Please wait

Care Home: Admirals Reach Residential & Nursing Home

  • Ridgewell Avenue Chelmsford Essex CM1 2GA
  • Tel: 01245266567
  • Fax: 01245280469
  • Planned feature Advertise here!

The Admirals Reach site consists of four single storey, purpose built houses each accommodating 30 residents. Each house is staffed on an individual basis. The central services building include administration, laundry, kitchen a hairdressing facility. There is a spacious car park. The home is situated approximately one mile from Chelmsford and within walking distance of the bus service. Nelson House is registered for up to 30 residents over the age of 60 years, and including up to five residents over the age of 40 who have a physical illness/disability. All residents are Nelson House are accommodated in single bedrooms with ensuite facilities. The majority of rooms overlook the landscaped gardens. Nelson House has a dining room and four different sitting areas to meet individual needs. Mountbatten House is registered to provide care for up to 30 service users aged over 65 and those who need nursing care because of a physical disability. All residents have a single en-suite room. Mountbatten house has four communal rooms plus a dining room. The unit is surrounded by landscaped and accessible open space. Jellicoe House is registered to provide nursing care for up to 30 residents overAdmirals Reach Residential & Nursing HomeDS0000015345.V377082.R01.S.doc Version 5.2 the age of 65 years with dementia. All residents are accommodated in single bedrooms with en-suite facilities. The unit has its own lounge and dining areas. The majority of rooms overlook the gardens. Benbow House is registered to provide nursing care for up to 30 residents over the age of 65 years with dementia. All residents on Benbow House are accommodated in single bedrooms with en-suite facilities. The majority of rooms overlook the gardens. Benbow House has its own sensory room, a small lounge used for smoking, a quiet lounge and a large lounge dining area. The current weekly fees, dependent up on needs and facilities are Residential Care between £560 and £800 per week and Nursing Care between £665 and £800 per week. This information was provided by the registered manager. Additional fees relate to hairdressing, chiropody, personal toiletries and newspapers. The home has a statement of purpose and service users guide available.Admirals Reach Residential & Nursing HomeDS0000015345.V377082.R01.S.docVersion 5.2Page 6

  • Latitude: 51.74100112915
    Longitude: 0.45800000429153
  • Manager: Mrs Chipema Chitambala
  • Price p/w: ~
  • UK
  • Total Capacity: 158
  • Type: Care home with nursing
  • Provider: BUPA Care Homes (CFHCare) Ltd
  • Ownership: Private
  • Care Home ID: 1416
Residents Needs:
Dementia, Old age, not falling within any other category, mental health, excluding learning disability or dementia, Physical disability

Latest Inspection

This is the latest available inspection report for this service, carried out on 2nd July 2009. CQC 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 CQC judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

For extracts, read the latest CQC inspection for Admirals Reach Residential & Nursing Home.

What the care home does well The care home provides people with a safe and homely environment that meets their needs. Visitors to the home are made to feel welcome. People are supported to maintain contact with family and friends and there is a good rapport between staff and residents. In general terms people are happy with the meals provided. There is a varied menu and various alternatives are available if required. Current and prospective people admitted to Admirals Reach can be assured they will have access to information about the service and facilities provided at Admirals Reach Residential & Nursing Home DS0000015345.V377082.R01.S.doc Version 5.2 the care home. People can be confident that they will be assessed before they are offered a place. There is a comprehensive quality assurance system in place to seek the views of residents and relatives pertaining to the service provided and the facilities available. Staff, receive regular formal supervision. People feel able and comfortable to raise concerns or queries. Complaints are well managed and there is a clear audit trail to show what action, if any, has been taken. What has improved since the last inspection? Some aspects of medication practices and procedures as highlighted at the previous inspection have now improved. There is now a varied programme of activities in place both `in house` and within the local community, so as to ensure that people have their social care needs met. The dining experience for people living at Admirals Reach has greatly improved. Staff, have now received appropriate training on how to deal with people who present with challenging and/or inappropriate behaviours. The home was observed to be clean and odour free on the day of the site visit. Staffing levels and the deployment of staff within Benbow, Jellicoe and Nelson were now seen to be appropriate for the needs and numbers of people who live there. There was sufficient evidence to show that staff, have received training in both core and specialist subject areas. What the care home could do better: Further improvements are still required to ensure that all areas of need as identified for an individual and areas of risk are clearly recorded within their plan of care. Further improvements are needed in relation to some aspects of medication practices and procedures.Admirals Reach Residential & Nursing HomeDS0000015345.V377082.R01.S.docVersion 5.2 Key inspection report CARE HOMES FOR OLDER PEOPLE Admirals Reach Residential & Nursing Home Ridgewell Avenue Chelmsford Essex CM1 2GA Lead Inspector Michelle Love Key Unannounced Inspection 2nd July 2009 09:00 DS0000015345.V377082.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Admirals Reach Residential & Nursing Home DS0000015345.V377082.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Admirals Reach Residential & Nursing Home DS0000015345.V377082.