Inspection on 27/04/06 for Cavell House

This inspection was carried out on 27th April 2006.

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

Cavell House 09/06/10

Cavell House 16/06/08

Cavell House 18/07/07

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 Mrs S Rodgers Unannounced Inspection 27th April 2006 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.V291870.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. Cavell House DS0000065235.V291870.R01.S.doc Version 5.1 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 cavell.house@ashbourne.co.uk Ashbourne (Eton) Limited ** Post Vacant *** Care Home 52 Category(ies) of Old age, not falling within any other category registration, with number (52) of places Cavell House DS0000065235.V291870.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Up to fifty-two (52) male and or female service users in the category of Old Age, not falling within any other category may be admitted/accommodated. Only service users over 65 years of age may be admitted. Date of last inspection 19th September 2005 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 range of monthly fees are £253 to £650. Additional charges include hairdressing, newspapers and chiropody. The most recent reports are made available to residents and relatves on request and a copy is displayed in the main entrance of the home. The responsible person on behalf of the company is Mrs Marlyn MacDougall. The registered managers post is vacant. Cavell House DS0000065235.V291870.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a period of 9 hours. Preparation for this inspection focused on reviewing the most recent inspection reports, additional visit letters and general correspondence held on file. During the course of this inspection the inspectors toured the premises and spoke with residents in communal areas of the home. Two relative who was visiting the home at the time of the visit spoke with the inspector privately. Two staff members were spoken with privately within the office. Comments from all people spoken with will be included in the main body of this report. The inspectors also undertook a review of records that are required to be kept by legislation. In the previous inspection year three visits to the home were made. Two visits were statutory inspections and one follow up visit. The follow up visit of 28th November 2005 was carried out in order to monitor compliance with the regulations, 4 of the 7 requirements were met 3 remained outstanding. & Requirements have been identified at this inspection 2 of which remain outstanding. What the service does well: What has improved since the last inspection? Since the last inspection a programme of redecoration to bedrooms on the first floor and all WC’s has been implemented. Cavell House DS0000065235.V291870.R01.S.doc Version 5.1 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. Cavell House DS0000065235.V291870.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 Cavell House DS0000065235.V291870.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, 6. The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A draft copy of the Statement Of Purpose and Service User Guide was available however it has not been finalised. Pre admission assessments are undertaken on all prospective residents. Intermediate care is not provided. EVIDENCE: The draft Statement Of Purpose and Service User Guide has not been finalized and the previous providers version remains in circulation this may cause confusion to people who are thinking of moving into the home. A finalised copy should be submitted to the Commission and also circulated in the home to ensure that all residents are aware of the changes. Four care plans were reviewed. Pre admission assessment documentation kept of resident’s individual files that indicated that assessments are undertaken on all prospective residents in order that the management and prospective Cavell House DS0000065235.V291870.R01.S.doc Version 5.1 Page 9 resident can make an informed decision on whether the service can meet their needs. Cavell House DS0000065235.V291870.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, 10 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 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. Residents feel they are treated in a respectful manner. EVIDENCE: Four care plans were reviewed. The documents contained the basic information required To monitor the health personal and social need of residents. Care plans are completed for identifed areas that need staff intervention or assistance. The acting manager informed the inspector that they the a new care plainning recording document is being introduced. The inspector viewed the new documentation. The new document is in a stuctured format that will ensure consistancy. Health care needs were identified in the care plans and records of Doctors and other health prrofessionals visits are recorded. Cavell House DS0000065235.V291870.R01.S.doc Version 5.1 Page 11 All medication is stored lockable trolleys and one wall hung lockable cupboard within a locked store room. The Monitered Dosage System is used, the medication being dispensed by the pharacist. There was no stock piling of medication. The Medicine Administration Record sheets were viewed, a photograph of each resident is attached. Staff sign the record sheets at the time of administration. The home has a contract with a Clinical Waste company. A record medication disposed of was awailable. Trained staff administer all medication. 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 when they are carring out personal care staff make sure that they are appropriatly covered at all times. During the visit the inspector observed that staff went about their tasks in a sensitive manner. Cavell House DS0000065235.V291870.