Inspection on 15/02/06 for Calway House

This inspection was carried out on 15th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Calway House 20/06/07

Calway House 27/09/06

Calway House 20/09/05

Calway House 31/03/05

Calway House 24/08/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Stallcombe House

Belma

Hunters Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Calway House Calway Road Taunton Somerset TA1 3EQ Lead Inspector Kathy McCluskey Unannounced Inspection 15th February 2006 09:15 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 Calway House DS0000016059.V278029.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Calway House DS0000016059.V278029.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Calway House Address Calway Road Taunton Somerset TA1 3EQ 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) 01823 333283 01823 324186 Somerset Care Limited Mrs Jane Elizabeth Lynch Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Calway House DS0000016059.V278029.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named service user who is under the age of 65 years. Date of last inspection 20th September 2005 Brief Description of the Service: Calway House is a new pupose built home registered with the Commission for Social Care Inspection to accommodate up to 34 service users over the age of 65 years who require personal care by means of old age. The home is not registered under the category of dementia. The home is not registered to provide nursing care. Calway House, is situated in a quiet residential area not far from Taunton town centre. The building is arranged over two floors with a shaft lift giving access to the first floor. The home is fitted with appropriate aids and adaptations. The gardens have been professionally landscaped and provides safe and pleasant areas for service users to enjoy. The second phase of the new build is well under way though to date, the CSCI have not received an application to register. Calway House in owned by Somerset Care Ltd which is a not for profit organisation. The registered manager is Jane Lynch.The responsible individual is Marion Osborn.The home has achieved the Somerset Social Services Quality Rating. Calway House DS0000016059.V278029.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over one day (2.75hrs) by CSCI Regulation Inspectors Kathy McCluskey and Jane Poole. At the time of this inspection 32 service users were living at the home and 2 were in hospital. The inspectors were informed that the home has a waiting list. The registered manager, Jane Lynch was present throughout the inspection. The inspectors were able to speak with service users, staff and a relative. A selection of bedrooms and communal areas were seen. Records relating to staff, service users and health and safety were examined. The inspectors would like to thank service users, staff and the registered manager for their time and cooperation with the inspection process. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report and the last announced inspection report. What the service does well: Calway House provides a new purpose built home for service users. All service users now benefit from spacious single bedrooms, all of which are fitted with en-suite facilities, which consist of a toilet and level access shower. Service users spoken with during the inspection stated that they really liked their rooms. The home encourages service users to personalise their bedrooms and service users are welcome to bring items of their own furniture if they so wish. The home has been well designed for service users with mobility difficulties and appropriate aids and adaptations are in place. The manager should be commended for her attention to detail when adding the final touches to the home. The ground floor has been decorated in line with current best practise for people with dementia, although the home is not yet registered for this category. The home is registered for 34 service users who require personal care by means of old age. The home has been designed to enable service users to live in smaller groups of 15. Calway House DS0000016059.V278029.R01.S.doc Version 5.1 Page 6 The home has beautiful and interesting gardens which have been professionally landscaped. All service users spoken with stated that they felt safe at the home and commented on the kindness of staff. The home is very effectively managed by Jane Lynch. Jane has a wealth of experience and training and promotes an open an inclusive style of management. The home takes appropriate steps to reduce the risk of harm or abuse to service users. Appropriate measures are in place to ensure the health and safety of service users, staff and visitors to the home. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Calway House DS0000016059.V278029.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Calway House DS0000016059.V278029.