Inspection on 10/08/05 for Cestria House

This inspection was carried out on 10th August 2005.

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

Other inspections for this house

Cestria House 17/12/08

Cestria House 10/01/07

Cestria House 31/01/06

Cestria House 11/10/04

Cestria House 17/05/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Cestria House 45 Sanderson Road Jesmond Newcastle upon Tyne NE2 2DR Lead Inspector Janine Smith Announced 10 August 2005: 9:30 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 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. Cestria House B53-B03 S435Cestria V233323 100805 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Cestria House Address 45 Sanderson Road Jesmond Newcastle upon Tyne NE2 2DR 0191 281 8714 0191 281 0377 NA Bawi Homes Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Kathleen Burns CRH 24 Category(ies) of DE(E) Dementia - Over 65 - 3 registration, with number OP Old Age - 21 of places Cestria House B53-B03 S435Cestria V233323 100805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: No additional conditions are in place. Date of last inspection 11/10/04 Brief Description of the Service: Cestria House provides a home for up to 24 older people who require residential care. Three of the residents may also require care due to a dementia type condition. Nursing care is not provided. The home is a three storey converted house. There is a passenger lift to each main floor but there are also mezzanine floors which have a small number of bedrooms which can only be reached by small flights of stairs. Residents occupying these bedrooms would therefore need to be mobile. All of the bedrooms are single. The home has several bathrooms with assisted baths or showers. Four of the bedrooms also have en-suite toilets. The home has a small town garden to the front of the property with seating and a large courtyard to the rear. Cestria House is located in a residential area of Jesmond, close to the main shopping area on Acorn Road, and other local amenities including public transport links. Cestria House B53-B03 S435Cestria V233323 100805 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was given prior notice of this inspection, which took place over ten hours. A partial tour of the premises took place and a sample of care records were inspected as well as other records. The Manager, four of the staff and eight residents were spoken to. Prior to the inspection comment cards were made available in the home for residents and relatives to complete and forward to the Commission. Ten comment cards were received from residents and eight from relatives. Comment cards were also forwarded to GP practices visiting the home and five replies were received. All of the responses received indicated that the home were providing good care to the people living here. This was a very positive inspection and there was good evidence that the home is well run and that residents were satisfied and happy living here. What the service does well: The home is well managed and has a caring and enthusiastic group of staff who enjoy their work. Both the management team and a substantial number of the staff have worked together in the home for a number of years which ensures good consistency of care and stability. From what was seen in the home, together with the comments of residents and staff, there was plenty of evidence to show that the managers and staff provide good care and support and that this is done with the wishes and choices of the residents uppermost at all times. All of those residents spoken to, who could comment, said that they were treated well by the staff and well cared for. Seven comment cards were received from residents, and all said they were well treated and cared for. Eleven comment cards were received from relatives and all indicated that they were satisfied with the overall care provided and that they were kept informed of their relative’s welfare. One also added, ‘My friend has been in care with Cestria for just a short time, however I am more than satisfied with the care and kind friendly manner she has been shown.’ Other comments were received as follows:- Cestria House B53-B03 S435Cestria V233323 100805 Stage 4.doc Version 1.30 Page 6 ‘My relative has been in Cestria House approx 10 years now and is well looked after and loved like the staff were his family.’ ‘My relative has now been in Kath Burns care for 7 years or more. One thing I find very good at the home is the fact that most of the staff have been together a long time and this brings greater stability and care for my relative and other residents. Also it helps to build up relationships with relatives and staff.’ ‘Care is very good, stimulating and individualised. Manageress sets the tone and sets an excellent example.’ Residents’ health care needs appear to be well met. Local doctors visiting the home were also consulted for their views and these were all good, with one commenting, ‘The senior care staff at Cestria are amongst the best I have ever seen.’ The menu offers choices at each mealtime but in addition, resident’s individual wishes were respected. What has improved since the last inspection? What they could do better: Statutory requirements made at the last inspection have not been carried out. These concerned information/documents provided to the Commission and the public; visits that have to be made by the owner of the home and repairs to the conservatory floor. These requirements must be acted upon within the revised timescales achieved or the Commission may be obliged to consider taking enforcement action. Some other requirements were made as a result of matters arising from this inspection. The manager ensures that they have obtained information about a person’s needs to ensure that these can be met before they are admitted to the home. Some of this significant information could be recorded in more detail to ensure staff have a thorough understanding of the residents’ needs. The day to day care of residents was very good, but residents should be given help to keep their spectacles clean, where this is needed to ensure that their vision is not impaired. Cestria House B53-B03 S435Cestria V233323 100805 Stage 4.doc Version 1.30 Page 7 A new CRB disclosure, including a satisfactory check of the Protection of Vulnerable Adults List, must be obtained before new staff are employed. This helps ensure that unsuitable people are not employed. Some repairs and maintenance need to be carried out, for example, the lift buttons, the lifting equipment in a bath, a bath panel, and vanity unit. In general, the décor of the home is showing signs of wear and tear and would benefit from refurbishment. The home need to be more vigilant to ensure that any health and safety matters, for instance, because items need repair, are identified and acted upon quickly to avoid any injury occurring. The emergency lights also need to be checked regularly as well as the electrical wiring system periodically checked in the interests of safety. The home also need to ensure that adequate lighting is available in corridors and bathrooms that have little or no natural light, for instance, making sure lights are working properly. Risk assessments are carried out regarding the use of bed side rails but need to be more thorough to ensure that any risk of harm occurring to a resident is eliminated as far as possible. 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. Cestria House B53-B03 S435Cestria V233323 100805 Stage 4.doc Version 1.30 Page 8 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 Standards Statutory Requirements Identified During the Inspection Cestria House B53-B03 S435Cestria V233323 100805 Stage 4.doc Version 1.30 Page 9 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 standard(s) 2, 3 and 6. The process followed in the home ensures that potential residents are provided with details of the services the home provides which helps them to make an informed decision about coming to stay in the home. The home carries out an assessment prior to agreeing to admit people into the home to ensure that the home can meet their needs but some of the information could be recorded in more detail to ensure a clear understanding of the person’s needs. Contracts were in place, which ensure that the resident has been given clear information about the Home’s charges and other relevant information. EVIDENCE: The records of a recently admitted resident were examined. The home had obtained a copy of the Care Manager’s Assessment and had also carried out their own assessment. This covered most of the significant areas, but would have benefited from more detailed information, for instance, why and when the resident needs to wear glasses, the type of dementia and how it affects them. Cestria House B53-B03 S435Cestria V233323 100805 Stage 4.doc Version 1.30 Page 10 The records showed that residents and/or their representatives were given opportunities to visit the home and have a trial stay prior to making a decision to stay. A new resident and his family confirmed that they had been offered the opportunity to visit the home and had been given full information about the services provided. Contracts were also in place. Cestria House B53-B03 S435Cestria V233323 100805 Stage 4.doc Version 1.30 Page 11 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 standard(s) 7, 8 and 10. There are good arrangements in place to ensure that residents’ health care needs are met. Personal support is offered in such a way as to promote and protect residents’ privacy, dignity and independence but residents who need help to clean their spectacles need to be monitored more closely. EVIDENCE: Three care records were inspected. These were found to contain relevant individual plans of care, which had been agreed with the resident or their representative. Residents confirmed that they saw doctors when they needed to as well as other health professionals, such as dentists, opticians and chiropodists. The outcome of these contacts was recorded in the care records, other than one where it appeared they had not seen a dentist for some time. There was evidence that GPs and Community Nurses were regularly consulted for advice and treatment. Comment cards received from three GP practices used by residents and all confirmed that the home communicated clearly and Cestria House B53-B03 S435Cestria V233323 100805 Stage 4.doc Version 1.30 Page 12 worked in partnership with them; that the staff demonstrated a clear understanding of the care needs of residents and that the practices were satisfied with the overall care provided to residents in the home. One practice also commented that, ‘The senior care staff at Cestria are amongst the best I have ever seen.’ Risk assessments are carried out to assess resident’s vulnerability to falls. Residents are weighed at regular intervals and the GP is informed of any nutritional concerns. All of those residents spoken to, who could comment, said that they were treated well by the staff and well cared for. Seven comment cards were received from residents, and all said they were well treated and cared for. Eleven comment cards were received from relatives and all indicated that they were satisfied with the overall care provided and that they were kept informed of their relative’s welfare. One also added, ‘My friend has been in care with Cestria for just a short time, however I am more than satisfied with the care and kind friendly manner she has been shown.’ It was apparent during the inspection, that attention was paid to residents’ dignity and staff were seen to act respectfully at all times. One resident, who needs assistance from staff, was wearing very dirty glasses. All seven comment cards from residents indicated that their privacy was respected by the staff at all times. The comment cards received from the three GP practices confirmed that they were able to see their patients in private when they visited the home. The medication system was not examined on this occasion. Cestria House B53-B03 S435Cestria V233323 100805 Stage 4.doc Version 1.30 Page 13 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 standard(s) 12, 13 and 15. Social activities and meals are well managed and provide daily variation and interest for people living in the home. Residents’ wishes concerning their day to day lives are respected, which means residents have control over how they live their lives. Visitors are made welcome, which enables residents to maintain contact with their family and friends. EVIDENCE: The Manager and Deputy Manager confirmed that a good range of social activities took place in and outside the home. Recently there have been outings to the see the Tall Ships, entertainments at three local theatres, a garden centre. Members of the staff team offer the residents the opportunity to go shopping in Newcastle City Centre. Two residents said that they enjoyed this but didn’t like it if the staff left them alone. The Manager advised that staff are accompanying residents in their own time and this is made clear to residents. All seven of those completing comment cards said the home provided suitable activities. Cestria House B53-B03 S435Cestria V233323 100805 Stage 4.doc Version 1.30 Page 14 It was noted during the inspection that the television was switched on and was very loud at various times, however, none of the residents in the lounge were watching it on these occasions. Five residents said that the food was very good and all seven completing comment cards said they liked the food. It was observed that meals were prepared and served in accordance with residents’ personal wishes, for instance, one resident had an unusual and late breakfast, another resident liked her meals in her room at the same time every day. One resident who eats in their room said staff had forgotten to give them an evening meal on three occasions but the resident had not wanted to tell staff. Choices are provided at each meal. Snacks are offered between meals. Residents were offered drinks throughout the day. The menu viewed showed that sausages had been offered for an evening meal and again for lunch the following day. Care needs to be taken to avoid frequent repetition of foodstuffs. The chefs were well informed about nutrition and suitable foodstuffs for older people and took an active interest in the residents to ensure that their dietary needs were met. Residents confirmed that they could receive visits from family and friends. Eleven relatives completing comment cards said that they were made welcome and could see their relative in private. Cestria House B53-B03 S435Cestria V233323 100805 Stage 4.doc Version 1.30 Page 15 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 standard(s) 16 and 18. There is an effective complaints procedure, which means residents and their representatives are listened to and concerns acted upon. Staff have good knowledge and understanding of Adult Protection issues which protects service users from abuse. Pre-employment checks need to be tightened up to ensure that residents are safeguarded from potential harm. EVIDENCE: