Inspection on 01/08/05 for Aylsham Manor

This inspection was carried out on 1st August 2005.

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

Aylsham Manor 07/06/07

Aylsham Manor 02/02/06

Aylsham Manor 20/01/05

Aylsham Manor 02/09/04

Aylsham Manor 04/03/04

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 Aylsham Manor 5 Norwich Road Aylsham Norwich NR11 6BN Lead Inspector Ann Catterick Announced 01 August 2005 09:30 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. Aylsham Manor I55 s27331 Aylsham Manor v234710 (an) 010805 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Aylsham Manor Address 5 Norwich Road Aylsham Norwich Norfolk NR11 6BN 01263 733253 01263 734944 aylsham.manor@btinternet.com Mr Carl Denis and Mrs Denise Denis 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) Mrs Lynda Howes Care Home 28 Category(ies) of Dementia (4), registration, with number Old age, not falling within any other category of places (24) Aylsham Manor I55 s27331 Aylsham Manor v234710 (an) 010805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The home is registered for up to 28 older persons, four of whom may have dementia. There are no additional conditions. Date of last inspection 20 January 2005 Brief Description of the Service: Aylsham Manor is a care home providing personal care and accommodation for 28 older people, four of whom may have dementia. The registered Providers are Mr Carl Denis and Mrs Denise Denis and the registered manager is Mrs Lynda Howes. The home is situated in the market town of Aylsham and is convenient for all local amenities. The property is a large Elizabethan Manor House that stands in its own three acres of grounds. The property is a grade 2 star listed building and has been tastefully modernised and extended over the years to provide comfortable accommodation in a period setting. There are 24 single bedrooms, two ‘sheltered flats’ and one double room. Many of the rooms have en suite facilities and communal space is plentiful and varied. There is a stair lift to the first floor in the main house and a stair lift to the first floor in the coach house. The grounds are large and well maintained and provide a very good facility in the summer months. The home also offers day care to a small number of people and these people are accommodated, during the day, in the main areas of the home. Aylsham Manor I55 s27331 Aylsham Manor v234710 (an) 010805 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and took place on the 1st of August and lasted 6 hours. Prior to the inspection the CSCI request written information relating to the home and this was received on time and included all relevant information. Feedback questionnaires were sent to the home and 15 were returned from service users, 11 from relatives and 2 from professionals. All feedback from relatives was very positive. The feedback from professionals was also positive. Most of the written feedback from service users was very positive and there were no negative comments. On the day of inspection the inspector was able to speak with the proprietor, staff, a volunteer, several service users and two relatives. The manager was on leave and the inspector had been aware of this prior to the inspection and was happy to complete the inspection in her absence, as both proprietors were available. The inspector was able to have a tour of the building and grounds, look at care plans, staff files and other relevant documents. The overall conclusion was that Aylsham Manor has well trained staff offering good quality care to older persons in a delightful setting. What the service does well: There are many aspects of the service that the home does well and the following are a selection of these. The home promotes activities and service users were pleased that the care they received included activities that kept their mind alert. Comments were made such as “have activities to keep the mind active”, “take us to the theatre in the mini bus”, “have a good laugh”, “I think we are lucky to be here.” The menu is varied providing good quality food, lots of positive comment about the food and on the day of inspection there was a themed 1940’s lunch which people were enjoying. The proprietor promotes good practice by having a comprehensive training programme that offers staff all statutory training as well as many additional relevant courses. The staff training programme is detailed and thorough and all staff have a training profile. One of the staff spoken to said that if she went to the proprietor or manager saying she had a specific interested in an area of Aylsham Manor I55 s27331 Aylsham Manor v234710 (an) 010805 Stage 4.doc Version 1.30 Page 6 care they would try to ensure that she was offered training in this area. Comments made by service users included, “ staff have humble jobs and do them very well, we are very lucky,” “staff are not allowed to work in the home unless they are suitable.” The inspector was very impressed with the quality of the training in the home and this area has been commended. The environment offers good quality accommodation in a delightful setting. The overall environment has been commended. 