Inspection on 02/02/06 for Aylsham Manor

This inspection was carried out on 2nd February 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 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 01/08/05

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 Norfolk NR11 6BN Lead Inspector Ann Catterick Unannounced Inspection 13:15 2 February 2006 nd 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 Aylsham Manor DS0000027331.V279171.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. Aylsham Manor DS0000027331.V279171.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Aylsham Manor Address 5 Norwich Road Aylsham Norwich Norfolk NR11 6BN 01263 733253 NO FAX # 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) Mr Carl Denis Mrs Denise Denis Mrs Lynda Ann Howes Care Home 28 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (28) of places Aylsham Manor DS0000027331.V279171.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st August 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 DS0000027331.V279171.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on the 2nd of February lasting for 3 1/2hrs. The manager was on site and available throughout the inspection. On the day of inspection the inspector was able to speak with the manager, staff, several service users as well as look at several areas of the building and look at files, care plans and other documents. Those service users spoken to were very positive about the care they received. 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 quality of the food is very good with service users having a hot meal option at both dinner and tea. There is a choice at lunchtime and service users can choose whatever they wish for tea. Homemade cakes are provided daily and the menu is nutritious and varied. The home often has themed lunches and the most recent of these was a Chinese meal. This included a Chinese person helping to serve and the home decorated with Chinese lanterns. Meals are taken in pleasant surroundings with fresh flowers on the table each day. The quality and variety of food has been commended. The overall environment including the garden is of good quality and this has been commended. Staff are well trained and all appear to enjoy the work they do. Service users always appear very happy with the care provided. Aylsham Manor DS0000027331.V279171.R01.S.doc Version 5.1 Page 6 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 DS0000027331.V279171.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 Aylsham Manor DS0000027331.V279171.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): None of these standards were inspected on this occasion. EVIDENCE: Aylsham Manor DS0000027331.V279171.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): 7 and 8 The service user’s health, personal and social care needs are set out in individual care plans. Service user’s health needs were being met within the home and health needs are reviewed on a regular basis. EVIDENCE: Care plans seen were comprehensive offering lots of detail of the needs of the service users. There was some information relating to weight and diet but a recommendation to include a nutritional assessment has been made. Care plans are kept in large ring binders and a recommendation has been made that they be made into individual files to give easier access to staff and/or service users when they are looking at them. There was clear evidence on file that the health needs of service users are assessed, met and reviewed on a regular basis. The manager said that the home had a good relationship with local health services. Evidence was seen that when needs change and become beyond the registration of the home there is an assessment to ensure that a more suitable placement can be found. Aylsham Manor DS0000027331.V279171.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 and 15 The home aims to empower service users and enables them to have as much control and choice within their lives as possible. The food within the home is of a high standard with service users having a balanced diet with lots of choice being eaten in comfortable surroundings. The outcome for this standard has been commended. EVIDENCE: On the day of inspection staff were seen to work with service users in a way that offered choice and control. Service users have several communal areas to sit in or can choose to stay in their rooms. Some service users were watching television, others were reading or with visitors. Those service users spoken to were satisfied with all aspects of their care and felt they were treated with well and with respect. The dinner on the day of inspection looked very good and at teatime service users had a choice including a cooked choice. The home often has themed meal times and service users had recently had a Chinese lunch, which they all enjoyed. The two dining areas are well furnished and tables are always well laid with fresh flowers and tablecloths and napkins. On the day of inspection a service user who was very elderly and had a small appetite was continually Aylsham Manor DS0000027331.V279171.R01.S.doc Version 5.1 Page 11 encouraged to eat and drink to maintain her well being. When she left her cup of tea for a while it was replaced with a fresh hot cup. This was seen as clear evidence of good practice. Aylsham Manor DS0000027331.V279171.R01.S.doc Version 5.1 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 the following standard(s): None of these standards were inspected on this occasion. EVIDENCE: Aylsham Manor DS0000027331.V279171.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The service users live in a safe, well maintained environment and 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. The outcome for this standard has been commended. EVIDENCE: The service users live in a safe, well maintained, environment that offers good quality accommodation that is comfortable, well decorated and furnished. 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 DS0000027331.V279171.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 Service users are protected by the home’s recruitment and selection policy and procedures. EVIDENCE: Three staff files were inspected and these were in good order including all of the relevant information needed to ensure good practice. The files themselves were easy to read as dividers were used to separate different bits of information. This included sickness record, appraisal/supervision, training, induction, contract and application as well as other relevant information. New staff are all given a copy of the General Social Care Council booklet and are made aware of their roles and responsibilities. Aylsham Manor DS0000027331.V279171.R01.S.doc Version 5.1 Page 15 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 35 and 38 The proprietors are actively involved in the management of the home and are experienced and able to fulfil their responsibilities. The manager is experienced competent and well trained able to carry out her duties and responsibilities in full. Service users financial interests are safeguarded by the good practice in this area. The health and safety of service users is protected by the home’s health and safety policies and procedures. Aylsham Manor DS0000027331.V279171.R01.S.doc Version 5.1 Page 16 EVIDENCE: The good quality of care provided is evidence of a home well managed. The manager has always been observed working in a competent caring way able to fulfil all of her roles and responsibilities. The only money that the home takes responsibility for is small amounts that are used for hairdresser, chiropody, newspapers or small items. This money is kept individually in a locked cupboard. All money received or spent is recorded with the records being countersigned on a weekly basis. The individual, their families or financial advisors deal with larger amounts of money and savings. All staff are offered induction and mandatory training to ensure that they work in a safe way with service users. Staff complete foundation training or complete NVQ level 2 or 3. Chemicals are stored safely and all services are serviced on a regular basis. Radiators are covered and water is of the required temperature. The home has a maintenance plan and repairs are carried out when need be. Risk assessments are completed for the individual and the environment. All accident and incidents are recorded. Overall the manager and proprietor promote safe practice in all areas. Aylsham Manor DS0000027331.V279171.R01.S.doc Version 5.1 Page 17 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 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x 4 x x x x x x 3 STAFFING Standard No Score 27 x 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x x x 3 x x 3 Aylsham Manor DS0000027331.V279171.R01.S.doc Version 5.1 Page 18 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. 1 2 Refer to Standard OP7 OP7 Good Practice Recommendations It would be good practice to include a nutritional screening within the care plan. It would be good practice to keep all care plans individual for easy access for service users and staff and to ensure confidentiality of information. Aylsham Manor DS0000027331.V279171.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Norfolk Area Office 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. Extracts may not be used or reproduced without the express permission of CSCI Aylsham Manor DS0000027331.V279171.R01.S.doc Version 5.1 Page 20 - 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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