Inspection on 10/08/07 for Caversham Residential Home

This inspection was carried out on 10th August 2007.

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

Caversham Residential Home 06/08/09

Caversham Residential Home 07/08/08

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Caversham Residential Home Astridge Road Witcombe Gloucester Glos GL3 4SY Lead Inspector Mr Adam Parker Unannounced Inspection 10th August 2007 09:40 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 Caversham Residential Home DS0000069091.V348285.R01.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. Caversham Residential Home DS0000069091.V348285.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Caversham Residential Home Address Astridge Road Witcombe Gloucester Glos GL3 4SY 01452 862554 01452 545295 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) Nazdak Limited Tracy Sally Miles Care Home 8 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (8) of places Caversham Residential Home DS0000069091.V348285.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home providing personal care only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following Categories: Old age, not falling within any other category (Code OP) Dementia over 65 years (Code DE(E)) - maximum number of places 1 The maximum number of service users who can be accommodated is 8. The registered person may continue to accommodate 1 person identified to CSCI whose primary care needs on admission were within the category dementia (DE). This condition will lapse when this person leaves the home. 10/05/07 2. 3. Date of last inspection Brief Description of the Service: Caversham is a small care home set in a residential area of Witcombe on the outskirts of Gloucester. The home is close to a local shop. The single bedrooms with ensuite toilets are located on the ground and first floors, with a bathing facility available on the first floor. There is a sitting room at the front of the house with a dining room and kitchen combined at the rear. The residents also have the benefit of a garden at the rear of the house. Current fees are £375.00 to £450.00. Hairdressing, chiropody and newspapers are charged extra. The home makes information about the service, including CSCI reports available to service users and their representatives through a service user guide and statement of purpose available in the home. Caversham Residential Home DS0000069091.V348285.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was carried out by one inspector on one day in August 2007. Four residents were spoken to during the inspection visit to gain their views on the service provided. The registered manager of the home was present for the inspection visit which consisted of a tour of the premises and examination of residents’ care files. In addition staff training was looked at as well as documents relating to the management and safe running of the home. A sample of residents were selected for inspection against a number of outcome areas as a ‘case tracking’ exercise. Comment cards were received from residents, their relatives and staff working in the home. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This is the first key inspection of the home since it was purchased by Nazdak Ltd. What the service does well: What has improved since the last inspection? Caversham Residential Home DS0000069091.V348285.R01.S.doc Version 5.2 Page 6 The last inspection was a random inspection to look at concerns raised about the provision of meals at the home. This situation has improved. In addition there has been some re-decoration in parts of the home. 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. Caversham Residential Home DS0000069091.V348285.R01.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 Caversham Residential Home DS0000069091.V348285.R01.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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Despite no admissions to the home since the current registration the home maintains a strong stance in declining any inappropriate referrals in the interests of the prospective residents and those already in the home. EVIDENCE: Since the start of the current registration the home has not admitted any new residents. A comprehensive assessment document is available for any prospective admissions. Details of any interest expressed in the home on behalf of prospective residents is recorded in an enquiries book. The home had recently received a number of referrals from the local authority which were deemed inappropriate for admission to the home in terms of their needs and the impact on other residents already in the home. The home is working on revising the statement of purpose and service users’ guide. Caversham Residential Home DS0000069091.V348285.R01.S.doc Version 5.2 Page 9 The home does not provide intermediate care and so standard 6 does not apply. Caversham Residential Home DS0000069091.V348285.R01.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): 7,8,9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home works well to meet residents’ health and personal care needs whilst upholding their privacy and dignity. EVIDENCE: Care Plans had been drawn up to cater for a range of residents needs. These were individualised giving clear instructions for staff to follow to meet residents’ needs and had been reviewed on a monthly basis. In addition there was evidence of the evaluation of care plans over time. During the inspection visit staff were observed to deal promptly with a request for help from one resident. One resident stated on a survey that they “Could not be more well looked after.” General risk assessments had been completed for all residents including risk assessments for falls. One resident had been made aware of any potential dangers of leaving the home alone and this had been fully documented. Caversham Residential Home DS0000069091.V348285.R01.S.doc Version 5.2 Page 11 Weights were being monitored and recorded on a monthly basis. Where there were concerns about fluid intake this was being recorded for one resident. Where residents had been receiving input from health care professionals such as community nurses this had been recorded. During the inspection visit two community nurses visited the home to attend to one resident’s health care needs. The arrangements for medication storage, administration and recording were checked. Medication was stored securely in a cupboard. However there were no records of storage temperatures for the cupboard and these should be monitored to check if medication is being stored at the correct temperature. Regular checks were being recorded on the refrigerator where some medication is stored and this showed that temperatures were within the correct range. The medication administration records were in good order with no gaps in recording seen. Handwritten entries had been signed and dated by the staff member making the entry. This practice should be extended to all handwritten comments or marks on the administration sheets such as where medication has been stopped with a check by another member of staff. All staff who administer medication have undergone training. No residents in the home were administering their own medication. Staff were observed treating service users with respect and residents confirmed that their privacy was respected by staff who knocked on doors before entering. Caversham Residential Home DS0000069091.V348285.R01.