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. Aylsham Manor I55 s27331 Aylsham Manor v234710 (an) 010805 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 Aylsham Manor I55 s27331 Aylsham Manor v234710 (an) 010805 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) 1,3,4 and 6 Prospective service users and/or their families are given the information they need to make an informed choice about whether or not they wish to live at the home. All service users have their needs assessed before admission to the home thus ensuring that their needs will be met. The staff working in the home are offered comprehensive training and have the skills and competence to meet the service users needs. Intermediate care is not offered in this home. Aylsham Manor I55 s27331 Aylsham Manor v234710 (an) 010805 Stage 4.doc Version 1.30 Page 9 EVIDENCE: When relatives or prospective service users are considering a placement at Aylsham Manor they are offered the Service Users Guide. This is comprehensive and includes a copy of the Statement of Purpose as well as all other relevant details. It also includes some feedback questionnaires and thank you letters from service users and relatives. It gives a clear understanding of what the service offers. Some service users are admitted to the home with the support of social services who provide the home with an assessment of need prior to admission. Other service users arrange for their own care, independently. The proprietor or manager would always complete their own assessment before a placement is offered. At the time of the initial contact brief notes are made to assess whether the prospective service user’s needs would fall within the remit of the homes registration. The person would then be visited and an initial care plan/assessment is made. Once admitted a care plan is generated and after four to six weeks the placement is reviewed to assess whether or not the placement will become permanent. The training profiles of staff were seen and it was clear that staff are offered all of the training needed to ensure that they can meet the care needs of service users. Evidence of good practice by staff was seen on the day of inspection. Aylsham Manor I55 s27331 Aylsham Manor v234710 (an) 010805 Stage 4.doc Version 1.30 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, 9 and 10 Individual care plans include all of the information needed to ensure that the health, personal and social care needs of service users are met. The homes policy and procedures for dealing with medication protect service users. Service users were seen to be treated by staff in a way that was respectful and promoted privacy. EVIDENCE: Individual care plans were seen and these were in good order and included all relevant information. They included general care needs, daily living goals, self-medication assessment forms as well as all other relevant information. Care plans had been reviewed on a regular basis. All of those service users spoken to felt that their needs were being met. The home has a policy and procedures for dealing with medication. One named member of staff is responsible for the monthly receipt and return of medication. All staff who deal with medication have had appropriate training. Aylsham Manor I55 s27331 Aylsham Manor v234710 (an) 010805 Stage 4.doc Version 1.30 Page 11 This includes the Start Safe Handling of Medicines Distance Learning and the Boots Care of Medicines course. Records of medication were seen and all in good order and the administration of lunchtime medication on the day of inspection was seen and this was administered and recorded in a way that promoted good practice. On the day of inspection several staff were seen working with service users and at all times staff worked in a way that was respectful, promoting the independence and privacy of service users. Fourteen comment cards were received from service users, twelve said their privacy and dignity was respected, one said it was respected sometimes and one left all boxes blank. All of those service users spoken to said that there privacy and self respect was promoted. Eleven feedback forms were received from relatives and all spoke positively about the care their relatives received. Aylsham Manor I55 s27331 Aylsham Manor v234710 (an) 010805 Stage 4.doc Version 1.30 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 and 15 The individual preferences, expectations and interests of service users were being met within the home. Contact with family and friends is supported and encouraged thus enabling service users to keep their contacts and links with friends, family and community. Service users are offered a wholesome appealing balanced diet that promotes their well being and general good health. EVIDENCE: The home aims to meet with service users individual preferences and needs. Service users can rise and retire when they wish unless any health needs recommended different. Service users spoken to said that they felt in control of their own lives and free to spend their time as they chose. Some residents used the communal facilities for most of the day whilst others preferred the privacy of their own rooms joining other residents just at meal times. Individual preferences were written on care plans. The home has a notice board in the centre lounge give information about weekly activities. Several service users said that they often had quizzes and games that kept their minds active and felt this was as important as meeting their more practical care needs. The home has a mini bus and service users are often taken to the Aylsham Manor I55 s27331 Aylsham Manor v234710 (an) 010805 Stage 4.doc Version 1.30 Page 13 theatre or coast. The home had recently enjoyed having a fete. There are links with local churches. Contact with family and friends are supported. Eleven feedback forms were received from relatives and all spoke positively about the way that they were made welcome within the home saying that they could meet with their relative in private. Those relatives spoken to on the day of inspection confirmed this view. Menu plans were seen for the home and these were varied and nutritious offering good quality food in an attractive setting. If service users do not like the main meal there is always an alternative provided. The home has recently included themed meals as part of the menu programme and on the day of inspection a 1940’s meal was being prepared. This included a choice of venison, rabbit and partridge with bread pudding (a resident’s recipe) and custard. The dining area had been decorated with flags and memorabilia as well as red white and blue