Inspection on 10/01/07 for Cestria House

This inspection was carried out on 10th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Cestria House 17/12/08

Cestria House 31/01/06

Cestria House 10/08/05

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 Tyne & Wear NE2 2DR Lead Inspector Jackie Burke Key Unannounced Inspection 10th January 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cestria House DS0000000435.V304624.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. Cestria House DS0000000435.V304624.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cestria House Address 45 Sanderson Road Jesmond Newcastle Upon Tyne Tyne & Wear NE2 2DR 0191 281 8714 0191 281 0377 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) Bawi Homes Limited Mrs Kathleen Burns Care Home 24 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (21) of places Cestria House DS0000000435.V304624.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st January 2006 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 dementia care needs. Nursing care is not provided. The home is a three storey converted house. There is a passenger lift to each main floor. There are two mezzanine floors, which have a small number of bedrooms, which can be reached by a flight of stairs. Residents occupying these bedrooms would therefore need to be mobile. All of the bedrooms are single. The home has three bathrooms with assisted baths or showers. Four of the bedrooms also have en-suite toilets. Cestria House 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. The cost for the service is £379 per week. Chiropody, hairdressing and newspapers are additional. Information, including inspection reports, is provided for service users to enable them to make a decision about moving to Cestria House. Cestria House DS0000000435.V304624.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over two days on Wednesday 10 January 2007 and Thursday 11 January 2007. The inspection took 7.5 hours. Time was spent in the main lounge talking with service users visitors and staff. Observations of staff and service users in communal areas also took place. Care plans, accident records, medication records and daily records were looked at during this inspection and this was linked to observations and discussions with service users. Staff files and training records were looked at to ensure that recruitment and employment practice follows policies which safeguard service users. What the service does well: What has improved since the last inspection? The Service Users Guide is now available in tape format for people who have difficulty reading. The flooring in the ground floor bathroom and the hoist have been replaced. The lift has been serviced and repairs undertaken. Cestria House DS0000000435.V304624.R01.S.doc Version 5.2 Page 6 The sluice room has been cleaned out and is now operational. All three bathrooms within the home are now operational. A regional manager has been appointed within the company and is responsible for undertaking Regulation 26 visits and supporting improvement within the group. 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. Cestria House DS0000000435.V304624.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 Cestria House DS0000000435.V304624.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): Standard 1, 2 & 3 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract with the home. Service users needs are assessed before moving into Cestria House and identified needs are met by the service. EVIDENCE: Three care files were looked at during this inspection and records show that each service user has a contract with the home, which contains terms and conditions and costs involved. Service users are provided with a service user guide, which is now available in tape format for people who have difficulty reading. There are plans to make a video version of the service user guide to include the views of people who live in Cestria House, which can be provided to prospective service users. Cestria House DS0000000435.V304624.R01.S.doc Version 5.2 Page 9 The three case files examined all contained assessment information from care managers. Assessment documents cover areas of social needs, health and personal care needs. The manager also does her own assessment prior to admission and this forms the basis for the care plan, which is developed for each person to ensure that care needs are met in full. Cestria House DS0000000435.V304624.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): Standards 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. Service users needs are set out in a plan of care so that staff have the information they need to provide care. Health care needs are met in full. Cestria House has a satisfactory policy for dealing with medication, which safeguards service users. Residents are treated with respect and privacy is safeguarded. EVIDENCE: Three care plans were looked at during this inspection and time was spent with service users to see how they spend their day and how staff support them. Staff showed that they had the skills to reassure service users and that they treated people with respect and dignity and spoke and acted with caring attitudes. Staff were observed talking to service users and explaining tasks they dealt with so as to minimise anxiety and confusion. Cestria House DS0000000435.V304624.R01.S.doc Version 5.2 Page 11 People are called by the name they prefer and their preferences are recorded in care files. Staff members approached service users in a gentle and caring manner. Care files included information relating to assessment, health, personal and social care needs. Care files contain risk assessments and action plans to deal with identified risks. Sensitive information is dealt with confidentially and daily records show that staff are aware of service users needs and act appropriately. Advice on the health care needs of service users is promptly sought from health care professionals and appropriate action is taken. Records are kept of GP and clinical appointments and of District Nurse visits and of the outcome of healthcare appointments. Care plans and daily records are kept together in an active file and show how people’s care needs will be met. Daily records are archived in individual care files and contribute to the monitoring process of individual care. The health, personal and social care needs of individuals are monitored and reviewed regularly. There is a satisfactory medication policy in place at Cestria House and senior staff are trained and authorised to give out medication. Staff were seen prompting service users to take medication and kept records to safeguard service users. Care files contain records regarding medication and homely medications, which follow the medication policy. Cestria House DS0000000435.V304624.