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Admirals Reach Residential & Nursing Home Address Ridgewell Avenue Chelmsford Essex CM1 2GA 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) 01245 266567 01245 280469 chitambc@bupa.com www.bupa.com BUPA Care Homes (CFHCare) Ltd Mrs Chipema Chitambala Care Home 128 Category(ies) of Dementia (30), Dementia - over 65 years of age registration, with number (60), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (2), Old age, not falling within any other category (30), Physical disability (30), Physical disability over 65 years of age (60) Admirals Reach Residential & Nursing Home DS0000015345.V377082.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N. to service users of the following gender: Either. whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP. Dementia - Code DE. Physical disability - Code PD. The maximum number of service users who can be accommodated is: 128 9th July 2008 2. Date of last inspection Brief Description of the Service: The Admirals Reach site consists of four single storey, purpose built houses each accommodating 30 residents. Each house is staffed on an individual basis. The central services building include administration, laundry, kitchen a hairdressing facility. There is a spacious car park. The home is situated approximately one mile from Chelmsford and within walking distance of the bus service. Nelson House is registered for up to 30 residents over the age of 60 years, and including up to five residents over the age of 40 who have a physical illness/disability. All residents are Nelson House are accommodated in single bedrooms with ensuite facilities. The majority of rooms overlook the landscaped gardens. Nelson House has a dining room and four different sitting areas to meet individual needs. Mountbatten House is registered to provide care for up to 30 service users aged over 65 and those who need nursing care because of a physical disability. All residents have a single en-suite room. Mountbatten house has four communal rooms plus a dining room. The unit is surrounded by landscaped and accessible open space. Jellicoe House is registered to provide nursing care for up to 30 residents over Admirals Reach Residential & Nursing Home DS0000015345.V377082.R01.S.doc Version 5.2 Page 5 the age of 65 years with dementia. All residents are accommodated in single bedrooms with en-suite facilities. The unit has its own lounge and dining areas. The majority of rooms overlook the gardens. Benbow House is registered to provide nursing care for up to 30 residents over the age of 65 years with dementia. All residents on Benbow House are accommodated in single bedrooms with en-suite facilities. The majority of rooms overlook the gardens. Benbow House has its own sensory room, a small lounge used for smoking, a quiet lounge and a large lounge dining area. The current weekly fees, dependent up on needs and facilities are Residential Care between £560 and £800 per week and Nursing Care between £665 and £800 per week. This information was provided by the registered manager. Additional fees relate to hairdressing, chiropody, personal toiletries and newspapers. The home has a statement of purpose and service users guide available. Admirals Reach Residential & Nursing Home DS0000015345.V377082.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for the service is 1 star. This means people who use this service experience adequate quality outcomes. This was an unannounced key inspection. The visit took place over one day by two inspectors and lasted a total of 20 hours, with all key standards inspected. Prior to this inspection the registered manager had submitted an Annual Quality Assurance Assessment (AQAA). This is a self-assessment document required by law detailing what the home does well, what could be done better and what needs improving. As part of the process a number of records relating to people who live at Admirals Reach, staff and the general running of the home were examined. Additionally a partial tour of the premises was undertaken, residents and members of staff were spoken with and their comments are used throughout the main text of the report. Observations of how members of staff interact and communicate with people living in the home have also been taken into account. In addition the manager’s progress against previous requirements from the last key inspection, were also inspected as part of our process. The registered manager, member’s of the management team and other members of the staff team assisted us on the day of the inspection. Feedback on the inspection findings were given throughout and summarised with the registered manager, operations manager and senior manager. The opportunity for discussion and/or clarification was given. What the service does well: The care home provides people with a safe and homely environment that meets their needs. Visitors to the home are made to feel welcome. People are supported to maintain contact with family and friends and there is a good rapport between staff and residents. In general terms people are happy with the meals provided. There is a varied menu and various alternatives are available if required. Current and prospective people admitted to Admirals Reach can be assured they will have access to information about the service and facilities provided at Admirals Reach Residential & Nursing Home DS0000015345.V377082.R01.S.doc Version 5.2 Page 7 the care home. People can be confident that they will be assessed before they are offered a place. There is a comprehensive quality assurance system in place to seek the views of residents and relatives pertaining to the service provided and the facilities available. Staff, receive regular formal supervision. People feel able and comfortable to raise concerns or queries. Complaints are well managed and there is a clear audit trail to show what action, if any, has been taken. What has improved since the last inspection? What they could do better: Further improvements are still required to ensure that all areas of need as identified for an individual and areas of risk are clearly recorded within their plan of care. Further improvements are needed in relation to some aspects of medication practices and procedures. Admirals Reach Residential & Nursing Home DS0000015345.V377082.R01.S.doc Version 5.2 Page 8 