Inspection on 15/12/05 for Carham Hall

This inspection was carried out on 15th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Carham Hall 07/08/07

Carham Hall 17/07/06

Carham Hall 10/05/05

Carham Hall 11/11/04

Carham Hall 22/07/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Carham Hall Cornhill On Tweed Northumberland TD12 4RW Lead Inspector Anne Urwin Brown Announced Inspection 15th December 2005 09:00 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 Carham Hall DS0000000511.V258176.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. Carham Hall DS0000000511.V258176.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Carham Hall Address Cornhill On Tweed Northumberland TD12 4RW 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) 01890 830338 01890 830338 carhamhall1@aol.com Mrs J Baxter Mr J Baxter Mrs J Baxter Care Home 22 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (12) of places Carham Hall DS0000000511.V258176.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate one identified resident - category MD for periods of respite care. 10th May 2005 Date of last inspection Brief Description of the Service: Carham Hall is a large detached stone house standing in its own grounds near the River Tweed. The nearest villages are about a mile away and Coldstream where there is access to public transport is about five miles from Carham Hall. The home is registered to accommodate up to twenty-two elderly people, ten of whom have dementia. Carham Hall is well furnished and appointed with all rooms having en-suite accommodation or the exclusive use of a bathroom or toilet. A shaft lift is fitted for access to the first floor and a wheelchair lift is fitted for stairs on the ground floor. Carham Hall DS0000000511.V258176.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over one day. It involved talking to the owners, residents and staff; inspection of four residents’ records and other associated records and a tour of the building. What the service does well: What has improved since the last inspection? What they could do better: The complaints procedure must reflect the right of a complainant to refer a complaint directly to the Commission for Social Care Inspection. Appropriate checks must be satisfactorily completed before new staff start working with residents. Carham Hall DS0000000511.V258176.R01.S.doc Version 5.0 Page 6 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. Carham Hall DS0000000511.V258176.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 Carham Hall DS0000000511.V258176.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): 6 Carham Hall does not provide intermediate care. EVIDENCE: The manager confirmed that intermediate care is not provided. Records also confirmed this. Carham Hall DS0000000511.V258176.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): 7, 10 Residents’ health, personal and social care needs are set out in an individual plan of care. Residents feel that they are treated with respect and their right to privacy is upheld. EVIDENCE: Records confirm that residents’ health, personal and social care needs are identified and met. Records show there is regular review of residents’ needs and plans reflect their changing needs. One resident’s record needed updating to reflect a recent change in her needs and this amendment was done during the inspection. Residents said that staff were aware of their needs and provided them with appropriate support. Staff showed a good understanding of residents’ needs during the inspection. One relative said during the inspection that she was very satisfied with the care provided to her mother. Staff were able to confirm that policies and procedures are in place relating to privacy and dignity. They also said that these areas are covered within Induction training. Residents said that the staff respect their privacy and dignity. Staff demonstrated that they were aware of issues relating to privacy and respect during the inspection by knocking on bedroom doors and speaking Carham Hall DS0000000511.V258176.R01.S.doc Version 5.0 Page 10 respectfully about and to residents. Residents confirmed that they have access to a telephone for use in private. Carham Hall DS0000000511.V258176.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 Residents find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests. Contact with family, friends and the local community is encouraged and supported. Residents are helped to exercise choice and control over their lives. EVIDENCE: Residents said that they could decide upon daily living routines and records confirmed this. There are regular activities arranged including musical afternoons, cards, dominoes, exercise class and skittles. There are trips out in the home’s mini bus and these include meals at a local pub, visits to the garden centres, woollen mills, and other places chosen by residents and records were available to confirm this. There are regular church services in the home and some residents choose to go to the local church every month when a service is held there. Residents’ interests are recorded and evidence was available to show that they are encouraged to maintain particular interests or hobbies. Residents said they were satisfied with the range of activities available. Residents are able to have visitors at any reasonable time and they can entertain visitors in their own room or use the large blue sitting room off the main hall. Five residents have a telephone fitted in their rooms to keep in Carham Hall DS0000000511.V258176.R01.S.doc Version 5.0 Page 12 touch with family and friends. Evidence was available from records that family are updated about any changes in residents’ care needs. Relatives confirmed this in person and by questionnaires completed. The manager confirmed that arrangements for visiting are discussed at the time of admission and families are encouraged to visit as frequently as they wish. The home held a Christmas lunch for local pensioners recently and residents said how much they had enjoyed this. Residents are encouraged to retain control of their own finances for as long as they are able and wish to. The manager confirmed that information is available about how to contact an external advocate for residents and relatives. Residents are able to bring personal possessions with them when they come to live at Carham Hall. Residents’ rooms show evidence of this. Residents are able to access their personal records, however none of the residents talked to during this inspection had asked to see their records. Carham Hall DS0000000511.V258176.