CARE HOMES FOR OLDER PEOPLE
Front Street Framwellgate Moor Durham DH1 5BL Lead Inspector
Bill Drumm Announced 08 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. Front Street v222762 b54 s7502 st aidan v222762 070605 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service St Aidan Lodge Address Front Street Framwellgate Moor Durham DH1 5EJ 0191 370 9691 0191 386 5806 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) Ideal Care North (Ltd). Carol Shannon CRH 62 Category(ies) of Dementia - over 65 years of age. (32) registration, with number Old age, not falling within any other category of places (30). Front Street v222762 b54 s7502 st aidan v222762 070605 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 30 Older Persons and 32 Older Persons with Dementia Date of last inspection 16th February 2005 Brief Description of the Service: St Aidan Lodge is a purpose built care home situated in the centre of Framwellgate Moor, on the outskirts of Durham City. It caters for 62 residential service users on two floors, with the kitchen, laundry and additional facilities located in a basement area. St Aidan Lodge is registered to provide residential care for 30 older people situated on the ground floor, and 32 older people with dementia situated on the first floor. The home is spacious, with a variety of communal space, including lounge and dining areas, a smoking room and spacious garden area. All bedrooms are large single rooms with en-suite toilet and washing facilities. Rooms are well equipped and furnished and there are a number of suitably equipped and adapted bath and shower rooms. Front Street v222762 b54 s7502 st aidan v222762 070605 stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This announced inspection took place on 8th June 2005 over 5.5 hours and was carried out as part of the annual inspection process. During the inspection time was spent talking with eleven service users, four members of staff and five visitors. During the inspection all the communal areas of the home were looked at and a number of records examined. What the service does well: What has improved since the last inspection? What they could do better:
Although the care planning and risk assessment documentation has been fully reviewed and a new system implemented, the manager of the home needs to
Front Street v222762 b54 s7502 st aidan v222762 070605 stage 4.doc Version 1.30 Page 6 develop a process for monitoring this system to ensure that all staff members do exactly what is required of them and the procedures are followed. In addition residents meetings should be minuted and records retained for reference. The activities co-ordinator should also develop links with other activity co-ordinators in order to share ideas and new initiatives. These measures will help to improve the number and, choice of activities offered to residents, and help to ensure they have the chance to voice their concerns or offer suggestions about the way the home is run. 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. Front Street v222762 b54 s7502 st aidan v222762 070605 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 Front Street v222762 b54 s7502 st aidan v222762 070605 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. New residents are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective resident or their representative has been included or involved. This helps to ensure that the home can meet the needs of those who live there. EVIDENCE: Each resident has a copy of the Statement of Terms and Conditions of residency in the home some of which had been signed by the individual resident or relatives on their behalf. Individual records kept for each resident and an inspection of records contained a copy of a care management assessment and where appropriate health care assessments. In addition the homes’ manager also carries out her own pre-admission assessment. Front Street v222762 b54 s7502 st aidan v222762 070605 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, 8, 9 and 10. Each resident has a comprehensive and individual plan of care, which provides staff with enough information to satisfactorily meet the needs of residents. The healthcare needs of residents are well met with evidence of good multidisciplinary working taking place on a regular basis. The systems for the administration of of medication are good with clear and comprehensive arrangements in place to ensure residents’ medication needs are met. Residents’ rights to privacy and respect are upheld. EVIDENCE: A number of individual residents’ files were examined and were all found to contain copies of care management assessments or healthcare professionals assessments in addition to the manager’s own pre-admission assessment. Although these records were in the main complete a number of minor omissions were noted across a number of different files. Some of the residents spoken to could confirm their involvement in this process.
Front Street v222762 b54 s7502 st aidan v222762 070605 stage 4.doc Version 1.30 Page 10 Residents’ files also contained evidence of multi disciplinary working with District Nurses, Social Workers, Opticians, Dentists and Therapy staff. Records relating to the administration of medication were also examined. None of the current residents at the home are able to manage their own medication needs. A number are however able to manage their own inhalers. A visitor to the home confirmed that residents are always treated with dignity and respect. Direct observation confirmed that a positive rapport exists between staff members and residents. Front Street v222762 b54 s7502 st aidan v222762 070605 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) 12, 13, 14 and 15. Residents within the home are regularly offered the opportunity to participate in a range of organised recreational activities, which helps to keep them active and prevent boredom. Residents maintain contact with family members and friends who are encouraged to visit the home at any reasonable time. Residents are able to exercise choice and control over their lives. This is promoted by the flexible routines followed within the home. The meals in the home are good offering both choice and variety. EVIDENCE: Discussion with the manager, staff and residents indicated that a, range of activities are offered within the home. The activities co-ordinator will shortly be leaving the home for a period of maternity leave. The manager confirmed that a member of the care staff team, will undertake the activities co-ordinator’s duties during this time. During discussion with the manager it became apparent that the activity co-ordinator would benefit from the support of others who undertake a similar role to help generate new ideas for activities and for general peer support.