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): 12,13,14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to benefit from exercising choice and having some control over their lives in a number of areas including recent improvements in the meals provided. EVIDENCE: Generally residents pursue their own interests and activities usually in conjunction with relatives and friends. One relative commented that “Caversham allows and adopts a policy whereby all residents are able to organise their day to day lives as they so wish.” One resident is involved in knitting and sewing projects for charities. Occasionally games of bingo are organised and at Christmas some seasonal activities take place out of the home. In the past visits were made from a local church although this was stopped at the request of the residents. The home has a policy of open visiting. One relative of a resident stated that “Visitors always have a friendly welcome anytime”. It was reported that there is a lack of community facilities in the local area for older people although this has not always been the case. Caversham Residential Home DS0000069091.V348285.R01.S.doc Version 5.2 Page 13 Some residents in the home manage their own financial affairs and information is available on advocacy services should these be needed. Residents can bring personal possessions including furniture into the home. Meals are chosen by the residents on a weekly basis and a menu is produced. Since the last inspection there has been an improvement in the supply of food into the home to make up the chosen menu for the week. Residents spoken to confirmed that they were enjoying the variety of meals provided. In relation to the meals provided one resident stated on a survey form “I can always have second choice if needed.” A record is kept of residents’ food likes and dislikes. Caversham Residential Home DS0000069091.V348285.R01.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): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although residents are supplied with the complaints procedure and staff have received training in adult protection residents could be further protected by a policy and procedure on preventing and dealing with abuse. EVIDENCE: The home has a complaints procedure which is given to all residents with a record of this kept on their files. It was reported that a copy of the complaints procedure was under preparation for display in the home. There had been no complaints received to give an example of how these might be dealt with. Although the home had a ‘whistle blowing’ policy to guide staff in voicing serious concerns there was no specific policy for protecting residents from abuse or dealing with reports of abuse to residents. However the registered manager and two other staff had received training at a local college in adult protection. Caversham Residential Home DS0000069091.V348285.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents would benefit from improvements to how maintenance is dealt with at the home including the issue of the hot water supply to some bedrooms. EVIDENCE: A tour of the premises was conducted and the home was noted to be generally clean. Two maintenance issues were noted these being a loose handrail in room 7 (although this room was unoccupied) which could give way if too much weight was put on it and the light fitting in the lounge was hanging by the electrical wires and not secured to the ceiling. Residents have access to the rear garden either directly through bedrooms on the ground floor at the rear of the home or through the side door where a gentle slope and hand rail has been provided. A new stair lift has recently been installed in the home. Caversham Residential Home DS0000069091.V348285.R01.S.doc Version 5.2 Page 16 Residents rooms contained personal items and a number had undergone redecoration with further work planned. At the previous inspection there was a problem with the hot water supply in a number of rooms on the first floor. Although it was reported that this had been remedied following the previous inspection a further problem had occurred which meant that in rooms 7 and 8 the hot water tap took several minutes to produce warm water and room 5 did not produce warm water at all which was a problem for the resident in that room when he needed to have a shave. A number of rooms in the home have their radiators covered to protect residents. It was explained that this is dealt with on an individual risk assessment basis and relevant documentation was seen. The laundry is situated in the rear garden detached from the home. Woodwork on the exterior of the building was in need of some attention and inside the floor surface did not extend to cover all areas and so did not form a readily cleanable surface nor did the walls which had areas of paint missing in some places. The laundry was also used to store food in two freezers as well as a number of other items. Caversham Residential Home DS0000069091.V348285.