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): 12,13,14,15 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 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 provided is satisfactory. EVIDENCE: A programme of activities is displayed on residents notice boards placed at various points around the home. The activities are programmed from Monday to Friday. Activities offered include group exercise, news and videos, games, arts and craft, sing a long, quizzes, life history discussions, walks in the garden and surrounding area weather allowing. Residents spoken with during the visit confirmed that they can take part in the activities or pursue their own interests as they wish. A number of relatives were visiting their relatives whilst this visit was taking place. The inspector spoke with two relatives. They confirmed that they are generally satisfied with the services their parent receives. They commented that they felt that ‘staffing levels were different at weekends’. They said that they ‘have no complaints’. Cavell House DS0000065235.V291870.R01.S.doc Version 5.1 Page 13 Care plans seen evidenced that resident’s wishes as to how care is provided is taken into consideration that enables resident to retain some control over their daily lives if they are able. The home uses the services of a catering company who supply the staff to run the kitchen. The inspector sampled the mid day meal. The meal was well presented, tasty and well balanced. Menus were seen and demonstrated that the menu is now more varied that it was at previous visits. Liquidised diets are provided as required; each ingredient is liquidised and presented separately. Residents spoke with felt that the food is fairly good however, that it did vary on occasion. Staff also confirmed this. It came to the attention of the inspector that neither of the two cooks have a formal catering qualification. Taking the number of residents that can be accommodated, their varying nutritional needs and the varied opinions on the quality of meals provided it would be beneficial to provide the head cook with some formal training. The majority of resident take their meals in the dining room however, should they wish to they can have their meals in their rooms. Cavell House DS0000065235.V291870.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): 16, 18 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously and are managed within an appropriate manner. Systems are in place to promote the protection of vulnerable adults. EVIDENCE: A complaints procedure is in place. The procedure informs residents and their relative 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 was available. There have been four complaints since the last inspection. All were dealt with within the allotted timescales. Training record evidence and staff confirmed that they receive training in adult protection procedures. Both care staff spoken with formally at this inspection are aware of the indicators of abuse. Both confirmed that they would report any suspected incidents of abuse to the manager/person in charge. They said that if they felt the matter was not being addressed they would take it further themselves. They said they would take their concerns to the Operations Manager. The inspector asked why not the Responsible Individual on behalf of the company. One staff member has only met her once and the other has not met her. Cavell House DS0000065235.V291870.R01.S.doc Version 5.1 Page 15 Cavell House DS0000065235.V291870.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,24,26 The quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The property both internally and externally is in need of some general maintenance. Washing and bathing facilities are insuffient due to bathrooms being out of order or used as storeroom. All equipment such as nursing beds must be in good working order so that the personnel care needs can be met and that the health and safety of resident and staff is maintained. The standard of cleanliness within the home was of a good standard. EVIDENCE: The home is situated in a semi residential area of Shoreham. The external appearance of the property is shabby in places. The inspector has been advised that some work is going to be carried out i.e. some new windows on the west side and a door to the south side of the building. The lawn surrounding the property is overgrown and has not been cut since last year, as the mower is broken. This means that residents are unable to access the garden safely. The inspector was advised that the registered providers are going to purchase a lawnmower and that whilst they are waiting they can use Cavell House DS0000065235.V291870.R01.S.doc Version 5.1 Page 17 the services of contractor to cut the lawn. Since the last inspection 6 WC’s and one shower room have been decorated. A number of rooms on the first floor have been redecorated. The maintenance person is carrying out all of the decorating tasks, this has meant that the routine maintenance takes a little longer to be addressed to the extent that relatives have commented on the length of time it is taking to address some tasks. There are seven bath/shower rooms within the home however only 3 were in working order, 3 were out of order and one upstairs is not generally used. At the last inspection it was noted that the bathroom that is now being renovated was being used as a storeroom, now all of the items stored in that bathroom have been moved to the adjacent bathroom. The inspector was advised that the bathroom now being used as a storeroom is not used anyway as residents do not like the bath, the sides of the bath are high and static meaning that resident have to be lifted high into the air which they do not like. In one of the usable bathrooms the rim of the baths is cracked. Staff confirmed that only one shower room is used regularly. This means that some residents have to be taken all the way through the home to have a shower, this is unacceptable. All bathrooms should be useable at all times. Since the last inspection an audit of nursing beds was undertaken, the audit was not available at this visit. Four new nursing beds have been purchased, however, a second audit should be undertaken as four of the old nursing bed do not work properly i.e. they do not pump; this is a health and safety risk to both residents and staff. The faulty beds must be repaired or new beds provided. The home was clean and free from offensive odours. Systems are in place to dispose of clinical waste. Protective clothing and hand washing facilities are available. Laundry equipment appears suitable for the size and needs of the home. Cavell House DS0000065235.V291870.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. 