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): Standards 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. Cestria House provides a good standard and variety of activities, which means that there is a stimulating environment for service users. Links with families, friends and the community are encouraged. People are enabled to exercise choice in their lives. People are provided with a balanced diet and meal routines are provided flexibly wherever possible. EVIDENCE: Time was spent with service users in the main lounge and visitors were observed to come and go freely. People spent time reading the newspaper and talking about items of interest in the paper and on television. Service users in Cestria House are supported to engage in activities within the local community. One person likes to maintain the appearance of the garden and another likes to spend time in the local shops on Acorn Road. Risk assessments are in place to support these activities and staff provide practical support and assistance to enable people to maintain their involvement. This includes reminder notices and actively providing coat, hat and gloves to keep Cestria House DS0000000435.V304624.R01.S.doc Version 5.2 Page 13 individuals warm and a fully charged mobile phone to maintain contact with service users who choose to go out. Policies are in place to safeguard individuals in their choice of activity. On the first day of inspection two people were going out for lunch and shopping in town with staff using the metro. People are encouraged to pursue their own interests. One person likes to spend time in her room and has opted to have her meals in privacy. Another person proudly showed certificates of achievement, which are prominently displayed in his room where he enjoys spending time on his computer. Mealtimes are flexible within Cestria House and people can choose when to get up and what to have for breakfast. A hot meal is provided at lunchtime and a choice is offered. Hot soups and sandwiches are provided at teatime and a snack in the evening for supper. On the first day of the inspection a choice of cauliflower cheese or roast chicken with vegetables and potatoes was available for the main meal. On the second day the menu was roast pork or chicken curry and rice. All meals are prepared and cooked on the premises and the chef and the manager work together to provide a four-week seasonal menu. Specialist diets are catered for in Cestria House and currently there are three people with diet controlled diabetes and one person who requires a soft consistency diet. The chef prepares fresh soup during winter months and includes salad and lighter options during summer month meal planning. All service users spoken to said that the meals in Cestria House were very good and that they looked forward to meal times. Drinks are served throughout the day and fruit and cold drinks are available in the kitchen. Cestria House DS0000000435.V304624.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): Standards 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a complaints policy in place and service users complaints are dealt with appropriately. Service users are protected from abuse. EVIDENCE: There is a complaints policy at Cestria House and where complaints have been made the procedure has been followed. The complaints log was examined during the inspection and two complaints have been investigated in the past 12 months. These had been dealt with appropriately. Service users spoken to were clear that they would speak to the manager if they had a complaint but said that they had no complaints about the service or the staff. There is a whistle blowing policy at Cestria House and staff have been provided with training in the protection of vulnerable adults. Staff spoken to were aware of the need to protect vulnerable adults and were clear about what they would do if they had any concerns about the care of people living in the home. Cestria House DS0000000435.V304624.R01.S.doc Version 5.2 Page 15 Staff files checked contained Criminal Record Bureau checks and written references as well as checks to cross reference and confirm each individual applicant’s identity. Cestria House DS0000000435.V304624.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 21, 22 & 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users live in a safe well-maintained environment. People have sufficient and suitable lavatories and washing facilities. People have the specialist equipment they require to maximise their independence. The lift requires attention to ensure it is fully accessible. The home is clean, pleasant and hygienic. EVIDENCE: The numbers on the lift buttons have been replaced but require further attention to ensure that they are clear and easy to see for those with visual impairment. The lift was serviced in October 2006 and a maintenance contract is in place. Cestria House DS0000000435.V304624.R01.S.doc Version 5.2 Page 17 The sluice room has been cleared and is in working order and COSHH guidance for dealing with hazardous substances is displayed and cleaning materials are stored appropriately. The bathroom on the ground floor has been improved and flooring and the specialist hoist replaced. The hoist in the first floor bathroom has been improved and the second floor bathroom is now in full working order. Cestria House provides a pleasant homely environment for people who live there. The home is clean and odour free and domestic staff ensure that the home is clean and hygienic. Cestria House DS0000000435.V304624.