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 5 Standard 6 is not applicable as the home is not registered to provide intermediate care. The home takes appropriate steps to ensure that prospective service users have the information they need to make an informed decision about moving to the home. The home takes appropriate steps to ensure the assessed needs of service users can be met. EVIDENCE: The home has a Statement of Purpose and Service user Guide which are made available to service users, prospective service users and their representatives. These documents provide information regarding the services offered by the home. The home is also currently in the process of developing a new brochure. Calway House DS0000016059.V278029.R01.S.doc Version 5.1 Page 9 The home’s current fee range is between £349 and £460 per week. Fees charged are dependant on the individual’s assessed needs and room to be occupied. Extra charges are met by service users for hairdressing, newspapers, magazines, chiropody and personal toiletries. Prospective service users are fully assessed at their home or in hospital, by the manager or the deputy to ensure that the home is able to fully meet their assessed needs and expectations. A pre-admission assessment is completed and the home obtains assessments from other professionals as appropriate. Prospective service users and/or their representatives are encouraged to visit the home prior to making a final decision about whether to move to the home. The home avoids emergency admissions and will only consider if a detailed and up to date assessment is available from appropriate professionals. Calway House DS0000016059.V278029.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 The home takes appropriate steps to ensure that service users health, social and personal care needs are met. The home follows the correct procedures for the management and administration of service users’ medication. Service users are treated with respect. EVIDENCE: Since the last inspection, the home has been piloting a computerised care planning system. The inspectors were able to view two service user care plans with the assistance of the registered manager. Service user computerised care records are password protected. Care records contained detailed information as to the preferences of service users, care needs and actions to be taken by staff to meet assessed needs. Appropriate assessments were in place which included reducing the risk of pressure sores, nutrition and moving and handling. Calway House DS0000016059.V278029.R01.S.doc Version 5.1 Page 11 Care plans are reviewed at least monthly and daily entries as to the health and well-being of service users are maintained. The home takes appropriate steps to ensure that service users have access to appropriate healthcare professionals. Details of all visits are maintained in the individual’s plan of care. Records seen indicated that service users receive regular visits from G.P’s, dentist and chiropodist. Specialist healthcare professionals such as those specialising in mental health, are accessed where there is an assessed need. An example was provided. Service users spoken with informed the inspectors that they were happy with the care they received at Calway House. One relative spoken with informed the inspectors that they were always kept well informed and were very happy with the care their loved one received. Service users commented on the kindness of staff and did not express any concerns regarding the manner in which they were assisted with personal care needs. The registered manager informed the inspectors that the majority of service users now preferred using their en-suite shower facilities. Staff were observed interacting with service users in a kind and respectful manner. The home takes steps to ensure that service user’s medication is managed and administered appropriately. The home uses the monitored dosage system (MDS) with pre-printed medication administration records (MAR). Medicines are appropriately stored and administered by senior staff who have received appropriate training. All MAR charts seen were found to be well maintained. Photos of service users are attached to MAR charts to aid identification. At the last inspection it was noted that the temperature of the room storing medicines was exceeding the limit of 25C. At this inspection, the registered manager advised that this was being closely monitored and that action would be taken to address where required. Calway House DS0000016059.V278029.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Service users are able to choose how and where to spend their day and have access to a range of varied activities. The home offers a varied and wholesome menu and is able to cater for special diets. EVIDENCE: Since the last inspection, the home has reviewed its programme of activities to ensure that it provides a selection of activities which meet a wide range of needs and abilities. A designated staff member is responsible for activities each afternoon. Service users and the relative spoken with were positive about the activities available at the home. The home welcomes visitors at any reasonable time in accordance with the wishes of the service user. Service users are able to choose where they see their visitors and can use the privacy of their own bedroom if they so wish. One relative spoken with informed the inspectors that they were always made to feel welcome at the home. Calway House DS0000016059.V278029.R01.S.doc Version 5.1 Page 13 Service users are supported to exercise choice and control over their lives in accordance with their agreed plan of care. At the time of this inspection service users were observed moving freely around the home choosing where to spend their day. All meals are prepared and cooked on the premises. Meals were not examined at this inspection though service user comments were positive. Care plans seen clearly identified any special dietary needs, preferences and needs. The home has a spacious dining room on each floor. Calway House DS0000016059.V278029.