts House 08/08/04

Ayletts House 14/04/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Ayletts House Main Road Broomfield Chelmsford Essex CM1 7LE Lead Inspector Alan Thompson Final Report Unannounced 23rd June 2005 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. Ayletts House I56 I05 S17758 AYLETTSV219047 UI 23.06.05 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Ayletts House Address Main Road Broomfield Chelmsford Essex CM1 7LE 01245 441854 01245 443604 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) The Croll Group Mrs S Ardley Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Ayletts House I56 I05 S17758 AYLETTSV219047 UI 23.06.05 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 27 persons) Date of last inspection 5th August 2004 Brief Description of the Service: Ayletts Residential Home was originally constructed as a large domestic dwelling and under went extensive building work and complete refurbishment for use as a care home for older people. There are two lounge/dining rooms on the ground floor and a sitting room, visitors room and activities room on the lower ground floor. Twenty four bedrooms continue to be offered as single room accommodation. The remaining bedroom (registered as a double room) was being occupied by two residents who wished to share. All private rooms benefit from fitted ensuite facilities, seven also have baths and four have showers. A shaft passenger lift provides access to all rooms on each of the four levels of the home. A small well maintained garden area with patio and lawn is available for residents to use. Ayletts is positioned just off the approach road to Broomfield Hospital and is close to Broomfield Village. There is a regular bus service to both Chelmsford and Braintree from close by. Visitor car parking is provided at the front, side and rear of the property. Ayletts House I56 I05 S17758 AYLETTSV219047 UI 23.06.05 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection began at 1045 hours and ended at 1515 hours on Thursday 23rd June 2005. This was the first inspection of this home in the inspection year 2005/6. The content of this report reflects the inspector’s findings on the day of the inspection, and from taking account of the findings from previous inspections of the home. Practice and procedures occurring after this inspection will be reported on in future inspection reports. Nine residents, one visitor and three staff were spoken with. Random samples of records, policies and procedures were inspected and a tour of parts of the premises and grounds took place. All residents spoken to confirmed that they were very satisfied with the care they received and with the accommodation and food offered. Staff confirmed they had been offered NVQ award level 2 training. What the service does well: What has improved since the last inspection? What they could do better: Staff records should include copies of proof of identity and a photograph. Portable electrical appliances need to be checked. Ayletts House I56 I05 S17758 AYLETTSV219047 UI 23.06.05 Stage 4.doc Version 1.30 Page 6 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. Ayletts House I56 I05 S17758 AYLETTSV219047 UI 23.06.05 Stage 4.doc Version 1.30 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 Ayletts House I56 I05 S17758 AYLETTSV219047 UI 23.06.05 Stage 4.doc Version 1.30 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 The home’s assessment format and process was adequate for ensuring that initial perceived needs were identified upon admission of new residents. EVIDENCE: The home’s written pre-admission assessment is completed by staff, who visit the prospective new resident in their own home. Relatives are requested to be in attendance at the time of the assessment to assist in information gathering process. The assessment format used included headings under personal details, next of kin information, life style and social needs, cultural, hobbies, previous occupation, physical needs, hygiene needs, personal care needs, psychological considerations, manual handling considerations, the individuals likes, preferences and dislikes, dietary considerations, a pressure sore assessment scale and personal safety and risk assessments. Files also evidenced that individual daily plan of care summaries are compiled using information from the pre admission assessment and after admission. The manager advised that she was compiling a new assessment format to include widen ranging information especially relating to medical background, funding implications and an in-depth life history. Ayletts House I56 I05 S17758 AYLETTSV219047 UI 23.06.05 Stage 4.doc Version 1.30 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 standard(s) 7 & 10 Care plans in place set out the residents daily needs to provide staff with the actions required to meet these. Staff pay attention to ensuring that residents privacy and dignity was respected. EVIDENCE: Residents’ care plans were inspected. These are initially compiled on admission taking full account of information recorded in the pre-admission assessment undertaken by staff, which in future will be signed and dated by staff on completion. The main section seen in the care plan documents covered life style and social needs, physical and psychological needs, as well as specific individual requirements. Also included in residents’ files were manual handling assessments pressure sore risk assessments and medical history profile. The plans clearly identified achievable goals and instructions for staff in how to work with the residents towards meeting these