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 & 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service user’s 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 recruitment policies and practices. Staff are trained and competent to do their jobs. EVIDENCE: The manager and staff team have worked in the home for some considerable time. They have built a good team of staff who work together to make sure that service users needs are fully met. There are fourteen care staff within the home, five ancillary staff and the manager and deputy manager. On the first day of the inspection there were sufficient staff on duty to allow service users to go out to a visit to town and to provide satisfactory cover for other service users at home. The manager was on leave and the deputy manager was responsible for the running of Cestria House. She showed Cestria House DS0000000435.V304624.R01.S.doc Version 5.2 Page 19 considerable skills and competency in her management of the home and her knowledge of policies and procedures. Care staffing in the home is as follows: 8am-3pm 4 3pm-9pm 3 9pm-8am 2 waking staff In addition the manager and deputy are available during the day until 5pm. An on call system operates during evenings and weekends. Service users spoken to were very positive about the staff. One person said that she was very happy with the staff and that everyone was very kind to her at Cestria House. Another said that he found the staff very helpful and if he had any questions he had only to ask and they would sort it out. Staff files contain records which show that recruitment and selection policies are in place to safeguard service users. Evidence was available of Criminal Record Bureau checks and of written references and identity checks being undertaken. Staff spoken to recognised the support of management and colleagues and said that they were encouraged to take part in training and to develop their skills. There are eleven staff who are qualified to NVQ level 2 or above and another staff member has begun NVQ course work. Seventeen staff members hold a first aid certificate. One staff member said that she was very happy in her work and that she felt settled in the home. Staff files contain records which show that training is supported within Cestria House and induction training and mandatory training is provided for staff. In addition there is evidence to show that staff are supported to take part in specific areas of training including dementia care and bereavement care. The manager and deputy both hold the Registered Manager’s Award and are qualified to level 4 NVQ. The manager and deputy are working toward achieving a degree in the Care of Older People. Their voluntary input demonstrates a high level of motivation and commitment to training and development. Staff rotas initially submitted were unclear. However, on the days of inspection the deputy manager provided staff rotas which were handwritten and more clearly set out. Discussion took place with the regional manager Mr Herrity regarding the use of a computer within Cestria House to standardise care plan formats and staff rotas. Cestria House DS0000000435.V304624.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35,36,37 & 38. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users live in a home which is run and managed by a person of good character, who is fit to be in charge and able to discharge her responsibilities fully. The home is run in the best interests of service users. Service users financial interests are safeguarded. Staff are appropriately supervised. Some improvements are needed to ensure that service users are fully safeguarded by record keeping, policies & procedures. The health safety and welfare of service users and staff are promoted and protected. Cestria House DS0000000435.V304624.R01.S.doc Version 5.2 Page 21 EVIDENCE: 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 manager is held in high regard by her staff and by the service users spoken to during the inspection. The home reviews aspects of its performance through a programme of selfreview and consultations. This includes seeking the views of residents, relatives and staff. Personal monies for residents are kept in the safe and receipts and records are kept. Three staff files were looked at and show that staff are given regular 1:1 supervision during which training needs are identified and practice issues discussed. Two staff files related to new members of staff and records were available to indicate that supervision has taken place since their appointment. A regional manager within the company is now responsible for audit visits of Cestria House. There were no records of these visits available on the inspection days as this is a new system, which has recently been introduced by the company. Some issues on record keeping and organisation need to be improved to ensure effective monitoring of the way the home is run. This includes file organisation and staff rotas. Both pages of the homes Certificate of Registration were not displayed. Staff rotas were not written clearly and did not include a key to show staff roles, so did not give clear information. A maintenance contract has been established with an electrician and maintenance checks of the electrical wiring system are undertaken on a regular basis. Fire safety records and equipment and lighting tests are up to date and recorded and fire alarms are tested weekly and records kept. Cestria House DS0000000435.V304624.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 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 3 x 3 2 x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 2 x 3 3 2 3 Cestria House DS0000000435.V304624.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP22 Regulation 23 (2 c) Requirement Ensure lift buttons are readable Outstanding requirement 31.3.06 Copies of Regulation 26 visit reports must be forwarded to CSCI and the Registered Manager. Outstanding requirement 16.10.04 Both parts of the Certificate of Registration must be conspicuously displayed. The staff rota must contain details of the roles of staff, the full date and a key to the codes used. Outstanding requirement 3.3.06 Timescale for action 01/03/07 2. OP33 26 01/03/07 3. OP37 Sec 28 CSA 17(2) 01/03/07 4. OP37 01/03/07 Cestria House DS0000000435.V304624.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations The organisation of care files should be reviewed to ensure that relevant information can be easily accessed. Cestria House DS0000000435.V304624.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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. 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