Inspection on 18/01/06 for Cheveley House

This inspection was carried out on 18th January 2006.

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

The inspector 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

Cheveley House 05/05/06

Cheveley House 23/11/05

Cheveley House 14/09/04

Cheveley House 07/05/04

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

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

CARE HOMES FOR OLDER PEOPLE Cheveley House Cheveley Park Estate Belmont Durham DH1 2AD Lead Inspector Kathy Bell Unannounced Inspection 18th January 2006 10:45 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 Cheveley House DS0000031184.V269524.R01.S.doc Version 5.0 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. Cheveley House DS0000031184.V269524.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Cheveley House Address Cheveley Park Estate Belmont Durham DH1 2AD 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) 0191 3863787 0191 3863787 Durham County Council Mrs Yvonne Gibbon Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (40), Physical disability (8) of places Cheveley House DS0000031184.V269524.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Named Individual The home may accommodate a named individual as set out in a letter to the registered person dated 25 October 2004 which establishes the basis on which the individual`s needs will be met by the home. Where necessary the home`s Statement of Purpose shall reflect any changes in service provision required for this arrangement. This condition may not apply to anyone else, other than the named individual, who falls outside the registered category. 23rd November 2005 Date of last inspection Brief Description of the Service: Cheveley House is registered to provide care (but not nursing care) for up to 36 older people. It can also take up to eight people under 65 with physical disabilities into the intermediate care unit, providing the total number of people cared for in the home is not over 36. The intermediate care unit provides care for people who need to improve their mobility and ability to care for themselves before they can return home, after, for example, a stay in hospital. The home is near the centre of Belmont Village and has large grounds. It is built on two floors and all the bedrooms are singles. On the ground floor the home has a separate day centre in a large lounge, the intermediate care unit for eight people, and four bedrooms for people who receive respite care. The remaining 24 beds are on the first floor which has two lounge/dining areas with small kitchens and two more small lounges. Cheveley House DS0000031184.V269524.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during one day in January 2006. It was one of the two inspections planned for the year. During the inspection, the inspector, Kathy Bell looked around the building, and at some records, and talked to six residents, four staff and the manager. Written comments were received from 11 residents and 12 relatives. Most were pleased with the home and praised the care but about a third of those who commented felt that there were not enough staff on duty all the time and that enough activities were only provided sometimes. The home has experienced a difficult couple of years. There have been a series of managers in post and recently there were not enough permanent staff and the home relied heavily on agency carers. A manager is now in post and has now applied to be registered with CSCI. She is aware of some of the areas in which the home needs to improve and discussed her plans to do so with the inspector. What the service does well: What has improved since the last inspection? Daily recording on the residents in the intermediate care unit has improved so that all those working with those residents receive good information on how they are progressing. Staff have begun to transfer information onto new care plans, making sure that it is up-to-date. However they must make sure that they include detailed information which enables staff to meet residents needs and wishes. During the inspection, the inspector saw that doors to rooms containing chemicals etc were kept locked, as they should be. There were no noticeable unpleasant smells, although she did not look in every bedroom. The manager has now applied for registration with CSCI. Cheveley House DS0000031184.V269524.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Cheveley House DS0000031184.V269524.R01.S.doc Version 5.0 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 Cheveley House DS0000031184.V269524.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed during this inspection. EVIDENCE: Cheveley House DS0000031184.V269524.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 10 Residents feel that they are treated with respect and that their privacy was respected. EVIDENCE: All the residents who completed comment cards said that their privacy was respected. Residents who were spoken with also felt that staff treated them with respect. Cheveley House DS0000031184.V269524.