CARE HOMES FOR OLDER PEOPLE
Calderbank House Shaw Wood Road Todmorden Lancashire OL14 6DA Lead Inspector
Cheryl Stovin Unannounced Inspection 12th October 2005 13:00 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 Calderbank House DS0000001024.V258752.R01.S.doc Version 5.0 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. Calderbank House DS0000001024.V258752.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Calderbank House Address Shaw Wood Road Todmorden Lancashire OL14 6DA 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) 01706 816188 Ms Marilyn Dorothy Wardroper Ms Marilyn Dorothy Wardroper Care Home 5 Category(ies) of Old age, not falling within any other category registration, with number (5) of places Calderbank House DS0000001024.V258752.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 4th May 2005 Brief Description of the Service: Calderbank House is a privately owned care home registered to provide accommodation and care for up to five older people. The establishment, a large stone built detached period property is well maintained throughout and furnished and fitted to a high standard. All of the bedrooms are for single occupancy and have the benefit of en-suite facilities or adjacent bathrooms. The bedrooms are sufficiently spacious to enable them to be furnished in the style of a bed sitting room. Externally, there are well maintained garden areas equipped with garden furniture and a summer house for the service users to enjoy in the warmer weather. The establishment is situated in a semi rural area with easy access to the town centres of Todmorden and Hebden Bridge. The manager/proprietor and her family live on the premises and the establishment is very much a family home, with the two Jack Russell dogs, Peggy and Ted being an integral part of the household. Calderbank House DS0000001024.V258752.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place during the afternoon of the 12th October 2005 Two service users were consulted at length, as to their views on the service provided, within Calderbank House. The service users expressed great satisfaction with the standard of services and facilities provided within the home, and of the care and attention they receive. What the service does well: What has improved since the last inspection?
The home continues to offer a high standard of services and facilities.
Calderbank House DS0000001024.V258752.R01.S.doc Version 5.0 Page 6 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. Calderbank House DS0000001024.V258752.R01.S.doc Version 5.0 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 Calderbank House DS0000001024.V258752.R01.S.doc Version 5.0 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): 3,6 The admission procedure into the establishment is detailed and thorough, and service users are provided with written information stating the terms and conditions of residence. EVIDENCE: A full assessment is carried out before admission to the home. The detailed assessment process and the associated record keeping indicated that the establishment meets the individual and collective needs of the service users. The statement of purpose and service user guide clearly indicates that the establishment does not cater for service users with high dependency needs. Intermediate care is not provided within the home. Calderbank House DS0000001024.V258752.R01.S.doc Version 5.0 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): 9,10 Service users needs are thoroughly assessed and the home has a good approach to promoting health care. EVIDENCE: Service users confirmed that they felt they were treated with dignity and respect at all times. All staff have undertaken accredited medication training and a detailed policy and procedure is in place. Each service user has an individual medication profile which details the medication prescribed, what the medication is prescribed for and details of the ailment and therapeutic properties of the drug, and pictorial descriptions of the medication. Each service user signs a medicine administration consent form which indicates whether the service user wishes to administrate their own medication, or not, as the case may be. The establishment uses a Nomad cassette system, supplied via a local pharmacy for the administration of medication. The medication is securely and appropriately stored, with detailed medication administration records held, the records are accurately completed and record the actual time the medication had been given.
Calderbank House DS0000001024.V258752.R01.S.doc Version 5.0 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): None of these standards were inspected on this occasion. EVIDENCE: Calderbank House DS0000001024.V258752.R01.S.doc Version 5.0 Page 11 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): 16,18 The home has robust systems to ensure that service users are safeguarded from abuse and that complaints will be dealt with promptly. EVIDENCE: The establishment holds a clear complaints procedure which is displayed in the entrance hall of the home. All staff have received training in adult protection awareness and procedures. Calderbank House DS0000001024.V258752.R01.S.doc Version 5.0 Page 12 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): 19,20,21,22,23,24,25,26 The home is well maintained, with high standards of cleanliness throughout, providing a pleasant and safe environment for service users. EVIDENCE: The establishment is situated in a semi rural area just off the main Halifax Road convenient for both the town centres of both Todmorden and Hebden Bridge. The establishment, a large stone built detached period residence, is well maintained throughout with a routine programme of maintenance and refurbishment. A stair lift is provided. All of the bedrooms are for single occupancy and are equipped with either an en-suite facility or an adjacent private bathroom. The bedrooms are very spacious enabling them to be furnished with a sitting and dining area. Externally there are well maintained and easily accessible garden areas, equipped with outdoor furniture including a summer house, which is well used by the service users. The proprietor has submitted an application to register another bedroom within the home, situated on the ground floor, building work was in progress at the time of the inspection.
Calderbank House DS0000001024.V258752.R01.S.doc Version 5.0 Page 13 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): 27,28,29,30 The home is appropriately staffed to meet the individual and collective needs of the service users. EVIDENCE: In addition to the resident manager six care staff are employed within the establishment. The staffing levels are sufficiently high to enable the social and emotional needs of the service users to be met. Staff have time to sit and talk to the residents and to accompany them on impromptu outings and social activities. Waking night staff are not routinely employed within the establishment, however, in case of illness will be provided. A call bell is provided to summon assistance during the night if required. Relationships between staff and residents were observed to be relaxed and friendly with appropriate use of informality and humour. Two of the staff team are undertaking their NVQ II award with another about to commence their award. Calderbank House DS0000001024.V258752.R01.S.doc Version 5.0 Page 14 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): 31,32,33,34,35,38 The home is well run and managed effectively, with robust health and safety procedures in place. EVIDENCE: The registered manager of the establishment is experienced and competent to run the establishment and as she lives on the premises is freely available to consult with the service users and the staff team. An open and inclusive atmosphere is prevalent within the establishment. The assistant manager who has recently returned from maternity leave, is currently undertaking her NVQ IV Registered Managers Award and will shortly be submitting an application to the CSCI for registration as manager of the home The establishment holds detailed and comprehensive health and safety policies and procedures and records seen indicated compliance with regulations. Detailed risk assessments are in place which has been reviewed recently. All
Calderbank House DS0000001024.V258752.R01.S.doc Version 5.0 Page 15 the internal doors within the home have been upgraded to ensure compliance with fire safety regulations, the work has been done sympathetically to retain the original features of the doors. Calderbank House DS0000001024.V258752.R01.S.doc Version 5.0 Page 16 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 4 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 3 3 x x 3 Calderbank House DS0000001024.V258752.R01.S.doc Version 5.0 Page 17 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 OP28 OP31 Good Practice Recommendations 50 of staff to be qualified to NVQ II. The deputy manager to submit an application to the Commission for registration as manager. Calderbank House DS0000001024.V258752.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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