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Residents and their relatives/friends are confident that their complaints will be listened to, taken seriously and acted upon. The guidance for dealing with complaints needs to be amended to show that a complainant can refer a complaint directly to the Commission for Social Care Inspection. EVIDENCE: Written guidance is in place for dealing with complaints. The guidance needs review to reflect the right of a complainant to refer a complaint directly to the Commission for Social Care Inspection. Staff were aware of the guidance and could confirm that they were aware of how to help a resident make a complaint. Records of complaints are kept in an appropriate manner. No complaints have been made within the last year. Carham Hall DS0000000511.V258176.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20, 21, 22 Residents have access to safe and comfortable indoor and outdoor facilities. There are sufficient lavatories and washing facilities and these are appropriate to residents’ needs. Residents have the specialist equipment they require to maximise their independence. EVIDENCE: The sitting and dining room areas are comfortably furnished and well decorated. Appropriate lighting is provided. There is sufficient space for residents to move easily around the rooms. Attention is given to providing a safe environment. Residents are able to easily access the attractive gardens. There is a path round the house and a private drive that is safe for residents. Residents said the home is comfortable and they are very happy with the facilities provided both indoors and outdoors. All bedrooms have at least an en-suite toilet and wash hand basin or access to a toilet or bathroom that is for the resident’s exclusive use. Sufficient baths are provided for the number of residents accommodated. Sluice facilities are separate from the residents’ bathrooms and toilets. Carham Hall DS0000000511.V258176.R01.S.doc Version 5.0 Page 15 Evidence was available from records that assessments are carried out to determine individuals’ needs for aids and adaptations. A shaft lift is fitted for access to the first floor and a wheelchair lift is available on the ground floor where there are stairs to the extension. Grab rails and other aids are provided to suit the needs of the residents in corridors, bathrooms and toilets. Hoists are available to suit residents’ needs. Evidence was available from records that hoists and the lifts are serviced regularly. A call system is fitted and points are accessible in each room. Carham Hall DS0000000511.V258176.R01.S.doc Version 5.0 Page 16 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 Residents’ needs are met by the number and skill mix of staff. Residents are in safe hands at all times. The home’s recruitment policy and practices generally protects and supports the residents, although one check has not been completed before a new member of staff started work recently. EVIDENCE: There were three care staff and the manager on duty at the time of this inspection. The rota confirmed that an appropriate level of staffing is achieved. At the time of this visit there were thirteen vacancies in the home and staffing levels have been maintained. One waking night staff is on duty throughout the night and the owners are on call on the premises. No staff members under twenty-one years of age are employed. No agency staff are employed. Appropriate numbers of catering and domestic staff are employed. Residents said there were enough staff on duty throughout the day to meet their needs. Staff confirmed that there are enough staff to cover the rota. Arrangements for staff to undertake appropriate qualifying training are in place. Seven staff have completed appropriate training in care. Written policies and procedures are in place for recruitment of staff. Records show that a Criminal Records Bureau check and two written references are obtained. One member of staff has started work prior to her Criminal Records Bureau check being satisfactorily completed. Carham Hall DS0000000511.V258176.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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, 33, 35, 38 Residents 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. The home is run in the best interests of the residents. Residents’ financial interests are safeguarded. The health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: The manager who is also one of the owners of the home has been at Carham Hall for eighteen years. She is experienced in caring for older people. Mrs Baxter holds the registered manager’s award and is an enrolled nurse. Evidence was available from records that she undertakes updating training and in the last year has completed training in Dealing with Abuse, Dementia Care, Diabetes and Medication. An annual development plan is available and this shows there is regular review of the operation of the service. The development plan shows there are Carham Hall DS0000000511.V258176.R01.S.doc Version 5.0 Page 18 arrangements in place to audit systems and practice within the home. There are also identified goals for future development of the physical standards within the home. Satisfaction surveys are carried out with relatives and residents and the information gained is used to prepare the development plan. Records are maintained of any money held on behalf of residents. Written procedures are in place for staff handling residents’ money. Arrangements for the storage of money are satisfactory. From records and discussion with staff it is evident that there is regular updating training provided in safe working practices. Evidence was available of regular servicing and testing of equipment including the fire alarm system, fire equipment, central heating boiler, electrical appliances and hot water temperatures. Fire training is provided to staff at appropriate intervals. Health and safety policies and procedures are in place. Risk assessments are in place for safe working practices. An accident book is maintained in an appropriate form. Induction training is provided for all new staff and records confirm this. Carham Hall DS0000000511.V258176.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X X 3 3 3 X X X X STAFFING Standard No Score 27 3 28 3 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 Carham Hall DS0000000511.V258176.R01.S.doc Version 5.0 Page 20 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 OP16 Regulation 22 Requirement The complaints procedure must reflect the right of a complainant to refer a complaint directly to the Commission for Social Care Inspection. A Criminal Records Bureau check must be completed prior to a new member of staff starting work in the home. Timescale for action 28/02/05 1 OP29 19 (4) 28/02/06 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 Carham Hall DS0000000511.V258176.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Carham Hall DS0000000511.V258176.R01.S.doc Version 5.0 Page 22 - 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!