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. Staffs do not receive formal induction training. The homes recruitment process promotes the protection of residents. EVIDENCE: Duty rota seen at this visit indicate that the 2 trained nurses and 8 carers are on duty am, 2 trained nurses 6 carers pm, 1 trained nurse, 4 carers on duty at night. Ancillary staff 1 laundry assistant, 3 cleaner weekdays and 1 laundry assistant and 2 cleaner at weekends. There was no significant drop in staff noted on the rota at weekends. Residents who were spoken with told the inspector that staff are ‘wonderful can’t speak to highly of them’ and]’staff are lovely’. They also complimented the deputy manager who is in charge of the day-to-day running of the home in the absence of a manager; they said ‘…is doing a good job of running the home she is very helpful’. At the present time 23 of staff hold a National Vocational Qualification level 2 or 3, the acting manager is aware of the requirement for 50 of staff to be trained to National Vocational level 2. The inspector was advised that 3 staff are in the process of being registered with a college to undertake National Vocational Training. Cavell House DS0000065235.V291870.R01.S.doc Version 5.1 Page 19 The records of 3 new staff were reviewed. All new staff undergo a formal recruitment process. References and Enhanced Criminal Record bureau check are undertaken. The acting manager advised the inspector that a fast track of Protection of Vulnerable Adults register is undertaken prior to new staff, staff who are commence work prior to the completed Criminal Records Bureau check being returned are supervised at all times. All new staff receive in house induction training. It is not clear whether they receive formal induction training in line with the Skills for Care induction framework. Cavell House DS0000065235.V291870.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35, 38 The quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is no registered manger in post. An annual quality and monitoring assurance system has not been completed. Residents manage their own finances. The health and safety of residents is put at risk. EVIDENCE: The manager’s post is vacant. The inspector was advised that a manager had been appointed and is due to commence work in early May 06. A requirement has not been made in respect of this standard as a manager has been appointed and an application to register the individual has been requested. The deputy manger has been acting manager whilst the post has been vacant. Although the home carries out audits of the physical environment there is no evidence to demonstrate that the views of residents, relatives and other Cavell House DS0000065235.V291870.R01.S.doc Version 5.1 Page 21 stakeholders are sought in order to monitor the service being provided, apart form the one specific questionnaire to gain the views of residents with regard meals provided. A full quality monitoring and quality assurance system should be undertaken and outcome from the findings should be collated in a report along with a development plan to address any improvements that need to be implemented. Resident or their family maintain personal finances. Money is held in safekeeping. All resident money is kept separate. Records of individual transactions are maintained. Staff receive training in safe working practices however there has been a recent change in who provides fire training. Fire training was last given on the 23rd March 2006 23 of the 43 staff attended, only one of whom was a member of the night staff. The acting manager told the inspector that due to changes, fire training is going to be given 6 monthly and only one day will be allocated. This will mean that some staff will not receive training for over a year possibly longer if they cannot attend on the one day allocated. Staff spoken with told the inspector that when the acting manger organised the training more than one date was offered allowing for staff who were on night duty or who have appointments could make one of the session. Current guidelines from the local Fire Brigade state that day staff should receive training at 6 monthly intervals and night staff at 3 monthly intervals. The changes have raised concerns with staff as there has also been a change in the procedure to follow should the alarms go off. Now a senior member of staff must stay in each zone to reassure resident, this is different to what they have been advised to do before. One staff member said ‘as some staff did not attend there are two procedures being operated which is causing confusion. Annual servicing is carried out on boilers, electrical systems and regulation of water temperatures. However it was noted that on the last check of the fixed electrical wiring carried out on the 12 July 2005, there are 13 outstanding issues, 8 require urgent attention 5 require improvement. The cold-water storage system is tested annually. On the last test carried out in September 2005 it was indicated that a new tank or lagging to old tank was required to as cold water should be store at 20 degrees and this was 26.7 it was also recommended that the taps should be descaled, to date work has not been undertaken on either the electrical or the cold water system, this could put the health and safety of residents and staff at risk and should be addressed as a matter of urgency. Cavell House DS0000065235.V291870.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 1 X 3 X X 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 X 18 3 2 X 1 X X 2 X 3 STAFFING Standard No Score 27 3 28 1 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 X X 2 Cavell House DS0000065235.V291870.R01.S.doc Version 5.1 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 OP1 Regulation 4&5 Requirement An up to date Statement of Purpose and Service User Guide must be provided and a copy submitted to the local office of the Commission. There must be sufficient bathing/showering facilities. Suitable equipment must be provided to ensure that they health and safety of residents and staff are maintained. The registered provider shall ensure that persons who work in the home receive training appropriate to the work they perform. The registered person shall establish and maintain a system for reviewing at appropriate intervals; and improving the quality of care provided at the care home. The premises must be kept in good state of repair both externally and internally. Staff must receive fire safety instruction at the recommended intervals of 6 monthly day staff and 3 monthly night staff. DS0000065235.V291870.R01.S.doc Timescale for action 16/06/06 2 3 OP21 OP24 23 23 16/06/06 16/06/06 4 OP30OP28 18 (1) (c) 16/06/06 5 OP33 24 16/06/06 6 7 OP38OP19 OP38 23 (2) (b) 23 (4) (d) 16/06/06 16/06/06 Cavell House Version 5.1 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. Refer to Standard Good Practice Recommendations Cavell House DS0000065235.V291870.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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. 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