Inspection on 18/07/07 for Cavell House

This inspection was carried out on 18th July 2007.

CSCI 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 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

Cavell House 09/06/10

Cavell House 16/06/08

Cavell House 27/04/06

Cavell House 19/09/05

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Cavell House Middle Road Shoreham-by-sea West Sussex BN43 6GS Lead Inspector Ms B Tye Key Unannounced Inspection 18th July 2007 09:30 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 Cavell House DS0000065235.V341204.R02.S.doc Version 5.2 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. Cavell House DS0000065235.V341204.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cavell House Address Middle Road Shoreham-by-sea West Sussex BN43 6GS 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) 01273 440708 01273441483 cavellhouse@schealthcare.co.uk www.southerncrosshealthcare.co.uk Ashbourne (Eton) Ltd. Trading as a subsidiary of The Southern Cross Health Care Group. Mrs Nicola Wheatley-Crowe Care Home 52 Category(ies) of Old age, not falling within any other category registration, with number (52) of places Cavell House DS0000065235.V341204.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th April 2006 Brief Description of the Service: Cavell House is a care home with nursing situated in the town of Shoreham by Sea. The establishment has been extended and adapted to provide accommodation for up to fifty-two service users in the category of older persons, over the age of 65years (OP). The establishment consists of the original building, which was a local authority care home and a new annex. The majority of the home is on one level, however one section of the older building has two floors, accessed by stairs and a passenger lift. The service provider is Ashbourne (Eton) Ltd. The most recent reports are made available to residents and relatives on request and a copy is displayed in the main entrance of the home. The responsible person on behalf of the company is Mrs Gaynor Ashton. The registered manager is Mrs Nikki Wheatly-Crowe. The fees for the home are currently £325 for a local authority funded residential placement. Between £468-£567 for a local authority funded nursing placement. Fees for private placements vary dependant on need between £568-£737. Additional charges include hairdressing, newspapers and chiropody. Cavell House DS0000065235.V341204.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the inspection all relevant information and correspondence relating to the home was examined. This included staff rotas, training records and a quality assurance assessment completed by the manager, which detailed all changes to the service, since the last inspection. The inspection was unannounced and started at 9.30am. It took place over six hours. The inspector spoke separately to six residents and interviewed four staff on duty. The manager showed the inspector around the care home and was on hand throughout the inspection to answer any questions. The inspector observed lunch being served and staff interaction with residents. Four care plans were case tracked and the homes records were examined. These included the new statement of purpose, menus, rotas, staff files, fire records, meeting minutes, incident and accident reports and information relating to health and safety. This is the first inspection of 2006/2007. This is called a key inspection and will determine the frequency of visits/inspections hereafter. What the service does well: The home has a competent staff team who understand the needs of the people living there. The residents who were spoken to said they liked living in the home and that staff ‘are very caring and considerate’. Staff were observed interacting with residents in a respectful way. Several of the residents were happy to discuss the care provided at the home and gave positive feedback. Residents are encouraged to pursue activities of interest within the home. The home provides regular resident and relatives meetings, which enables those with an interest to have a say about the way in which the home is run. Cavell House DS0000065235.V341204.R02.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Cavell House DS0000065235.V341204.R02.S.doc Version 5.2 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 Cavell House DS0000065235.V341204.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. A finalised copy of the Statement Of Purpose and Service User Guide is now available. Pre- admission assessments are undertaken on all prospective residents prior to admission. A requirement was made to include a variation to the homes registration. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement Of Purpose and Service User Guide has now been finalized and provides up to date information. A copy of this is provided to prospective residents to enable them to make an informed decision about what is on offer at the home and whether it suits their needs. During the visit four residents care plans were examined. A pre-admission assessment had been completed on all files seen. A copy of the pre admission assessment is included in the service user plan. This ensures that the management and prospective resident can make an informed decision on whether the service can meet their needs. Cavell House DS0000065235.V341204.R02.S.doc Version 5.2 Page 9 It was noted that a long standing resident at the home is under the age of 65. The manager may need to apply for a variation to amend and update the current registration certificate. The manager will check with CSCI registration team to confirm appropriate action. Cavell House does not provide intermediate care. Cavell House DS0000065235.V341204.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Recording systems are in place to promote the health and social care need of residents. The homes policies and procedures for the management of medication promote safe practices, however some gaps in records highlight the staff need for medication refresher training. Residents feel they are treated in a respectful manner. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the visit four care plans were case tracked. Each plan contained up to date information relevant to the health, personal and social need of residents. A new care planning document has been introduced since the last inspection. This provides a stuctured format which promotes staff consistancy in meeting residents identified health needs. Health care records include detailed health monitoring charts and risk assessments. These are reviewed on a monthly basis. Records of visits by doctors and other health professionals are recorded on files. Cavell House DS0000065235.V341204.R02.S.doc Version 5.2 Page 11 The care staff now monitor correct bed inflation twice nightly and complete a record sheet of their findings. This process is monitored by the homes manager. Each resident is assigned a keyworker from the care staff. Each of these is supported by a trained nurse. Keyworkers are responsible for updating the careplans weeekly and undertaking personal care for the specific needs of their assigned residents. Care files refelcted that reviews are undertaken on a 3-6 monthly basis, dependant on need. All reviews include input from residents and their families and/or representatives. Involved parties sign careplans to demonstrate their involvement. All medication is stored on lockable trolleys and one locked cupboard within a secure store room. The Monitered Dosage System is used and all medication is delivered and audited by the local pharmacist. The home has a contract with a Clinical Waste company. A record of all disposed medication is available. Trained staff administer medication and senior carers administer medication to residential service users. The Medicine Administration Record sheets were viewed for four residents and some gaps were found in the recording of their daily medication. The manager stated she intends to provide refresher training for staff. This will ensure their practice is in line with homes medication policies and procedures. A recommendation was made in respect of this. Residents spoken with confirmed that they felt that their dignity and privacy is maintained. They confirmed that staff knock on closed doors prior to entering and that they are respectful, when they are carrying out personal care. During the visit the inspector observed that staff conducted their tasks in a sensitive and respectful manner. Cavell House DS0000065235.V341204.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. Residents are provided with a planned programme of activities. Residents are encouraged to maintain contact with family and friends. Residents are able to access the community as they wish. The standard of meals currently provided does not meet the dietary requirements and preferences of all the residents in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A programme of activities is displayed on resident notice boards throughout the home. Activities offered include group exercise, news and video, games, arts and craft, music, quizzes, life history discussions, walks in the garden and visits out to the local community. Residents spoken with during the visit confirmed that they could take part in the activities or pursue their own interests as they wish. The home provides a monthly newsletter and photographs of recent trips were displayed on notice boards. Care plans seen evidenced that resident’s preferences are taken into consideration. This enables resident to retain some control and choice within their daily lives. Cavell House DS0000065235.V341204.R02.S.doc Version 5.2 Page 13 Residents and relatives meetings are held on a monthly basis. Minutes of each meeting are kept on file and action points are delegated accordingly. A copy of the minutes is sent out to each relative to encourage feedback and participation. This promotes involvement of residents and their families about how the home is run. One of the points raised at the last meeting was the ‘adequate’ standard of food served within the home. Since this meeting the menus have been changed to include more preferences of residents. Updated menus were seen and demonstrated that the new menu is now more varied. Although at the time of the visit this had not been implemented and old menus were still in use. Liquidised diets are provided as required; each ingredient is liquidised and presented separately. Some residents have their meals in the dining room however, should they wish to they can have their meals in their rooms. Whilst speaking to the residents and case tracking it was noted that although a vegetarian meal is offered, there is no choice available to residents who did not eat fish or meat. Discussion with the manager resulted in her agreement to provide a separate vegetarian menu for the minority of residents. This would offer a main meal and an alternative on a daily basis. A requirement was made in respect of this. Cavell House DS0000065235.V341204.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. Complaints are taken seriously although not all have been resolved within appropriate timescales. Staff training and recruitment systems are in place to promote the protection of vulnerable adults. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A complaints procedure is in place. The procedure informs residents and their relatives who they should address their concerns to in the first instance and timescales in which a response will be made. The procedure contains the address and telephone number of the Local office of the Commission for Social Care Inspection so that in the event that they are not satisfied with the outcome of the homes investigation they can contact Commission directly. A complaints folder is available. There have been six complaints in the last 12 months. 83 of them were dealt with within the allotted timescales. Four of these complaints were upheld. There has been a recent referral to the Adult Protection team regarding a resident, that is being investigated by the local authority at present. The Commission will be notified of the outcome once the investigation is complete. All staff are issued a handbook with the complaints and whistle blowing policy. A stringent recruitment process ensures staff have an enhanced CRB, two references and a PoVA check prior to commencing employment. Cavell House DS0000065235.V341204.R02.S.doc Version 5.2 Page 15 Training record evidence and staff, confirmed that they receive training in adult protection procedures. Care staff spoken with formally at this inspection were aware of the indicators of abuse. Cavell House DS0000065235.V341204.R02.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. Some areas of improvement have been made since the last inspection. The property both internally and externally is still in need of general maintenance. Washing and bathing facilities are insufficient, due to bathrooms being out of order or used as storeroom. The standard of cleanliness within the home is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection some improvements have been made to the premises. One bathroom has been refurbished and converted into a shower room. The home has purchased ten new profiling beds. All fire doors have been replaced but at the time of the visit had not been painted. The sluice has been repaired and is in good working order. The potholes in the front drive and parking area have been repaired and potted plants have been placed around the entrance to make it more attractive. Cavell House DS0000065235.V341204.R02.S.doc Version 5.2 Page 17 The manager has implemented air pressure bed checks and a hoist-cleaning rota. This limits potential risk to residents. Resident’s rooms are clean, tidy and personalised. Communal areas are clean and homely. A full compliment of domestic staff ensures the home is clean and tidy throughout. General maintenance in the home is kept up to date and regular safety checks promote the health and welfare of residents