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Admirals Reach Residential & Nursing Home DS0000015345.V377082.R01.S.doc Version 5.2 Page 9 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 Admirals Reach Residential & Nursing Home DS0000015345.V377082.R01.S.doc Version 5.2 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3, 5 and 6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective people have the information they need to make an informed choice about where to live and are assured that their needs will be assessed. EVIDENCE: There is a formal pre admission assessment format and procedure in place, so as to ensure that the staff team are able to meet the prospective person’s needs. Admissions are not made to the home until a full assessment is undertaken and where appropriate additional information is sought from the person’s placing authority and/or hospital. As part of this site visit we looked at a random sample of care files for people newly admitted to both Benbow and Jellicoe. Records showed that a pre admission assessment was completed by the management team of the home Admirals Reach Residential & Nursing Home DS0000015345.V377082.R01.S.doc Version 5.2 Page 11 prior to the person’s admission and information recorded was noted to be detailed and informative, including the rationale for the decision to be admitted to the service. In addition records showed that the above process was completed with the prospective person and/or their representative and that people are given the opportunity to visit Admirals Reach and to spend time in the home prior to their admission. This enables the prospective person and/or their representative the opportunity to meet other people who live within the home, care staff, members of the management team and to look around the premises. Residents and/or relatives spoken with confirmed that they had been provided with information about the home prior to admission (Service Users Guide) and given the opportunity to visit Admirals Reach. One relative spoken with confirmed they had visited the service on behalf of their relative and that the admission process had been smooth. The AQAA details “comprehensive written information is provided to all prospective clients, outlining the ethos of Bupa Care Homes and the home, as well as vital information to help with the process of choosing a care home”. The AQAA also details that in order for the organisation to monitor its effectiveness in providing prospective people with the right information about the service, “regular mystery shops are conducted to ensure the home is providing the correct information to enquirers”. The home does not provide intermediate care. Admirals Reach Residential & Nursing Home DS0000015345.V377082.R01.S.doc Version 5.2 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Whilst people are happy with the care provided, identified shortfalls in care planning, risk assessing and medication could effect the health and wellbeing of people living in the home. EVIDENCE: Records showed there is a formal care planning system in place to help staff identify the care needs of individual service users and to specify how these are to be met by care staff. As part of this site visit we looked at a random sample of 6 care files from Benbow, Jellicoe and Nelson. Improvements were noted in relation to the standard of information recorded within each person’s care plan. In general terms records showed that the care needs of each person were recorded, the care plan was person centred and there was reference to individual’s strengths, Admirals Reach Residential & Nursing Home DS0000015345.V377082.R01.S.doc Version 5.2 Page 13 abilities and personal preferences, likes and dislikes. One person’s care file made reference to their past employment and records showed that the person’s family had provided items of their relative’s past trade for them to carry round with them as they found this to be a source of comfort and staff were ensuring this was undertaken. Another person’s care plan made reference to them having poor dietary intake and requiring regular weekly monitoring to ensure that there was clear evidence pertaining to any weight gain and loss. Records were observed to be well documented and maintained. However some further improvements are required to ensure that all areas of assessed need are clearly documented within the person’s plan of care and where changes have occurred the care plan is amended to reflect accurately their current care needs. This refers specifically to the care records (including the pre admission assessment) for one person recording them as being agitated and displaying aggression towards others on occasions. Records showed that no plan of care was devised for this area. A risk assessment was completed however this provided little detail as to the specific nature of agitation and/or aggression exhibited and provided limited guidance for staff as to how to deal proactively with the person’s behaviours. In addition both daily care records and formal behaviour monitoring charts showed that the person was agitated and/or aggressive towards both staff and other people who live at the care home on a regular basis. Medication records showed that the person was prescribed PRN (as and when required) medication for their agitation and/or aggressive behaviours however there was no detailed guidance for care staff on the circumstances these are used, either with the medication records or in the care plan. We spoke with the senior person in charge of the shift and they demonstrated a good understanding and awareness of the person’s care needs and the actions to be taken should their behaviours increase and become detrimental to the wellbeing of others living at the care home. However they acknowledged that a lack of information within the care plan could potentially lead to inconsistencies of care practices by some staff. Another person’s care plan made reference to them being non-compliant with taking their medication periodically. There was evidence to show that this had not been reviewed and updated at the time of the site visit to reflect they had consistently refused their medication during the previous month and following a review by the person’s GP all but one medication