Inspection on 06/02/07 for Ayletts House

This inspection was carried out on 6th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 14/12/05

Ayletts House 23/06/05

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 Sarah Hannington Unannounced Inspection 6th February 2007 11:30 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 Ayletts House DS0000017758.V329695.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. Ayletts House DS0000017758.V329695.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ayletts House Address Main Road Broomfield Chelmsford Essex CM1 7LE 01245 441854 01245 443504 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) The Croll Group Manager post vacant Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Ayletts House DS0000017758.V329695.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 27 persons) 14th December 2005 Date of last inspection 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, visitor’s 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 DS0000017758.V329695.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took over 4 hours. Throughout the inspection the acting manager Carol Armitage and Puraneswari Balah senior staff were present throughout. A tour of the building took place and 10 residents; two relatives and three staff were spoken with as part of this process. The visit mainly focused on all Key standards”. There were no requirements or recommendations from the last inspection report. Random samples of records, policies and procedures were inspected. What the service does well: 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. The summary of this inspection report can be made available in other formats on request. Ayletts House DS0000017758.V329695.R01.S.doc Version 5.2 Page 6 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 Ayletts House DS0000017758.V329695.R01.S.doc Version 5.2 Page 7 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 and 6 Quality in this area is good. This Judgement has been made using available evidence including a visit to this service. Initial assessments were in place and the homes systems for assessing individual needs prior and once admission has taken place are to a good standard. EVIDENCE: The policies and procedures of the home provide evidence that it meets the requirements expected for the admission of any new residents. The home does not provide intermediate care. Ayletts House DS0000017758.V329695.R01.S.doc Version 5.2 Page 8 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 and 10 Quality in this area is excellent. This Judgement has been made using available evidence including a visit to this service. Care plans were to a good standard and involved service users and that they have been consulted with. EVIDENCE: Care plans evidenced that residents had been consulted with and that they were to a good standard. All residents have a named key worker and when spoken with were aware of whom this key person is and complimentary about their key workers. A high standard of risk assessments and good preventative practice are in place, regarding monitoring of weights, nutrition, falls and pressure sores and are to a high standard. Medication is stored in a lockable cabinet and the administration records were being maintained in accordance with agreed procedures. Training records indicated that all staff that administers medication have had medication training. Ayletts House DS0000017758.V329695.R01.S.doc Version 5.2 Page 9 Residents can have BT lines installed in their own rooms if they wish, there is also the main office phone which can be transferred to individual rooms for privacy. Residents mail and fax are kept for the individual to collect, if support is needed then the staff or relatives give this assistance. Ayletts House DS0000017758.V329695.R01.S.doc Version 5.2 Page 10 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 and 15 Quality in this area is excellent. This Judgement has been made using available evidence including a visit to this service. There is an activity plan for each individual, activities in general still are to a high standard, and choices and involvement are regularly recorded. Relatives and friends are encouraged to have regular contact with the home. A relatives meeting is held twice a year. A variety of regular nutritious meals were being provided. EVIDENCE: An activity co-ordinator and staff spoken with evidenced that choice of activities are offered. These included group and individual activities, inside and outside of the home. The home also has access to a minibus. A wide range of artists come into the home to provide entertainment. Residents spoken with informed me that they did have a good choice. Residents have an activity room where they can access, music, games, crosswords, puzzles and paint if they wish to do so. Activity choices and refusal by individuals is recorded appropriately and evidence that staff try to encourage that individual are in place. Good history and likes dislikes of individuals are kept as an aid to staff working with groups and individuals. Paperwork looked at evidenced that staff in general gave a high quality service and support. Ayletts House DS0000017758.V329695.R01.S.doc Version 5.2 Page 11 Residents and relatives spoken with evidenced that visits happen without any restrictions attached. Relatives felt that the acting manager, key workers and staff in general keep them well informed of any issues regarding their relative. During Inspection lunchtime was observed and it was noted that the service users were encouraged to have a choice of foods available. Menus looked nutritious and reflected residents tastes. On the day of inspection residents were asked about the food provided and were very complementary about the food and how staff supported them. Food smelt and looked appealing and was presented nicely. Meal times were unrushed and had a relaxed atmosphere. Meals provided are wholesome and homemade and reflect the resident’s choices. Ayletts House DS0000017758.V329695.