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home encourages the views of service users and their representatives. An appropriate complaints procedure is displayed. The home has appropriate systems in place to reduce the risk of harm or abuse to service users. EVIDENCE: The home displays an appropriate complaints procedure which is headed, ‘Seeking your views’. No complaints have been received by the home since the last inspection and no concerns have been raised directly with the CSCI. Service users are encouraged to express their views at regular meetings or at any time. Service users spoken with informed the inspectors that they would not hesitate in raising any concerns with the management or care staff. At the time of this inspection, the home is taking appropriate steps to reduce the risk of harm or abuse to service users. Appropriate policies are in place for staff and the home ensures that staff receive appropriate training regarding safeguarding service users from abuse. The home follows robust staff recruitment procedures which include enhanced CRB checks and, where appropriate, POVAFirst checks. Calway House DS0000016059.V278029.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 Service users live in a new purpose built home which provides a safe and very comfortable environment. Service users have the benefit of single bedrooms with en-suite facilities. The home takes appropriate steps to reduce the risk of the spread of infection. EVIDENCE: Calway House is a new purpose built home with accommodation arranged over two floors. On each floor there is a good sized lounge and separate dining room with kitchenette area. On the ground floor there is also a smaller ‘quiet’ lounge, which is temporally being used as a smoking room as the home has one service user who smokes. Also located on the ground floor is an additional very large lounge/dining area. Since the last inspection, the registered manager has taken appropriate action Calway House DS0000016059.V278029.R01.S.doc Version 5.1 Page 16 to ensure that this area is readily available to all service users. This area was previously fitted with a keypad. Corridors are wide and are fitted with grab rails. Ramps are appropriately sited. All areas of the home are fitted with a nurse call system and during this inspection, staff were noted to respond to call bells promptly. A shaft lift gives access to the first floor. There is an assisted bathroom/toilet on each floor, plus a separate toilet on each floor. All are able to accommodate wheelchair users. Bedrooms are located on each floor. Bedrooms and communal areas are arranged to enable service users to live in smaller groups of 15. All service users are accommodated in spacious single bedrooms, which have an en-suite toilet and level access shower. All bedrooms are fitted with a telephone & television point and computer point. A selection of bedrooms were seen and these were noted to be very comfortable and personalised. Service users spoken with were very positive about their bedrooms. All outside areas are accessible to wheelchair users. The home has several garden areas which have been professionally landscaped. The gardens provide beautiful safe areas for service users to enjoy. Many bedrooms and lounge areas on the ground floor have French doors opening out onto the garden. At the last inspection, some service users expressed concerns about using their patio doors as it activated an alarm. It was positive to note that following the last inspection the registered manager had taken action to address this. Doors are now alarmed only at night or where there is an assessed need. Service users appeared relaxed in their environment and were very positive about the facilities available. All spoken with informed the inspectors that they ‘loved’ their rooms. One relative spoken with spoke highly of the home stating that they would definitely recommend Calway House. At the time of this inspection the home was warm and very clean. No malodours were noted. The home takes appropriate steps to reduce the risk of the spread of infection. Calway House DS0000016059.V278029.R01.S.doc Version 5.1 Page 17 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 and 29 Staffing levels are adequate. The home follows robust procedures for the recruitment of staff. EVIDENCE: The inspectors were informed that there had been no changes to the staffing structure/numbers since the last inspection. Mornings are covered by 1 shift leader, 1 supervisor covering both floors, 2 carers based on the ground floor and 1 carer on the first floor. A care support worker, whose responsibilities are mainly cleaning, is located on each floor. During the afternoon and evenings there are, 1 supervisor and 1 care support worker covering both floors, 2 carers on the ground floor and 1 on the first floor. Nights are covered