had been discontinued. In addition their pre admission assessment recorded them as occasionally experiencing bouts of low mood, episodes of anxiety and restlessness. A plan of care was devised in relation to these areas, however from discussions with the senior person in charge no rationale could be provided as to why this was compiled 11 days after they were admitted and not sooner. Other records showed that not all areas of assessed risk had been recorded, and in some instances not all elements of the care plan or where there was a risk assessment devised, had been reviewed and updated to reflect changing needs. Although some of the evidence contained within this section shows Admirals Reach Residential & Nursing Home DS0000015345.V377082.R01.S.doc Version 5.2 Page 14 continued shortfalls and deficits in relation to some aspects of care planning and risk assessing, the quality of information recorded has improved. The AQAA details that the incidence of pressure sores within the care home are monitored, recorded and the information is collated so as to identify possible trends and inform the purchase of appropriate equipment. Care records showed that all people who reside in the care home have access to a range of healthcare provision and services as and when required. The home’s nursing staff provide assistance and care to those people admitted for nursing care whilst arrangements are in place for the community nurse and/or district nurse services to provide care and support to those people accommodated for residential care. In discussion with 2 relatives at the time of the site visit, both confirmed that appropriate interventions and healthcare support is provided to their member of family by staff and they are kept informed and up to date with any issues. Interactions between staff and residents were observed to be much improved within the 3 houses inspected. Staff, were observed to verbally interact with people regularly and provide support and assistance which was respectful and with due regard to their privacy and dignity. In discussion, one resident said staff, are very good and thats what you need as an older person, staff who are very polite and respectful. The person also stated that staff respond to the buzzer promptly and always knock and wait before entering. Another person advised us, “I have no complaints, the care is very good”. Comments noted within the most recent ‘customer satisfaction survey’ included, “my relative always looks clean and happy in their own way” and “the staff are very caring and helpful”. We were concerned during the inspection to see a resident on Jellicoe being taken to their room from the lounge/dining room in their chair (had wheels) by a member of staff who was unaware that they were moving at a significant pace and the person’s left heel was repeatedly hitting the floor. We advised the senior in charge of the situation immediately. We looked at medication practices and procedures within each of the 3 houses (Benbow, Jellicoe and Nelson). Storage systems within each of the houses for medication were seen to be appropriate and secure. The temperature of each room where medication is stored is monitored and recorded each day. Records showed that on most occasions over the past 3 months, there have been few occasions whereby the temperature exceeded the recommended level. Medication that requires cold storage is stored within a dedicated fridge, however on Benbow and Jellicoe records showed that fridge temperatures over a 3 month period have been on several occasions above the recommended levels of between 2-8° centigrade. Records showed that action was taken by the organisation to address the issues and new fridges have been purchased and are in situ. The manager advised that air conditioning units are to be Admirals Reach Residential & Nursing Home DS0000015345.V377082.R01.S.doc Version 5.2 Page 15 installed in the near future to ensure that medication is stored at the correct temperature. Medication Administration Records (MAR) were examined and improvements noted since the last key inspection in relation to no medication past its expiry date, packets and bottles of medication were now signed and dated when opened and where handwritten MAR records are in place these are double signed by staff to ensure their accuracy. We watched the administration of medication to service users within 2 houses (Benbow and Jellicoe) and this was seen to be appropriate and undertaken in a respectful manner. However some discrepancies were observed and these relate to, the MAR record for one person detailing that one of their medications was prescribed 5 times daily however the MAR record recorded “none supplied this cycle” and there were 9 staff signatures recorded. No rationale could be provided at the time of the site visit as to why this had happened. In addition the MAR records for one person showed that 2 of their medications were “out of stock” for a 2 day period and one person’s prescribed cream was “unavailable ordered from GP”. The number of unexplained gaps in records was noted to have significantly reduced, although there were still some gaps observed. Only qualified nursing staff administer medication to people living at the care home. A qualified staff member advised of planned training updates on medication administration for some staff and evidence of this was provided and seen to be satisfactory. Admirals Reach Residential & Nursing Home DS0000015345.V377082.