The home has a detailed complaints procedure and there was evidence that any complaints are listened to, investigated and a written record kept. Since the last inspection one complaint had been received by the home concerning the building. This had been acted upon. Six of the residents completing a comment card said that they knew who to complain to if they were unhappy about anything. Seven relatives were also aware but four were unsure. A procedure for responding to allegations of abuse has been drawn up previously. Some staff had received training in adult protection and arrangements are being made for the other staff. Two carers spoken to during the inspection were clear about what they would do if they had any concerns about any resident. The procedures for vetting staff prior to employment need tightening up to ensure that applicants are not listed on the Protection of Vulnerable Adults List. Cestria House B53-B03 S435Cestria V233323 100805 Stage 4.doc Version 1.30 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 standard(s) 19, 20, 21, 22, 23, 24, 25 and 26. The home is homely but showing signs of wear and tear, so is not as pleasant an environment as it could be. Repairs to essential equipment and to the lighting need to be carried out to ensure that the home provides a safe environment. EVIDENCE: A tour of the premises was undertaken and eight bedrooms viewed. The home is in need of some maintenance work and updating of décor. The Manager advised that this work is to be undertaken shortly. The last inspection identified a need to re-enforce part of the conservatory floor and replace the carpet. This work has not been carried out, which is a concern. All residents have a single bedroom, four of which have an en-suite toilet. The bedrooms seen were personalised by residents to their own tastes. Some bedrooms would benefit from redecoration. Cestria House B53-B03 S435Cestria V233323 100805 Stage 4.doc Version 1.30 Page 17 The home has a passenger lift but the indicator buttons were worn and the floor numbers could not be seen. There is a large lounge, a conservatory and a dining area, providing pleasant sitting areas. The home has a small garden area to the front with seats and a yard to the rear. Hot water temperatures were tested and found to be appropriate. The home was very warm and is ventilated by the windows. The radiators are fitted with protective covers for the safety of residents. The lighting level on a second floor corridor where there are three steps was poor. The area was lit only by one emergency light as the main light and the wall lights were not in working order. There was also no light bulb in a bathroom/toilet which had no source of natural lighting and was therefore dark. A trolley also partially obstructed the hand wash basin. The lifting device in a bath was reported to have been broken for over two months and could not therefore be used. The home was clean and staff had protective clothing available to them. The Manager was informed of the comment made by a resident that the toilets are not always clean and not always cleaned promptly when this is pointed out. Cestria House B53-B03 S435Cestria V233323 100805 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30. The number and type of staff on duty throughout the day and night is sufficient to meet the needs of residents. Staff morale is good resulting in an enthusiastic workforce that works positively with residents to improve their quality of life. The procedures for the recruitment of staff are not as robust as they should be to ensure the protection of people living in the home. The arrangements for the induction and training of staff are good, which ensures that the staff have a clear understanding of their roles. EVIDENCE: The Manager, Deputy Manager and a number of care staff have worked together in the home for a number of years which helps ensure consistency of care and stability in the home. Examination of staff rotas and discussion with the manager and members of the staff team provided evidence that there are adequate care staff, including senior carers, on duty for the thirteen residents living in the home at the time of the inspection. Care staffing was as follows:8 am to 5 pm 4 Cestria House 5 pm to 9 p.m. 3 B53-B03 S435Cestria V233323 100805 Stage 4.doc 9 pm to 8 am 2 waking Version 1.30 Page 19 The Manager confirmed that staffing levels will be increased as the occupancy of the home increases. Additional staff are employed for duties such as food preparation, laundry and cleaning. All eleven of the relatives completing comment cards felt that there were sufficient staff. Additional comments were also received from relatives completing comment cards, as follows:‘It is only possible to visit occasionally but when I have done so I’ve found the staff more than satisfactory and obliging.’ ‘My relative has been in Cestria House approx 10 years now and is well looked after and loved like the staff were his family.’ Staff at Cestria House have always presented as extremely pleasant and welcoming…..’ ‘My relative has now been in Kath Burns care for 7 years or more. One thing I find very good at the home is the fact that most of the staff have been together a long time and this brings greater stability and care for my relative and other residents. Also it helps to build up relationships with relatives and staff.’ ‘Care is very good, stimulating and individualised. Manageress sets the tone and sets an excellent example.’ The record of one recently employed carer was examined. Recruitment checks need to be improved. The records indicated that a check of the POVA list had not been carried out or a CRB disclosure obtained. CRB Disclosures have also not yet been obtained in respect of some longer serving staff. This means that the home are not checking that the staff they employ have criminal offences or are on the list of people unsuitable to work with vulnerable adults (POVA List). The Home is therefore not complying with the law. It was confirmed from discussion with the Manager and examination of records that induction training to Topss standards is carried out. The Manager confirmed that nine of the care staff team have achieved an NVQ2 or above, which represents 70 . The remaining care staff are expected to complete their qualification before the end of the year. Evidence was also seen to demonstrate that staff have been given training in caring for people with dementia. The staff on duty were observed to be kind and respectful when supporting residents. They demonstrated good communication skills and were seen to consult and respect residents’ choices and wishes. Staff spoken to during the inspection enjoyed their work and were keen to develop their skills further. Cestria House B53-B03 S435Cestria V233323 100805 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36, 37 and 38. The Manager provides clear leadership, which ensures that the home is well run and the staff team are fully aware of their roles and responsibilities. The home regularly reviews aspects of its performance through a good programme of self-review and consultations, which include seeking the views of residents, relatives and staff. However, the owners of the home also need to carry out audit visits to satisfy themselves that the home is being run appropriately, is complying with health and safety and to comply with the Care Home Regulations. Several health and safety issues were raised, which must be addressed to ensure that the home provides a safe environment for residents. Some issues on record keeping need to be improved which ensures good monitoring of the way the home is run. Cestria House B53-B03 S435Cestria V233323 100805 Stage 4.doc Version 1.30 Page 21 EVIDENCE: The Registered Manager, Mrs Kathleen Burns, has successfully managed the home for some years. She has achieved the Registered Manager’s Award as has the Deputy Manager, Mrs Cheryl Grier, who strengthens the management team. Both Mrs Burns and Mrs Grier are planning to undertake an Honours Degree in the Care of Older Persons to further develop their existing skills and knowledge. The positive comments of residents, relatives and the staff team give confidence that the Manager provides good leadership throughout the home and has an ‘open door’ policy which encourages good communication. Staff confirmed that they receive 1-1 supervision and there were records supporting this. The home has a quality assurance programme in place, which includes seeking the views of residents, relatives and other interested parties, to provide feedback on the quality of care provided. The owner, however, is not currently carrying out monthly, unannounced visits as required by regulation. Only one part of the Home’s Certificate of Registration was displayed; both pages need to be clearly on view. Other records were generally in place apart from the staff records and more detail being required on the staff rota. There is a system in place to ensure that the staff team are given training in moving and handling skills, fire safety and first aid. Insufficient evidence was seen that staff are trained in infection control. During a tour of the home, some health and safety issues were identified as follows:A bath panel was damaged and potentially hazardous as sharp wood chippings were exposed. Similarly, a vanity unit in Bedroom 10 was damaged exposing the wood chippings. The curtains in one bedroom were coming away from the curtain rail. It was reported that staff had difficulty drawing the curtain and had to stand on a chair to do this. As the window is at a low level on an upper floor, this is putting staff at unnecessary risk. A letter was left with the home requiring urgent action to be taken to address these matters. It was noted that two of the upper floor windows did not have window opening restrictors fitted which is a safety concern. An intumescent strip was peeled away from the door to a bathroom and should be repaired in the interests of fire safety. Cestria House B53-B03 S435Cestria V233323 100805 Stage 4.doc Version 1.30 Page 22 