by 2 waking care staff. In addition to care hours, the home employs an activities person for 24 hrs a week. Cooks, kitchen assistants and laundry staff cover 7 days a week. In addition to the registered manager, the home employs a deputy manager, 7 care supervisors, 17 care staff and 7 care support workers and 3 care relief workers. Calway House DS0000016059.V278029.R01.S.doc Version 5.1 Page 18 At the last inspection, some staff expressed concerns about staffing levels. No concerns were raised with the inspectors at this inspection and the registered manager confirmed that staffing levels would always be increased to meet any increase in dependency levels. The home follows robust recruitment procedures. This was ascertained on examination of recruitment records for the most recent staff member. Records contained information as required in Schedule 2 of the Care Homes Regulations 2001. This included enhanced CRB checks and, where appropriate, POVAFirst checks. Calway House DS0000016059.V278029.R01.S.doc Version 5.1 Page 19 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 and 38 Service users and staff benefit from an experienced and committed manager who promotes an open and inclusive style of management. The home takes appropriate steps to ensure the health and safety of service users, staff and visitors. EVIDENCE: The registered manager, Jane Lynch, has been in post since October 2003 and has had 8 years experience in managing Somerset Care homes. Jane Lynch is committed to the care of the service users and of the training and development of staff. She is an appointed first aider, an NVQ assessor (D32/33/34) and a moving & handling training. Jane has also completed the NVQ level 4 award in management and has a strong interest in dementia care. Calway House DS0000016059.V278029.R01.S.doc Version 5.1 Page 20 The registered manager went to great lengths to ensure that the transition to the new build was carried out in a manner which caused as little stress and anxiety to service users as possible. Service users, staff and visitors continue to be kept fully informed of events regarding the second phase of the new build. The registered manager actively encourages the views of service users and staff. Regular meetings are held. The minutes of the last staff meeting were made available to the inspector. These were dated 17th January 2006. Appropriate topics were discussed. All records seen at the time of the inspection were appropriately stored in accordance with the Data Protection Act 1998. At the time of this inspection, the home is taking appropriate steps to ensure the health and safety of service users, staff and visitors. This was ascertained by a tour of the premises, discussions with staff/service users and on examination of the following records: FIRE SAFETY – The home conducts weekly checks on the home’s fire detection systems. It was noted that emergency lighting was being checked 2 monthly as opposed to the recommended monthly basis. This was discussed and addressed by the registered manager at the time of the inspection. Fire detection systems and fire fighting equipment are serviced by an outside contractor on an annual basis. ELECTRICAL SAFETY – The home’s portable appliances (PAT) are tested annually. This was last carried out in August 2005. The home has an up to date electrical hardwiring certificate. GAS SAFETY – The home has an up to date Landlords Gas Safety certificate. ACCIDENTS – The home maintains appropriate records for all accidents. All accident records were seen to be appropriately stored in accordance with the Data Protection Act 1998. The manager analyses accidents monthly and takes appropriate action where required. HOT WATER OUTLETS/SURFACES – The home maintains records of monthly checks on all hot water outlets. Records seen indicated that bath hot water outlets were within HSE recommended limits. To reduce the risk of injury to service users, all hot water outlets have been fitted with thermostatic controls. EQUIPMENT SERVICING – The following equipment, used to move or transport service users, was serviced by an external contractor in accordance with LOLER regulations: - The three mobile hoists and slings were serviced on 02/09/05 - The two bath hoists were serviced on 26/08/05 - The shaft lift was serviced on 13/02/06 Calway House DS0000016059.V278029.R01.S.doc Version 5.1 Page 21 To ensure the safety of service users, all upstairs windows are restricted, low heat surface radiators are installed and any free standing wardrobes are secured to the wall. The home has a qualified first aider on every shift. Calway House DS0000016059.V278029.R01.S.doc Version 5.1 Page 22 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 3 x 3 x 3 N/A 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 Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 x x x x x 3 Calway House DS0000016059.V278029.R01.S.doc Version 5.1 Page 23 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. 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. Refer to Standard Good Practice Recommendations Calway House DS0000016059.V278029.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Calway House DS0000016059.V278029.R01.S.doc Version 5.1 Page 25 - 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!