Front Street v222762 b54 s7502 st aidan v222762 070605 stage 4.doc Version 1.30 Page 12 Discussions with residents and visitor’s confirmed that visiting times are very flexible and visitors are welcome at all reasonable times, one visitor described the home as, “a home from home”. During the inspection residents spoke fondly of staff members and how they are enabled to do as much for themselves as possible. In addition they all spoke of enjoying the food and the size of individual protions. Front Street v222762 b54 s7502 st aidan v222762 070605 stage 4.doc Version 1.30 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18. The home has a satisfactory complaints system with some evidence that residents feel that their views are listened to and acted upon. Staff, were confident in demonstrating an awareness of POVA to ensure the protection of residents living in the home. EVIDENCE: A complaints policy and procedure is in place. There have been no recorded complaints since the last inspection. Relatives spoken to during the inspection were aware of the complaints procedure. One resident said he would, “feel confident about making a complaint”. Staff members at the home all receive training in relation to the protection of vulnerable adults (POVA). Staff during discussion were able to demonstrate an awareness of POVA. Front Street v222762 b54 s7502 st aidan v222762 070605 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 and 26. The standard of the environment within the home is good providing residents with an attractive and homely place to live. The home is clean, pleasant and hygienic for residents. EVIDENCE: All communal areas were inspected during this inspection and were found to be in a good state of repair. The manager indicated that when repairs are necessary the homes owners quickly respond and these are undertaken with the minimum of delay. The home was clean and free from any offensive odours. Front Street v222762 b54 s7502 st aidan v222762 070605 stage 4.doc Version 1.30 Page 15 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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 and 30. Residents’ needs are met by a full staffing compliment, who possess a range of skills and abilities. The arrangements for the recruitment and induction of staff are good with the staff demonstrating a clear understanding of their roles. Staff, are trained and competent to do their job maintaining the safety and well being of residents. EVIDENCE: The home currently has no vacancies for staff although the activities co-ordinator will shortly be leaving for a short period due to maternity leave. The manager indicated that it is her intention to try and build a “bank” of staff, which they can call upon to cover periods of ill health or holidays. Training records examined suggest that the home has a good mix of staff with a variety of skills and abilities. The home operates a thorough process of recruitment and selection, personnel files examined were found to contain all the information required to help protect and support residents. Personnel files examined also contained evidence that staff have undergone a period of induction prior to taking up their full responsibilities. Training records and discussions with staff also confirm that training is provided in a range of areas essential to the needs of this client group.
Front Street v222762 b54 s7502 st aidan v222762 070605 stage 4.doc Version 1.30 Page 16 Staff files also contained copies of some of the homes procedures such as the, burglary and accident procedure. It was not clear whether these should have been held within the staff files or the staff manual. Front Street v222762 b54 s7502 st aidan v222762 070605 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) 33, 35 and 38. The systems for service user consultation in this home are adequate with a variety of evidence that indicates that residents’ views are both sought and acted upon. Robust procedures for the safekeeping of residents’ money are in place. Records in general including health and safety are up to date. EVIDENCE: Notes of meetings with residents are currently recorded in the activities book by the activities co-ordinator and are not formally recorded elsewhere. Regulation 26 visits are undertaken by the homes owner copies of which are regularly received by the CSCi. The home has a comprehensive policy in place for the handling of residents’ finances and records kept are accurate and upto date.
Front Street v222762 b54 s7502 st aidan v222762 070605 stage 4.doc Version 1.30 Page 18 The manager was able to demonstrate that as far as is reasonably practical the health, safety and welfare of residents, staff and visitors to the home is maintained. Staff during discussion said they had completed training on moving and handling, fire safety and first aid. Front Street v222762 b54 s7502 st aidan v222762 070605 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 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 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 Standard No 16 17 18 Score 3 x 3 x x 3 x 3 x x 3 Front Street v222762 b54 s7502 st aidan v222762 070605 stage 4.doc Version 1.30 Page 20 YES 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 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. 3. 4. Refer to Standard OP7 OP12 OP30 OP33 Good Practice Recommendations It is recommended that the homes manager introduce a quality audit tool for the periodic audit of residents care plans in order to ensure consistency and full compliance. It is recommended that the activities co-ordinator develop links with other activity co-ordinators in the area in order to share good ideas and to offer each other support. It is recommended that procedures are retained in one specific area, eg. within the staff manual or within each staff members personnel file. Residents meetings should be minuted and retained centrally for staff reference. Front Street v222762 b54 s7502 st aidan v222762 070605 stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection No 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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