fresh posies of flowers on the table. All service users spoken to were satisfied with the quality and quantity of food provided. Aylsham Manor I55 s27331 Aylsham Manor v234710 (an) 010805 Stage 4.doc Version 1.30 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 and 18 Complaints are always taken seriously and the home has an open and transparent procedure for addressing any complaints and concerns. Service users are protected from abuse. EVIDENCE: The home has a complaints procedure and the management encourages service users and/or families to use this as a way of addressing any concerns. On the day of inspection the details of complaints were seen and they had all been recorded and dealt with appropriately in an open and transparent way. The home has a policy for the protection of vulnerable adults. The home has a folder that is full of relevant information and training material relating to adult abuse. Within staff training profiles there was evidence of training that staff had completed in this area and those staff spoken to on the day of inspection were knowledgeable in this area. There have been no concerns regarding adult protection since the last inspection. The work completed in this area has been commended. Aylsham Manor I55 s27331 Aylsham Manor v234710 (an) 010805 Stage 4.doc Version 1.30 Page 15 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 and 26 The service users live in a safe, well maintained, environment that offers good quality accommodation that is comfortable, well decorated and furnished. The overall quality of the home, garden and accommodation has been commended. The home is clean, pleasant and hygienic offering desirable accommodation in a delightful setting. EVIDENCE: Aylsham Manor is a grade 2 star listed Elizabethan manor house that has been restored and maintained to a very high standard. Individual and communal areas are well decorated and furnished offering good quality accommodation. The house is set in its own grounds that offer additional communal space that is well used within the summer months. The grounds accommodate many well established trees and shrubs as well as many flowerbeds and borders. Seating areas are plentiful enabling service users to sit alone or in company depending on their preference. The garden, like the house, is well maintained. Aylsham Manor I55 s27331 Aylsham Manor v234710 (an) 010805 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 and 30 The numbers of staff on duty at any one time are able to meet the needs of service users. Staff are well trained and competent to fulfil their roles and the homes positive and proactive work in this area has been commended. EVIDENCE: The rota showed that there were ample staff on duty at any one time. Those service users spoken to felt that the number of staff on duty at any one time met their needs. The proprietor offers staff good supervision and training and the satisfaction of staff is reflected in the low turnover of staff at the home. The home has a diverse mix of staff in relation to age and experience and this is seen as positive for the service users as it offers the general variety of life that is experienced within the general community. The proprietor is actively involved in the promotion and delivery of training and all staff at the home have staff training profiles. These profiles show that staff are offered a wide range of training that promotes good practice and develops skills and improves knowledge. Those staff spoken to said that if ever they expressed an interest in any specific training the proprietor will try to ensure they were offered training in this area. The homes promotion of training for all staff has been commended. Aylsham Manor I55 s27331 Aylsham Manor v234710 (an) 010805 Stage 4.doc Version 1.30 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 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) 31,32 and 33 The proprietors are actively involved in the management of the home and are experienced and able to fulfil their responsibilities in full. The registered manager is qualified and experienced, able to discharge her responsibilities in full. The home is run in the best interests of service users and the outcome of this is that service users views are sought to audit the quality of service being provided. Aylsham Manor I55 s27331 Aylsham Manor v234710 (an) 010805 Stage 4.doc Version 1.30 Page 18 EVIDENCE: The quality of the care provided and the feedback from service users and their relatives supports the view that the home is well managed. This was also observed on the day of inspection. The home promotes life long learning for staff and this ensures that those staff working within the home are always up to date with modern thinking and practice continue to aim to provide a good quality service. The home continues to self monitor its service by using questionnaires for staff, service users and relatives. These can be seen within the home. The home publishes the findings of these quality audits. The proprietors are actively working within the home on a regular basis and are continually monitoring the quality of the service that they are providing. Aylsham Manor I55 s27331 Aylsham Manor v234710 (an) 010805 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 4 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 4 3 x 3 x x x x x Aylsham Manor I55 s27331 Aylsham Manor v234710 (an) 010805 Stage 4.doc Version 1.30 Page 20 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 Regulation None 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. 1. Refer to Standard None Good Practice Recommendations Aylsham Manor I55 s27331 Aylsham Manor v234710 (an) 010805 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection 3rd Floor Cavell House St Crispins Road Norwich NR3 1YF 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. 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