Inspection on 05/05/06 for Cheveley House

This inspection was carried out on 5th May 2006.

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

Cheveley House 18/01/06

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 Mr Leonard Hird Unannounced Inspection 5th May 2006 10:00 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.V291630.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cheveley House DS0000031184.V291630.R01.S.doc Version 5.1 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 Brenda Mason 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.V291630.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 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 single occupancy. 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.V291630.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection of Cheveley House took place on the 5th May between 0930 and 1500 hrs as well as the 10th May between 0930 and 1430 hrs. The inspection process considered all of the Key standard areas as identified by the Commission for Social Care Inspection within the Care Homes for Older People National Minimum Standards. These Key standards are: Choice of Home (NMS 3 NMS 6), Health and Personal Care (NMS 7, 8, 9 and 10), Daily Life and Social Activities (NMS 12, 13, 14 and 15) Complaints and Protection (NMS 16 and 18), Environment (NMS 19 and 26), Staffing (NMS 27, 28, 29, 30,) and Management and Administration (NMS 30, 31, 33, 35 and 38). The Commission for Social Care Inspection received 7 written comments from residents and their relatives as well as comments on the days of inspection from residents, family members, visitors and visiting health professionals. Comments were also received from the registered manager, members of the care staff team and team manager. What the service does well: Cheveley House was clean tidy and comfortably furnished in a pleasant and homely way. Residents in both the residential and intermediate care units spoken to said “the home was meeting their needs”, “they look after us” and “the home was very good”. Residents were satisfied that they could make choices, “we are free to choose what we want to do”. The health and safety of residents was being well managed and staff had received appropriate training to enable them to look after the residents. Cheveley House DS0000031184.V291630.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? 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.V291630.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cheveley House DS0000031184.V291630.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 3 and NMS 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Cheveley House ensured that prior to admission, an assessment of the needs of the prospective resident seeking to be admitted to either the residential care or intermediate care unit, had been undertaken. EVIDENCE: Care plans inspected contained records of an assessment undertaken by the local Social Care and Health Team as well as a record of assessment undertaken by the home. Residents living on the residential unit and spoken with during the inspection confirmed that assessments had been made prior to admission. Similarly a resident confirmed that prior to their admission to the intermediate care unit that they also had received an assessment of needs. They also commented that, “the service they were receiving in the intermediate care unit was of great benefit to them”. Cheveley House DS0000031184.V291630.R01.S.doc Version 5.1 Page 9 Discussions with a visiting health professional involved in the delivery of intermediate care at the home confirmed that assessments of need were being made on individual residents prior to them being admitted to the intermediate care unit by qualified staff. The visiting health professional also commented, “the services provided by Cheveley House within the intermediate care unit had helped many older people keep their independence and return to their own homes”. Cheveley House DS0000031184.V291630.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 7 NMS 8 NMS 9 and MS 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual residents health, personal and social care needs were being set out in their care plan. Residents were able to make decisions about how they could lead their lives and were treated with respect and dignity. The homes medications policies, procedures, guidance and training programme ensured that staff were able to dispense medication to residents safely. Residents residing in the intermediate care unit, where appropriate, could store and administer their own medication. EVIDENCE: Residents living at Cheveley House had individual plans of care in place and information was being maintained on the individual residents health and personal needs. Cheveley House DS0000031184.V291630.R01.S.doc Version 5.1 Page 11 Individual care plans covered important areas such as personal care, mobility and health requirements. Assessments of risk were also included in the plans and these assessments took into account the individual resident’s views. There were some inconsistencies in the recording of information on residents’ files as the home had recently introduced a new system of care plan recording and not all of the residents’ files had been fully updated. Staff had reviewed individual residents plans of care and where any changes had been identified then these had been actioned. Records were being maintained by the home of the individual resident’s health needs as well as records of visits made by GPs and other health professionals to the home. Written comments received from residents confirmed that they were receiving the medical support