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Admirals Reach can be confident that their social care and dietary needs and wishes are met. EVIDENCE: We spoke with an activity co-ordinator and were advised that 100 hours per week Monday to Friday is devoted to activities and ensuring that the social care needs of people within each of the 4 houses are met. A written weekly and monthly activity programme is displayed within each of the 4 houses and in entrance to the administration office. Records showed that people have the opportunity to participate in a varied range of activities and these include, arts and crafts, music club, reminiscence, hand massage, cooking, cinema club, religious observance, games, sensory sessions, bingo, planned community based activities and there are visits from external entertainers. In addition a newsletter is compiled every 3 months and distributed. The ‘Spring’ edition showed that various themed festivals were Admirals Reach Residential & Nursing Home DS0000015345.V377082.R01.S.doc Version 5.2 Page 17 celebrated and events undertaken including ‘Burns Night’ celebrations with folk dancers, haggis and shortbread eating and ‘Chinese New Year’ with staff dressing up and each house enjoying a selection of Chinese food and appetisers. In addition the newsletter provides details of people’s special birthdays, poems and/or stories and information about staff. A resident of Nelson unit told us there are activities and outside entertainers they can choose to join in with, that they can go to bed and get up in their own routine and that the night staff get you a nice cup of tea and biscuit. A resident of Mountbatten unit told us that there are activities available and that they join in when they can but that they can also read their paper or watch television in their room and sometimes go outside for a walk around. There is an open visiting policy whereby visitors to the home can visit at any reasonable time. Visitors spoken with said that they choose the times they come to visit, with some visiting most days and they are always made welcome. Visitors were seen to make drinks for themselves and their relatives in the satellite kitchen on the unit. There is a rolling 4 week menu and from inspection of this, showed that people within each house are provided with a varied diet throughout the day. From our observations and records, there was evidence to show that people can have alternatives to the main meal if they so choose. As stated at the last key inspection, consideration should be made to devise the menu in larger print and/or pictorial format so as to ensure that people living at the care home are able to make an informed choice. A senior staff member advised us of the fluid monitoring chart in place for all residents because of the recent hot weather. It was disappointing to note that while lunch was served within one house from 12.30 p.m. residents did not begin to receive a drink with their meal until 1.20 p.m., unless a relative was present and got the person a drink independently. In some instances on both Benbow and Jellicoe a choice of drinks was not readily available and everyone was provided with tea or the same fruit juice (orange squash), despite alternatives being available within the satellite kitchens in each house. The dining experience for people living at Admirals Reach was observed to be positive. Staff were observed to support resident’s during lunch with sensitivity and respect, interacting with the person, saying ‘please’ and ‘thank you’ and patiently encouraging them to eat and for example asking how is that. The quality and quantity of food provided to people was observed to be appropriate and looked appetising. Foods were pureed separately where this was required, so retaining flavour and appeal. Dining tables were pleasantly set with cloths and, in some units, with condiments, flowers and menu cards. Admirals Reach Residential & Nursing Home DS0000015345.V377082.R01.S.doc Version 5.2 Page 18 Kitchen staff confirmed that staff cover is available in the kitchen from 6.00 a.m. to 6.00 p.m. and they then top up the satellite kitchens with nite-bite stocks should residents require snacks during the evening and throughout the night. Many residents spoken with were satisfied with the food served and residents were clearly offered choices. One person said food is first class while another person said this place gets 8 out of 10 only as the food is not good. Admirals Reach Residential & Nursing Home DS0000015345.V377082.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be assured that their concerns will be listened to and dealt with appropriately. They can expect to be safeguarded by staff knowledge and supporting policies and procedures. EVIDENCE: A complaints procedure was displayed in the entrance hallway and now needs to be updated to reflect the current title and contact details for the Commission. In addition this needs to be provided in a suitable format for people who live at the care home e.g. larger print, simple language and/or pictorial so as to ensure that people know what to do if they need to make a complaint. The operations manager advised that a new and very detailed BUPA complaints procedure and recording format came into effect on the day prior to the inspection and was being disseminated. Visitors and residents spoken with who are able to express a view confirmed that they would feel able to raise any complaints or issues with the staff. One visitor told us that they meet every month with a qualified nurse to review the residents care and could raise any concerns at that time. Admirals Reach Residential & Nursing Home DS0000015345.V377082.R01.S.doc Version 5.2 Page 20 The manager advised that seven complaints had been received this year and these were logged, dated and responded to in a timely way. Complaints related to issues such as laundry, fish with too much batter and not enough fish, lack of access to drinks and response to call bell times. The Commission has not received any complaints about the service since the last inspection. A number of cards and letters of thanks and compliments were available on display in the foyer of the administration unit. These included the comments all the staff on Jellicoe are polite, professional and really caring, you have done a brilliant job, thanks to all the staff in Nelson with the kindness and care given and I appreciate the good care given. Qualified staff spoken with confirmed they had attended training on dementia care and for some this included a three-month module that also looked at management of behaviour that challenges. One of the qualified staff confirmed that they are a trainer on safeguarding and that training includes types of abuse and how to recognise it in daily practice, for example using a table in front of a resident to keep them in one place, or not telling people what you are about to do when providing care or moving and handling. They advised that staff watch a video and also complete a questionnaire. Information