goals. Regular in-house reviews had taken place. Ayletts House I56 I05 S17758 AYLETTSV219047 UI 23.06.05 Stage 4.doc Version 1.30 Page 10 Residents spoken said that staff do pay regard to ensuring that privacy and dignity is maintained when they are providing personal care support Only one room was being used as a shared room and this was occupied by a married couple. Residents spoken with also confirmed that medical examinations and personal care support is provided to them in the privacy of their rooms. A pay phone was located in the main ground floor hallway available for residents use. In addition all private bedrooms were equipped with internal telephone extensions to receive incoming phone calls via the office. The main office phone had been changed to a portable phone in case residents wished to take their call without having to return to their private room. Some residents have chosen to have private BT telephone lines installed in their rooms. Ayletts House I56 I05 S17758 AYLETTSV219047 UI 23.06.05 Stage 4.doc Version 1.30 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 standard(s) 13 The home had maintained good contact with and encouraged involvement from relatives. Involvement had also been welcomed from community contacts. EVIDENCE: Visitors are welcome at all reasonable times. This was confirmed by residents and visitors spoken with. Staff offer refreshments and meals were available. Visitors spoken with also said that staff keep them informed about residents. All bedrooms were single occupancy or shared by choice, there was also a designated ‘visitors lounge’ on the lower ground floor. Written information on this subject was included in the statement of purpose and service users guide. Ayletts House I56 I05 S17758 AYLETTSV219047 UI 23.06.05 Stage 4.doc Version 1.30 Page 12 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 & 18 The home’s complaints procedure allowed for residents and relatives to formally raise any concerns or areas of dissatisfaction with the service. The home’s adult protection policies, procedures and practices were aimed at ensuring residents welfare. EVIDENCE: The homes complaints policy remains unchanged. Written details confirmed whom the complainant should complain to. Also clearly shown were time scales for the homes response which confirmed that a written response will be provided to the complainant within 28 days from the date of the complaint. Written details were also included on how to contact the registration authority. A written record is maintained of any complaints. None had been recorded since the last inspection. The homes written policy on abuse was seen. This sets out the values and principles underpinning the homes approach to abuse. A detailed procedural guide for staff to follow in the event of suspicion or allegation of abuse was included. The latest written guidelines on POVA (protection of vulnerable adults) procedures, and the Essex Vulnerable Adults Protection Committee booklets had been obtained for reference. Training on this subject has been provided to staff. Ayletts House I56 I05 S17758 AYLETTSV219047 UI 23.06.05 Stage 4.doc Version 1.30 Page 13 Also available for inspection was the in-house written policy for staff regarding the acceptance of gifts/bequests and the homes written financial procedural guide. Information was available for residents and relatives in the homes main entrance hallway on the availability of independent financial consultants. Also available for inspection was a written policy guide for staff on dealing with aggression and challenging behaviour, and the home’s whistleblowing policy. Ayletts House I56 I05 S17758 AYLETTSV219047 UI 23.06.05 Stage 4.doc Version 1.30 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 standard(s) 19, 20, 21, 22, 23, 24, 25, 26 Furnishings in the home looked comfortable and the premises were very well maintained. Private accommodation was comfortable and suited to needs and preferences. The premises appeared safe, were accessible, and had sufficient (according to these standards) numbers of toilets and bathrooms. The home was considered clean and hygienic. EVIDENCE: General maintenance in and around the home is provided by a visiting maintenance person each week. Renewal of the fabric and redecoration of the premises takes place on an ongoing rolling programme. On the day of this inspection external re-decoration was taking place. In the inspectors view the premises were very well maintained, furnished and equipped to a good standard. Ayletts House I56 I05 S17758 AYLETTSV219047 UI 23.06.05 Stage 4.doc Version 1.30 Page 15 All residents’ bedrooms in Ayletts benefit from fitted ensuite facilities, seven of these have baths and four have showers. Communal bathing facilities are provided for with the main bathroom on the first floor, a second bathroom on the ground floor (refurbished since the last inspection), and a shower room on the second floor. Communal toilet facilities were seen to be located close to the lounge areas. The homes sluice facility was located in the laundry room on the lower ground floor. The laundry facilities were suitable for the size of the home and were appropriately equipped according to these standards. A call bell system was seen fitted in every communal room, bathroom and all bedrooms inspected. Bedrooms inspected were varied in shape and size. All were well decorated, equipped and furnished to a comfortable and homely standard. Residents spoken with confirmed that they were satisfied with the accommodation provided them in Ayletts. They also said that they had been