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 & 14 Although leisure activities are provided, some residents feel that there is not enough to occupy or entertain them. Residents are able to keep up contact with visits from their families. Residents were certain that they could make decisions about day-to-day life, such as whether to spend time in their rooms or with other people but in some ways their choices were limited by their awareness of how busy staff were. The manager has explained her intentions to encourage residents to say what they want, without them taking into account set routines in the home. EVIDENCE: There is a day centre on the ground floor and if space is available, up to three residents a day can join in activities there. This is a useful extra resource but only available to a few people a day. Outings have been arranged and entertainers brought into the home. There is a plan of activities for each day but staff are only able to lead activities in one lounge at a time. Residents can join in singalongs, play dominoes or take part in craft activities. However, a number of residents felt that there were not enough activities often enough to occupy them. Residents are able to receive visitors at any reasonable time. Cheveley House DS0000031184.V269524.R01.S.doc Version 5.0 Page 11 Residents said that they could choose how they spent their time, when they wanted to get up and whether they wanted to stay in their rooms or sit with other people. However, some said that they would like a bath more than once a week but knew staff were busy. They all had their baths in the evening and some said that this was because this was easier for staff. Cheveley House DS0000031184.V269524.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Residents were confident that they could talk to staff about anything they werent happy about. However, a number of residents and relatives did not seem to know about the complaints procedure so might not know who to contact if the home did not respond to their complaint properly. The home has systems in place to make sure that people are protected from financial abuse and all staff have had training to make them aware of how to protect people from abuse. EVIDENCE: Residents said that they would be able to take any complaints to the manager. If you have any problems she will try and solve them. Although there is a poster about how to complain in the main hallway into the building, in a number of written comments people said they were not aware of the complaints procedure. The most important thing is that residents do feel they have the right to complain and expect to be taken seriously. Although they did not know how they would take their complaint further if the manager did not respond to their satisfaction, they felt they would be able to get advice on this if it ever happened. The manager should still try again to make people aware of the complaints procedure. Staff have all had training to make sure they understand the different kinds of abuse which people can suffer so that they can report any concerns to the manager. When the home looks after residents money for them, it keeps Cheveley House DS0000031184.V269524.R01.S.doc Version 5.0 Page 13 proper records of this, with receipts, so that they are protected from any financial losses. Cheveley House DS0000031184.V269524.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed during this inspection. EVIDENCE: Cheveley House DS0000031184.V269524.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 There have not always been enough staff on duty to meet residents needs fully and provide them with the attention they expect. However in recent weeks, some extra hours have been provided. CSCI will continue to check whether enough staffing hours are provided. Over 83 of staff have achieved the recommended qualification of NVQ 2 and have the personal qualities required for this work. Recruitment procedures help the manager make sure, as far as possible, that only suitable people begin work in the home . Staff are receiving the training they need to work safely and provide good care. EVIDENCE: The standard rota provides two care staff on duty in the intermediate care unit. These staff are also responsible for domestic work on that unit except for Wednesdays . The rota provides another two care assistants and a supervisor on duty through the waking day for the rest of the residents, up to 24 on the first floor and four respite care on the ground floor. This is fewer staff than the same provider supplies in other homes it runs which have fewer residents . There had been eight times in the six weeks before the inspection when only four care assistants were on duty for the entire home, with one of them Cheveley House DS0000031184.V269524.R01.S.doc Version 5.0 Page 16 carrying out some of the duties of the supervisor. This is not satisfactory and the home must make sure that staffing does not drop to this level again. Although the supervisors hours have been counted as care hours they have other responsibilities. As well as the normal duties of administering medication and taking responsibility for ordering, checking and disposal, health and safety checks, supervision and appraisal, the supervisors currently have a major task in setting up care plans in the new format for all residents. They also have supervisory responsibility for the intermediate care unit and the regular meetings with health staff and a high turnover of residents will result in them being less able to provide direct care to residents than in a home without this facility. The NCSC (now CSCI) was advised that the Residential Forum guidance on staffing levels should only be applied to new registrations. However it provides a useful guideline figure for staffing, taking into account the dependency levels usually found in care homes now. The home is not providing as many hours as recommended. 