on whistle-blowing with contact details was displayed in the office on Nelson house and staff spoken with, were aware of this. Staff spoken with confirmed that safeguarding training is provided as part of induction and that they have an annual update. Staff spoken with also advised that they had had a training session on management of aggression as well as in dementia care. Staff, were able to identify types of abuse that could occur in care homes, were aware of whistle-blowing and were clear that they would report it, one person said we must do it, tell seniors, manager or social services. The manager did not have a current copy of the local safeguarding protocols and guidance and was recommended to access this so that they have up-todate knowledge on best practice and procedure in relation to safeguarding. Within the past 12 months there have been 2 safeguarding issues. Evidence showed that appropriate action was undertaken by the management team of the home to deal effectively with both issues so as to ensure people’s safety and wellbeing. The manager provided information on a safeguarding incident that related to a visitor to Admirals Reach and confirmed that they had worked with other professionals and the family to safeguard and promote the residents well being. Records available demonstrated that a number of staff had attended training on managing behaviours that challenges since the last inspection and this was confirmed by a number of staff spoken with. This is an improvement from last inspection. A relative spoken with said I am very satisfied with the care [name Admirals Reach Residential & Nursing Home DS0000015345.V377082.R01.S.doc Version 5.2 Page 21 of resident] receives… staff, are able to manage and care for [name of resident] who can be aggressive, I couldnt ask for better. Admirals Reach Residential & Nursing Home DS0000015345.V377082.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Admirals Reach, benefit from living in a safe and homely environment. EVIDENCE: Each resident at Admirals Reach has their own bedroom. Those residents spoken with on the different houses and able to express a view were satisfied with their room and confirmed it was comfortable and met their needs. Rooms were personalised to various degrees and residents told us they had been able to bring some familiar pieces such as photographs and small items of furniture with them when they moved to the home. The grounds were well maintained and residents rooms looked out onto these. Residents were seen to use the central courtyard area to walk or sit. Admirals Reach Residential & Nursing Home DS0000015345.V377082.R01.S.doc Version 5.2 Page 23 Each house has a central lounge and dining room as well as a separate smaller lounge/quiet room for residents use. These were pleasantly furnished and comfortable. As it was a hot day, some of the conservatory type areas were uncomfortably hot and some residents needed to move from that area. Each house also has its own satellite kitchen where breakfast can be served from and drinks made during the day. On Jellicoe, each residents bedroom door had their room number, a photograph of the resident with their name in large print to help those who needed it to recognise their own bedroom. The information was behind secured perspex covers and looked neat and well presented as was that on resident bedroom doors in Mountbatten and Nelson. This orientation support was not available to the people living with dementia on Benbow. The manager said that they had been available but that confused residents had removed them all. Each resident door on Benbow and Jellicoe was fitted with a lock and the doors closed automatically from outside that could be opened from inside by people who were able. Most residents did not have a key which meant they were locked out of their room unless they were able to ask a staff member to open it for them. All staff had a master key for the bedroom doors. A staff member told us they do open doors as people request it but otherwise rooms are kept locked as families complain if confused residents go into the persons room. Some residents are nursed in/unable to get out of bed and so were in a room where the door was locked. The manager stated that many of these residents would be unable to express a view on this matter and they may like to be quiet and undisturbed. The manager was recommended to review and reassess this as some people may not be able to call for assistance, or be heard or easily monitored in this situation. Residents spoken to on Nelson unit confirmed that they did have a key to their room. The covering button/plate on some light switches in some areas was observed to be missing, presenting as confusing and making it difficult to turn on the light. The manager was recommended to review this and ensure that it is addressed. Hot water temperatures were sampled in bathrooms and found to be within safe limits. Labels on bath hoists sampled demonstrated that they had recently been inspected and serviced. Liquid soap and paper towels were also available in hand washing areas supporting management of cross infection. Staff, were seen to wear appropriate protective clothing both for personal care and food handling. The laundry and kitchen were clean and well organised. The AQAA details that since the last key inspection all corridor and bedroom carpets have been replaced. Admirals Reach Residential & Nursing Home DS0000015345.V377082.R01.S.doc Version 5.2 Page 24 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Admirals Reach can be confident that their needs will be met by a competent staff team with the skills and competencies to provide good quality care. EVIDENCE: Senior staff are employed on each of the four houses who manage the day-today running of individual house and report to the home’s manager. Rotas reviewed on Benbow and Jellicoe were accurate to the staff on duty. Staff and rotas sampled confirmed that there is always at least one qualified nurse on duty on each house. Staff on Jellicoe confirmed that there are always seven staff in the morning, five in the afternoon and three at night, and that currently with the five vacant beds they are able to spend more time with the residents. On Benbow staff