and staff. The manager has a health and safety system in place to monitor fire checks, water temperatures, risk assessments and maintenance. These records are up to date and in good order. The dining area is large, but sparse and not homely. There are not enough tables and chairs to accommodate all the residents. However a lot of residents chose to eat in their rooms, so at present this does not pose a problem. Plans for refurbishment of the dining room have been outlined in the homes annual redevelopment plan for 2007/08. There are still areas of maintenance required around the home. A downstairs bathroom had a broken bath chair, which had failed a safety inspection. The side of the bath panel was torn and jagged, posing a possible risk of injury. One communal toilet was out of order and not in use. Bathroom 4 is due for refurbishment and not in use. A grant has been secured for refurbishment work to commence on this, however there is no start date for works at present. Due to the disrepair of the bathrooms the home has limited bathroom/shower facilities for the number of residents. A requirement is on going for this work to be undertaken. The home has now secured a grant to refurbish the large courtyard at the home. Rotten ramps, which give residents access to the area, will be replaced and the paving stones re-pointed. At present the area is in poor condition and poses some risk to residents with limited mobility. A requirement has been made to ensure all aspects of maintenance are under taken in line with the proposed re-development plan. Cavell House DS0000065235.V341204.R02.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. Staff are on duty in sufficient numbers to meet the needs of the current residents. The ratio of 50 of care staff holding a National Vocational Qualification is not met. The homes recruitment process promotes the protection of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Duty rotas seen at the visit indicate that there are sufficient trained staff on each shift to meet the residents needs. During interviews with staff and manager it was noted that the home currently cares for a high number of residents with complex needs. As a result the residents would benefit from additional staffing at peak times during the day to avoid delays in staff responses. At the present time less than 50 of staff hold a National Vocational Qualification level 2 or 3. The manager is aware of the requirement for 50 of staff to be trained to National Vocational level 2. A training matrix is now in place to promote this and ensures all staff will complete mandatory training within the home. The records of four staff were reviewed. All staff have undergone a formal recruitment process. References and Enhanced Criminal Record bureau checks are on each staff file. Cavell House DS0000065235.V341204.R02.S.doc Version 5.2 Page 19 All new staff will now receive in house induction training over a six-week period. This conforms to national training targets and ensures staff are clear in respect of their roles and responsibilities. Staff spoken to and observed during the visit demonstrated their commitment to their roles and showed a clear understanding of how to meet residents needs within the home. Cavell House DS0000065235.V341204.R02.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. A registered manager is now in post. An annual quality and monitoring assurance system has been implemented. Residents manage their own finances. The continued requirements mean the health and safety of residents is put at risk in some areas. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home now has a registered manager in post. Mrs Wheatly-Crowe is a trained nurse with management experience in residential care settings. She is planning to commence the Registered Managers Award before the close of 2007. Staff spoken to stated they received regular supervision and support from the manager. Some records were evidenced on staff files. Staff and residents Cavell House DS0000065235.V341204.R02.S.doc Version 5.2 Page 21 confirmed the manager was ‘approachable’ and they would speak to her if any issues or problems arose. The inspector examined record keeping for all aspects of health and safety, risk assessments and policies. These are in good order and up to date. Accidents and incidents within the home are audited monthly by the manager and on a quarterly basis, by the operations manager. This practice ensures the occupants of the home are safeguarded and protected. The home has ten appointed first aiders and one staff member is appointed as Fire Marshall. The manager has recently completed a supervision course in health and safety. This will promote good practice within the home in respect of the health and welfare of residents. The home holds regular relatives and residents meetings, alongside regular audits of the environment. These meetings incorporate the views of residents, relatives and other stakeholders. A full quality assurance system has been implemented and the findings have been collated in a published report, available to all interested parties. Resident or their family maintain personal finances. Money is held in safekeeping and records of individual transactions are maintained. Following feedback at the close of the visit. Mrs Wheatly-Crowe stated she is keen to address on going requirements/improvements and bring the home up to an overall good standard. Cavell House DS0000065235.V341204.R02.S.doc Version 5.2 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 3 3 X X 3 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 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 2 2 X X 3 2 3 STAFFING Standard No Score 27 2 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Cavell House DS0000065235.V341204.R02.S.doc Version 5.2 Page 23 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 OP21 Regulation 23 Requirement There must be sufficient bathing/showering facilities in good working order to accommodate the number of residents in the home. The premises must be kept in good state of repair both externally and internally. CSCI to be sent a development plan for the home by Religious or cultural dietary needs must be catered for. The registered person must ensures a menu which offers a choice of meals (that are changed regularly) Staff training for the home must result in no less than 50 of staff undertaking the NVQ Level 2 in line with the National Training Organisation Timescale for action 31/12/07 2. OP19 23 (2) (b) 30/09/07 3. OP15 12 30/09/07 4. OP30 18 (c) 31/12/07 Cavell House DS0000065235.V341204.R02.S.doc Version 5.2 Page 24 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 OP9 Good Practice Recommendations For staff to undertake a refresher course in dispensing medication in line with the homes policies and procedures Cavell House DS0000065235.V341204.R02.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Cavell House DS0000065235.V341204.R02.S.doc Version 5.2 Page 26 - 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!