Fire safety checks are generally carried out but the emergency lights were not being checked at the frequency recommended by the Fire Brigade. Coupled with the poor lighting in one area of the home, this could place residents at greater risk of falls as well as compromising fire safety. Maintenance/servicing contracts were seen to be in place except for the electrical wiring system which appears not to have been inspected by a competent person for some years. Risk assessments are carried out where bed side rails are used for individual residents, but these could be more detailed especially where there is a risk of a resident climbing over them. The Registered Manager was advised to obtain copies of warning letters provided by the Medical Devices Agency about the use of lap belts in wheelchairs and maintenance of hoists. The Registered Manager was also advised to carry out a risk assessment in respect of a large low window in a bedroom on the top floor to ensure that any risks of anyone falling through this are identified and acted upon. Cestria House B53-B03 S435Cestria V233323 100805 Stage 4.doc Version 1.30 Page 23 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 2 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 3 2 2 3 3 1 3 STAFFING Standard No Score 27 3 28 4 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 x x 3 2 1 Cestria House B53-B03 S435Cestria V233323 100805 Stage 4.doc Version 1.30 Page 24 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 4 Requirement The home must produce a comprehensive Service Users Guide and Statement of Purpose in a range of formats. The original timescale of 2/2/05 has not been met. Ensure that relevant information is sufficiently detailed when assessments carried out. Ensure that residents are provided with assistance to clean their spectacles where this is needed. The Proprietor must make arrangements for the conservatory floor to be reenforced and replace the carpet in this area. The original timescale of 1/12/04 has not been met. Ensure lift buttons are readable. The lifting equipment in a bath must be repaired or replaced. The lighting level must be improved in the corridor and bathroom. Suitable lighting levels must be provided at all times in all parts of the home. Satisfactory checks of the POVA list must be obtained before staff commence employment. Ensure Timescale for action 31/12/05 2. 3. 3 10 14 12(1) & 13(4)(c) 23(b) 31/12/05 30/9/05 4. 20 31/10/05 5. 6. 7. 22 22 25 & 38 23(2)(c) 23(2)(c) 23(2)(p) 30/9/05 31/12/05 11/8/05 8. 29 19 16/8/05 Cestria House B53-B03 S435Cestria V233323 100805 Stage 4.doc Version 1.30 Page 25 9. 29 10. 33 11. 12. 37 37 13. 38 14. 38 15. 38 16. 38 POVA List checks requested for those outstanding by 16/8/05. 19 Full and satisfactory CRB disclosures must be obtained for those staff employed where this has not previously been done. 26 The Proprietor must ensure that Regulation 26 visits are carried out. Copies of the reports of these visits must be forwarded to the CSCI and the Registered Manager. The original timescale of 16/10/04 has not been met. Section 28 Both parts of the Certificate of CSAct Registration must be conspicously displayed. 17(2) The staff rota must contain details of the roles of staff, the full date and a key to the codes used. 13(4) Ensure curtains can be drawn safely. Repair damaged bath panel. Repair damaged vanity unit in Bedroom 10. 13(4) and Ensure that all upper floor 23(4)(c)(i windows have window opening ) retrictors fitted where appropriate. Replace worn intumescent strip on door to bathroom near Bedroom 9. 23(3)(b) The electrical wiring system must be inspected at appropriate intervals as determined by a competent, suitably qualified electrician. The results of the inspection must be documented within a Periodic Inspection Report. 13(4) Ensure detailed risk assessments carried out and documented where bed side rails used in accordance with the advice given by the Medical Devices Agency. Ensure that copies of warning letters issued by the Medical Devices Agency are obtained and followed up re hoists and wheelchair belts. B53-B03 S435Cestria V233323 100805 Stage 4.doc 31/8/05 31/10/05 31/8/05 31/8/05 11/8/05 31/10/05 31/10/05 31/10/05 Cestria House Version 1.30 Page 26 17. 18. 19. 20. 38 13(3) Provide infection control training to the staff team. 31/3/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 15 12 38 Good Practice Recommendations Review menu to ensure foodstuffs are not repeated within short intervals. Review use of television. Carry out risk assessment to identify and act on any risks associated with large low window in top floor bedroom. Cestria House B53-B03 S435Cestria V233323 100805 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Northumbria House Manor Walks, Cramlington Northumberland NE23 6UR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cestria House B53-B03 S435Cestria V233323 100805 Stage 4.doc Version 1.30 Page 28 - 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. 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