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this area is good. This Judgement has been made using available evidence including a visit to this service. The home has a complaints procedure. The homes policy and procedures and training of staff appear to protect residents from abuse. EVIDENCE: There have been no recent complaints and the last one recorded evidenced that the acting manager had good practice and professionalism when dealing with complex and sensitive issues within the home. Evidenced within the complaints folder is the acting managers pro-active approach in maintaining residents rights. A number of compliments from relatives had been received. Staff spoken with had adequate understanding and knowledge of Protection Of Vulnerable Adults reporting procedures. Records were also available of where staff had attended P.O.V.A. (Protection Of Vulnerable Adults) training. Ayletts House DS0000017758.V329695.R01.S.doc Version 5.2 Page 13 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 and 26 Quality in this area is good. This Judgement has been made using available evidence including a visit to this service. On the whole the outside environment is pleasant, attractive and provides appropriate and practical usage for the residents. The home environment provides a clean, comfortable and safe environment in which to live in. EVIDENCE: On the day of inspection the home was observed to be clean, tidy and odour free. Individual’s rooms were clean and personalised. Overall the home environment present no health and safety issues, the environment was homely comfortable and practical for the use of residents at Aylett’s. Ayletts House DS0000017758.V329695.R01.S.doc Version 5.2 Page 14 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 and 30 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The number of staff on duty, their experience and skill was able to meet the needs of residents. Good recruitment records were in place. EVIDENCE: Aylett’s have a well-established team and management structure. The home has an experienced well-dedicated staff team in place. At the time of inspection, the home was fully staffed and the skills mix of the staff group was being used positively in meeting the various needs of residents. Staff rotas evidenced that there is adequate cover throughout the day and night. Paperwork for staff recruitment was looked at and overall was to an appropriate standard. Regular mandatory and specific client led training is in place for staff. Promotion of independence and learning/retaining skills was evident. All service users have access to a GP, district nurse, chiropody and dental practice either local or of the individuals choice. Specialist services are catered for if necessary and of beneficial to the individual. Good paperwork was evidenced which shows strong links and good partnerships with the local PCT team. Recording of health care appointments, decisions and meeting were in place. Ayletts House DS0000017758.V329695.R01.S.doc Version 5.2 Page 15 A Monitored medication dosage system is in place for service users. Medication is stored in a lockable cabinet and the administration records were being maintained in accordance with agreed procedures. Record sheets had been correctly recorded and signed. Ayletts House DS0000017758.V329695.R01.S.doc Version 5.2 Page 16 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 and 38 Quality in this outcome area is excellent. This judgment has been made using available evidence including a visit to this service. Management systems are good and the home is run in the best interests of residents. The management respond robustly & rectify matters of health & safety when identified. The acting manager ensures that all staff receive regular mandatory training. The home records staff and residents meetings. EVIDENCE: The acting manager has clearly made a positive impact on the running of the home. Staff and relatives of residents appear contented with the home under her leadership. The acting manager has good experience and is RMA (registered managers award) and NVQ 4 in care qualified. The home provides a good standard of experienced staff who hold a mixture of NVQ 2, 3 and 4 Ayletts House DS0000017758.V329695.R01.S.doc Version 5.2 Page 17 qualifications. Regular support of staff is continuous and resident’s views underpin the philosophy of the home. Policy and procedures that are put into place reflect the service user group that the home caters for. The acting manager and staff are observed to have good communication between the team. The acting manager makes sure the recording of staff and resident’s meetings/consultation are kept updated. Ayletts House DS0000017758.V329695.R01.S.doc Version 5.2 Page 18 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 4 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 3 X 3 Ayletts House DS0000017758.V329695.R01.S.doc Version 5.2 Page 19 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ayletts House DS0000017758.V329695.R01.S.doc Version 5.2 Page 20 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Ayletts House DS0000017758.V329695.R01.S.doc Version 5.2 Page 21 - 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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