permitted to bring into the home with them items of personal possessions. Doors to private rooms were fitted with locks. All rooms were centrally heated with thermostats fitted to bedroom radiators, as were radiator guards. The manager confirmed that hot water was regulated for delivery at or close to 43 degrees Celsius (not tested). The inspector asked residents if the lighting in their rooms was adequate for them, those who expressed an opinion said it was. Ayletts House I56 I05 S17758 AYLETTSV219047 UI 23.06.05 Stage 4.doc Version 1.30 Page 16 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 & 29 Staffing levels and skills appeared to meet the needs of residents. Staff recruitment procedures aimed at the protection of residents had been generally followed, however improved retention of proof of identity records would further evidence this. EVIDENCE: The staff rota was inspected and evidenced a minimum of four carers on duty throughout the day with three waking carers on duty at night. In addition, cooking, domestic and maintenance duties are undertaking by additional rostered staff. The management team comprises of a registered manager, a care manager, a deputy manager and up to five senior carers. The care manager was undertaking the registered managers award (NVQ 4), with a hoped for completion date of October 2005. Since the last inspection chef and housekeeping staffing has been increased, and a new part activities coordinator post had been created. Staff files were inspected and those seen contained application forms, two references, job descriptions, evidence of training, contracts of employment and induction records. Criminal Records checks had been undertaken. There were no photographs or copies of evidence of identity on the home’s files. Ayletts House I56 I05 S17758 AYLETTSV219047 UI 23.06.05 Stage 4.doc Version 1.30 Page 17 It was understood that these are held at the registered provider’s administrative offices, however copies should now be available at the home and there is recommendation on this issue in this report. Ayletts House I56 I05 S17758 AYLETTSV219047 UI 23.06.05 Stage 4.doc Version 1.30 Page 18 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) 34, 37, 38 Residents monies held in the home had been managed competently. Records required by regulation were up to date but until staff recruitment records held in the home include evidence of identity, these procedures cannot be fully judged. The health and safety of residents and staff was generally ensured, however until evidence is provided that all portable electrical appliances have been checked there is a potential risk to residents and staff. EVIDENCE: Residents’ personal allowance monies were held for safe keeping in the home. No benefit books were held however. All personal allowance monies are provided by relatives. Transactions were recorded and receipts had been kept as evidence of these transactions. A random sample of these records were inspected and were considered to be appropriately maintained. Ayletts House I56 I05 S17758 AYLETTSV219047 UI 23.06.05 Stage 4.doc Version 1.30 Page 19 Random samples of other records inspected included: care plans, staff rota, records of monies held for safe keeping, regulation 37 notices, details of next of kin and background information, service user assessments, accident records, visitors book, fire drills, fire procedures and staff recruitment records. All were considered appropriately maintained except staff recruitment records which is explained by the recommendation made under standard 29. Staff are trained in manual handling, infection control, first aid, and fire safety. Updated food safety training is now due to take place in July 2005. The homes’ accident records were inspected, as were individual risk assessments. Information was available for staff on the control of substances hazardous to health regulations (COSHH). Certificates/records seen confirmed that the homes gas equipment, electrical systems, emergency lights, water temperature, passenger lift and portable hoists had all been tested/serviced by appropriate contractors. There was not however a record that the home’s portable electrical appliances had been checked within the past twelve months. There is a requirement on this issue in this report. The fire alarm systems are tested internally by staff. The homes’ in-house induction training package includes topics covering health and safety and safe working practices. The premises risk assessment had been updated in September 2004. Ayletts House I56 I05 S17758 AYLETTSV219047 UI 23.06.05 Stage 4.doc Version 1.30 Page 20 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 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x 3 x 2 2 Ayletts House I56 I05 S17758 AYLETTSV219047 UI 23.06.05 Stage 4.doc Version 1.30 Page 21 No 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 38 Regulation 13(4) Requirement The registered provider must ensure that evidence is available for inspection to confirm that all portable electical applicances have been tested. Timescale for action 30/9/05 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 29 Good Practice Recommendations The registered provider should ensure that staff records in the home include copies of proof of identity and a photograph. Ayletts House I56 I05 S17758 AYLETTSV219047 UI 23.06.05 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Ayletts House I56 I05 S17758 AYLETTSV219047 UI 23.06.05 Stage 4.doc Version 1.30 Page 23 - 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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