and the manager told us that they adjust their staff allocation depending on the needs of the unit, sometimes having six staff on in the morning and six in the afternoon rather than seven in the morning. Staff spoken with said that the staffing levels were adequate to meet the care needs of residents. Two staff are allocated to each corridor of 15 residents, one staff Admirals Reach Residential & Nursing Home DS0000015345.V377082.R01.S.doc Version 5.2 Page 25 floats to help as needed, one staff is in the lounge/dining room to serve people as they come to breakfast and support those who need assistance with eating and the qualified member of staff administers the medication. Visitors spoke highly of the staff with comments such as very satisfied with staff, couldnt be better, a staff do a good job, senior staff are absolutely brilliant, I am very satisfied with staff and the care they provide and the staff are fine though I would like to see more of them. Staff spoken with indicated they felt that staffing levels were adequate to allow them to meet residents needs and on some units where resident numbers were lower, advised that this gave them opportunity to give more individual time to residents. Staff also indicated that morale in the staff team was good. Staff interactions with residents were, in the main, seen to be positive and supportive. Residents spoken with were also positive about the staff who provide care for them with comments such as the staff are lovely and staff are very good. The AQAA details that every endeavour is made to ensure that staffing levels are appropriate for the numbers and needs of people living on each of the 4 houses. It also states that there is good staff retention and the ‘skill mix’ of staff has improved. Recruitment files for three staff employed since the last inspection were sampled to review if robust recruitment procedures were operated. All files contain an application, photograph and evidence of identity as well as all records and checks undertaken to ensure their prospective staff were suitable people to work with residents at Admirals Reach. Only part of the criminal record bureau check for each person was available, which did not include the date, number and level of check undertaken. Evidence that staff completed induction training to Skills for Care standards was available for each of the three staff files sampled and were signed by both the mentor and the staff member. Certificates on the staff files demonstrated in house training in issues such as fire, basic infection control, safeguarding, managing violence and aggression in the workplace and load management/ client handling techniques. Staff also attended a one hour training session on dementia care, which would seem to be limited training for people working in Benbow or Jellicoe units, where care is provided to people diagnosed as living with dementia. This is clearly an area for further development. Staff files sampled indicated that staff had been provided with formal supervision. Records kept on Jellicoe recorded that a number of staff had attended training in the past year including in relation to fire, COSHH (Control of Substances Hazardous to Health), moving and handling, management of aggression and dementia. In addition, records indicated that staff on various house’s had undertaken training, including distance learning training, on infection control, food hygiene, nutrition, oral hygiene, catheter care, stoma care and epilepsy awareness. The manager maintains a matrix to demonstrate an overall view of Admirals Reach Residential & Nursing Home DS0000015345.V377082.R01.S.doc Version 5.2 Page 26 mandatory training for staff. This indicates that staff had completed training/updates in basic issues such as fire awareness, moving and handling, safeguarding vulnerable people and health and safety. Admirals Reach Residential & Nursing Home DS0000015345.V377082.R01.S.doc Version 5.2 Page 27 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at Admirals Reach can be confident that the management arrangements within the home ensure that it is run in their best interests. EVIDENCE: The manager stated that they had updated their mandatory trading since the last inspection including in relation to health and safety and safeguarding vulnerable adults. They have also attended training on managing investigations, palliative care, Mental Capacity Act and Deprivation of Liberty Safeguards. The manager advised that they have almost completed their Masters degree in public health. Admirals Reach Residential & Nursing Home DS0000015345.V377082.R01.S.doc Version 5.2 Page 28 It is evident that the registered manager and members of the management team are continuing to take steps to improve the service and to ensure that they comply with regulatory requirements and provide positive outcomes for the people who live at Admirals Reach. Of 13 statutory requirements highlighted at the previous inspection to the home, 10 have been met. The remaining 3 requirements relate to some aspects of care planning, risk assessing and medication practices and procedures. Although improvements were noted, these requirements have not been fully met and a new timescale for action has been set. There is a quality assurance system in place at the home to seek the views of residents and relatives about the quality of the service provided at Admirals Reach. The results showed 57 of relatives felt that the quality of the service provided was either excellent or good. People felt staff were respectful, that their relative’s privacy was always met, that staff were prompt in attending to their relative’s needs and that people were enabled and supported to make choices. Mixed comments were noted in relation to the cleanliness of the home and food provided. Comments for improvement included, “for the domestics to clean the room more thoroughly” and “cleanliness of the home, the smell of the home and an increase in the quality of food”. The results from residents showed that 68 of people rated the quality of service received as either excellent or good. People were complimentary regarding the level of privacy received and consistency of staff working on each house. Positive comments included, “all staff are very