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. In order that residents are always supported in times of staff shortages there needs to be more staff resources available than relying on the good will of existing staff. EVIDENCE: Staffing in the home is arranged so that the home is always covered by one member of care staff with 2 working at the home during the times of 8:00 to 10:00 in the morning and 12:00 to 14:00 in the afternoon. A cleaner works on weekdays. Staff sickness had recently been a problem at the home and covering this had put a strain on the registered manager and other staff who had to work over their allocated shifts. The home has three members of staff who have achieved an NVQ although there are four care staff who have not. In terms of the residents being cared for by a trained staff group, further staff should undertake an NVQ. There has been no recruitment at the home under the current registration although advertisements have been placed for new staff, no suitable candidates have been found. The registered manager has been given information by the Commission about the requirements for obtaining information and documentation for staff recruitment. Caversham Residential Home DS0000069091.V348285.R01.S.doc Version 5.2 Page 18 As there has been no recruitment of new staff there has also been no induction training undertaken. However the general training needs of staff should be assessed and a plan put in place to meet these. Caversham Residential Home DS0000069091.V348285.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. More formalised management and maintenance systems need to be in place in order that the home is always run in the interests of the residents. EVIDENCE: The manager has been registered since April 2007. She has completed an NVQ level 4 in care as well as the registered managers award. The registered manager does not have a job description as a formal reference point for her role in the home. In addition there is no specific time allocated to fulfil the management role and this has to be carried out between care duties or in the managers own time. A more formal arrangement should be considered. Caversham Residential Home DS0000069091.V348285.R01.S.doc Version 5.2 Page 20 A quality assurance survey has been completed in the home under the previous registration and no findings were made regarding improvement. The registered manager felt that the exercise could be improved upon. The home provides secure facilities for residents money and looks after money for two residents although there are some that look after their own financial arrangements. Appropriate records were kept for any residents’ money held. Staff have received training in moving and handling, first aid and basic food hygiene. However no staff in the home have undertaken training in infection control or fire safety and this situation must be addressed. It was reported that central heating boilers had been serviced although no supporting documentation was available in the home. Electrical systems in the home had been serviced although it had been over a year since the last checks on the safety of portable electrical appliances had been made. The home has a stair lift and a bath lift although it was not evident during the inspection that there were arrangements in place for servicing and maintaining this equipment. To ensure residents safety the home has a number of security arrangements in place. Caversham Residential Home DS0000069091.V348285.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 2 2 X X X X X 1 2 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 1 Caversham Residential Home DS0000069091.V348285.R01.S.doc Version 5.2 Page 22 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 OP18 Regulation 13 (6) Requirement In order to guide staff in dealing with any incident of reported abuse there must be a policy available in the home. Maintenance issues identified in this report both inside and outside of the home must be attended to so that residents can live in a safe and well maintained environment. The registered person must ensure that there is hot running water at a safe temperature available in all residents’ rooms where washbasins are fitted. This requirement has been repeated from the last inspection. To ensure residents safety and comfort, regular checks must be made with records kept on the temperatures from hot water outlets. The laundry must be provided with impermeable and cleanable floor and wall surfaces in order to maintain a hygienic environment for handling residents’ laundry. DS0000069091.V348285.R01.S.doc Timescale for action 31/10/07 2 OP19 23 (2) (b) 31/10/07 3 OP25 23 (2) (j) 31/10/07 4 OP25 13 (4) (a) & (c) 31/10/07 5 OP26 13 (3) 31/12/07 Caversham Residential Home Version 5.2 Page 23 6 OP30 18 (1) (c) (i) 7 OP31 8 OP33 17 (2) Schedule 4 Paragraph 6 (e) 26 9 OP38 23 (4A) (b) 10 OP38 13 (3) 11 OP38 13 (3) 12 OP38 23 (2) (c) Staff training needs must be identified and recorded in order to plan for providing training to enable residents to be cared for by a competent staff group. The registered manager must have a job description that demonstrates how the home is managed in the interests of the residents. Unannounced visits must be carried out and reports produced in accordance with regulation 26 with copies supplied to the registered manager and to the Commission. Staff must undertake appropriate fire safety training in line with current fire safety regulations in order to ensure the safety of residents. Staff must receive training in infection control procedures in order to promote the wellbeing and safety of residents. The home must make an assessment of the risk to residents in the home from Legionella. In order to ensure the safety of residents the home must ensure that there are arrangements for servicing and maintaining the stair lift and the bath lift. 30/11/07 31/10/07 31/10/07 31/12/07 31/12/07 30/11/07 31/12/07 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 The temperature in the medication storage cupboard should be monitored and recorded to check that residents’ DS0000069091.V348285.R01.S.doc Version 5.2 Page 24 Caversham Residential Home 2 OP9 3 4 5 6 7 OP18 OP27 OP28 OP31 OP38 medication is being kept at the correct temperature. The practice of signing, dating and checking handwritten directions on the medication administration charts should also be used when any medication is stopped and the chart is marked accordingly. All care staff should receive training in protecting residents from abuse. Staff resources should be available to provide cover for staff sickness so that existing staff are not working excessive hours. More care staff should undertake NVQ training. The registered manager should be allocated set hours in which to carry out management duties. Portable electrical appliance testing should be repeated. Caversham Residential Home DS0000069091.V348285.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Caversham Residential Home DS0000069091.V348285.R01.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. 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