12 relatives sent in written comments before the inspection: Three of these said there were not enough staff on duty and one said there were sometimes not enough staff on duty. The comments about not enough leisure activities and the homes failure to have in place updated care plans also indicate that there have not been enough care hours provided. On the day of inspection, a resident with confusion waited for quite some time, sitting alone at the dining table after tea, for staff to take her elsewhere. Her resulting impatience and uncertainty about what was happening was affecting the other residents in the lounge next to the dining area. The member of staff who was able to respond when the inspector pressed the buzzer was unable to help because she was still administering medication for the entire home. In addition, to the hours on the rota, home care workers may spend time in the home when they are not required for domiciliary work. They fit in as needed but the home can never predict when they will be available. The manager should take a fresh look at all working routines and discuss with staff and residents the best way of making use of these extra hours. Domestic staff can help out when necessary, for example, by taking a resident to the toilet if a care assistant is not available. Residents are clearly aware that staff are very busy and one explained how she would like a bath more often but doesnt like to ask because she doesnt think the staff have the time . Overall, residents feel that staff treat them well and provide good care. One described them as caring and loving. The National Minimum Standards Cheveley House DS0000031184.V269524.R01.S.doc Version 5.0 Page 17 recommend that 50 of care staff should achieve NVQ 2 in care and of this home has over 80 of care staff qualified to this standard which is a commendable achievement. The home has established procedures for recruiting staff, which include obtaining a Criminal Records Bureau check and references. Training has been provided in core areas such as moving and handling and infection control. A number of staff have also had training in areas which help them improve the care they offer, such as dementia care, foot care and promoting independence. Cheveley House DS0000031184.V269524.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 & 38 The home has some systems to check that the home is running well and meeting peoples needs but should develop and improve these. Where the home looks after residents money for them there is a system to make sure that they account for all the money and that it is kept safely so that residents are protected from abuse. Regular checks are made and servicing carried out to make sure that the home is a safe place to live and work but staff had not been made aware of the extra care they needed to take when one essential part of the fire containment system was not operating correctly. If a fire had occurred in this area of the building, this would have been a very serious failure. Cheveley House DS0000031184.V269524.R01.S.doc Version 5.0 Page 19 EVIDENCE: Senior staff from outside the home carry out a monthly inspection to check home is operating properly, and seek residents views on these visits. However, these checks do not appear to have highlighted the issues raised in this report and the previous inspection. The manager has provided a book for residents and relatives to write any comments or concerns in but this has not yet been used. The home should also try and obtain views from residents, relatives and professionals who visit the home to make sure they obtain as full a picture as possible of how people see the home. This would help them find out if there are issues which people dont mention because they are pleased with the service in general. The home keeps full records of any money they look after for residents and keeps receipts for money spent. There are comprehensive systems to make sure that the home provides a safe place to live and work. Equipment is serviced regularly, and the fire safety system is checked weekly. However, the handyman who carries out the checks had recorded that a door fitted with a magnetic catch and self-closing device on a stairwell had not been working correctly from the 14th of December until he had checked it on the day of inspection. The manager said that this had been repaired but that someone would come out again to look at it. The inspector asked two staff about this door-they did not know which door was faulty or what was wrong. This meant that if the fire alarm sounded, they would not have known that they needed to make sure this door was closed, to prevent any smoke rising through the stairwell to the first-floor. Cheveley House DS0000031184.V269524.R01.S.doc Version 5.0 Page 20 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 1 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 2 Cheveley House DS0000031184.V269524.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? No 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 OP7 Regulation 15 Requirement Timescale for action 31/03/06 2 OP9 13 3 OP27 18 4 OP38 13 Care plans must be kept up-todate and reviewed regularly. They must include all the information listed in Standard 3 of the National Minimum Standards. They must include explicit guidance if residents rights or choices are restricted Staff must make sure they all 31/01/06 record whether as required medication is administered or not the same way. Care staffing levels must not fall 31/01/06 below five on duty during the waking day for the entire building.The management of the home must keep staffing levels under review and find out whether working routines can be arranged so that best use is made of the varying, unplanned hoursworked by the domiciliary care workers.They must keep CSCI informed of progress on this When any part of the fire safety 18/01/06 system is not operating correctly, staff must be told of action they should take when the DS0000031184.V269524.R01.S.doc Version 5.0 Page 22 Cheveley House fire alarm sounds. 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 OP33 Good Practice Recommendations The home should develop systems for finding out what residents, relatives, care managers etc think of the home. Cheveley House DS0000031184.V269524.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 Cheveley House DS0000031184.V269524.R01.S.doc Version 5.0 Page 24 - 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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