kind” and “staff are kind and caring”. Comments for improvement included “food varies from good to inedible depending on who is cooking and what is served”, “poor response to buzzer on occasions” and “midday meal could be improved. In addition to the quality assurance system as detailed above, monthly visits are conducted by a representative of the organisation and a report compiled. Records also showed that a range of audits are undertaken for BUPA to analyse with regards to finance, health and safety, reportable incidents, recruitment, medication etc. The AQAA details that the home is supported by a national team of quality and compliance officers, whose role includes supporting quality issues within the home, auditing and providing guidance on policies, procedures and practice. The administrator manages personal allowance money for some residents. Receipts issued for money paid in is kept in one account that earns proportionately allocated interest. Statements of the account were readily available and systems are in place to reconcile balances each month. Balances and statements sampled for three people were noted to be accurate. Residents sign for withdrawal of money where they are able and where this is not possible two staff, sign the records. Payments for items such as chiropody, hairdressing and newspapers are invoiced to the administrator who arranges payments. Admirals Reach Residential & Nursing Home DS0000015345.V377082.R01.S.doc Version 5.2 Page 29 The AQAA contains clear, relevant information about the service and lets us know about changes they have made and where they still need to make improvements. The data section of the AQAA is accurate and fully completed. Aspects of health and safety were reviewed to assess that systems were in place to safeguard residents. Current safety inspection certificates were available in relation to the fire alarm, emergency lighting, water tank chlorination, gas and electrical fixed wiring. Records were available of weekly checks of the fire alarm in each unit. The operations manager advised that an assessment is printed out each week for each house in relation to the fire risk assessment for each resident using a traffic light system for example in terms of their moving and handling needs. Accident records for each unit are monitored by the manager who sends them to head office monthly where they are audited for trends to assist in preventative planning. The AQAA details that BUPA Care Homes has a comprehensive set of policies and procedures that are regularly reviewed by experts and updated as and when required. Admirals Reach Residential & Nursing Home DS0000015345.V377082.R01.S.doc Version 5.2 Page 30 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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X 3 2 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Admirals Reach Residential & Nursing Home DS0000015345.V377082.R01.S.doc Version 5.2 Page 31 Are there any outstanding requirements from the last inspection? YES 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 OP7 Regulation 14 Requirement There is a plan of care, clearly identifying all aspects of the person’s care needs and how these are to be met by staff. This will ensure that staff, have the information they need so as to provide appropriate care to meet the individual’s care needs. Previous timescale of 1/11/08 not fully met. Where the person’s care needs have changed, ensure that the plan of care is regularly reviewed and updated to reflect the most up to date information. So as to ensure that staff have the most up to date information. Previous timescale of 1/11/08 not fully met. Risk assessments must be devised for all areas of assessed risk. So that risks to residents can be minimised. Admirals Reach Residential & Nursing Home DS0000015345.V377082.R01.S.doc Version 5.2 Page 32 Timescale for action 01/12/09 2. OP7 15 01/12/09 3. OP7 13(4) 01/12/09 4. OP9 12(1)(a)1 3(2) Previous timescale of 1/11/08 not fully met. Residents must be protected from harm by having their medication administered safely and in accordance with the prescriber’s instructions. So as to ensure their health and wellbeing. Previous timescale of 18/7/08 not fully met. 01/10/09 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 OP12 Good Practice Recommendations Consider devising the activity programme in a larger print/simple language and/or pictorial format so as to ensure that people within the care home are able to make an informed choice. Consider devising the menu’s in larger print/simple language and/or pictorial format so as to ensure that people within the care home are able to make an informed choice. To support residents living with dementia, including those people resident on Benbow, individual bedrooms should be clearly identified to help them to recognise their own personal space. To ensure the well being of residents, the manager should risk assess and review the practice of immobile residents being in bedrooms where doors lock as they close. Staff working on units where care is offered to people living with dementia to be provided with additional training on dementia care. 2. OP15 3. OP19 4. 5. OP24 OP30 Admirals Reach Residential & Nursing Home DS0000015345.V377082.R01.S.doc Version 5.2 Page 33 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Admirals Reach Residential & Nursing Home DS0000015345.V377082.R01.S.doc Version 5.2 Page 34 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!

The Provider has not yet updated their profile and added details of the services and facilities they offer. If you are the provider and would like to do this, please click the "Do you run this home" button under the Description tab.

The Provider has not yet updated their profile and added details of the services and facilities they offer. If you are the provider and would like to do this, please click the "Do you run this home" button under the Description tab.

Promote this care home

Click here for links and widgets to increase enquiries and referrals for this care home.

  • Widgets to embed inspection reports into your website
  • Formated links to this care home profile
  • Links to the latest inspection report
  • Widget to add iPaper version of SoP to your website