their required. A visiting relative also commented, “that care staff kept them informed of the health of their family member and nothing was a problem for the staff”. There were well-established systems in place for the handling and recording of medication by care staff. Care staff involved in the administration of medication to residents had received training in the safe handling and administration of medication and a record of this training had been kept on the individuals training files. A visiting health professional confirmed that the home kept them informed of the health problems of the residents verbally and in writing via a communications book. The district nurse also confirmed that they had regular meetings with the care staff to discuss individual residents health needs. The district nurse also commented, “the home has a good working relationship with the local health services”. Residents confirmed that staff treated them with respect, dignity and listened to what they said at all times. A written comment received from a resident stated “staff are always friendly and polite”. It was observed during inspection that staff spoke in a pleasant and civil manner to residents and always knocked and waited before entering any resident’s room. Cheveley House DS0000031184.V291630.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 12 NMS 13 NMS 14 and NMS 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The routines of daily living and activities available at Cheveley House were varied and flexible and generally meeting the needs of the residents. The independence and personal choices of residents at Cheveley House were being actively promoted by the home. The dietary needs of residents were well catered for with a balanced and varied selection of food being made available. EVIDENCE: It was observed that the daily routines of living were flexible and meeting the needs of residents. One resident commented in writing, “every day they ask me what I want to do, but I prefer to sit quietly in my room”. Cheveley House DS0000031184.V291630.R01.S.doc Version 5.1 Page 13 Residents also commented that they “could get up and go to bed whenever they wanted to and that staff would assist them at all times”. Relatives visiting the home spoke highly of the homes visiting policy and a relative commented “they could visit at any time to the home and were always made welcome”. Activities were also arranged for residents within the home and residents had been consulted as to the type of activities they would like to take part in and the home’s manager had drawn up a full activities programme effective from June. A small number of residents were also making use of the day centre recreational facilities located in the home. Records were being maintained of activities undertaken by residents in the home as well as of those organised by the Create programme. Written and verbal comments received from residents were generally positive about the types of activity been offered at the home though some residents felt that there could be more trips. Menus were being displayed in the home of the different choices of food available and special diets were being catered for where required. Written comments received from residents stated that ‘the meals were beautiful’, ‘very good indeed always varied’, ‘if I dont like something, there is always a choice’. Records were being maintained of the choice of food being made by residents as well as records of the homes Menus. Records of training including Food Hygiene undertaken by the catering staff were being maintained on their personnel file. Regular residents meetings were being held and the types and choice of food being made available on the home were discussed minutes were being kept. Cheveley House DS0000031184.V291630.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 16 and NMS 18 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to the service. The complaints and adult protection policies and procedures currently being used in Cheveley House provide for a safe environment for residents to live in. EVIDENCE: Cheveley House had appropriate policies and procedures in place for the Protection of Vulnerable Adults. Staff had received training on how to deal with the Protection of Vulnerable Adults and records were being maintained of this training. In discussions with staff they confirmed that they were fully aware of the importance of acting quickly in cases of suspected abuse and that they would follow the homes policy and procedures if necessary. They also confirmed that they had received training in how to deal with the Protection of the Vulnerable Adult. The home also had appropriate policies and procedures in place for residents and their families on how and who to complain to if they needed. Information on how to complain was being displayed on the notice boards throughout the home as well as being contained in the residents guide to the home. Residents were aware of how and who to complain to. One resident commented, “if they wanted to complain they could and they knew who to complain to and that the manager would listen to them”. A resident’s written comment stated “no complaints but I am aware of the complaints procedure”. Cheveley House DS0000031184.V291630.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 19 and NMS 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Cheveley House is clean, pleasant and hygienic and provides a safe and comfortable environment for its residents. EVIDENCE: Cheveley House had been decorated and furnished to a pleasing and homely standard. A residents spoken with commented, “ “the room I live in is just how I like it” and “it is a nice place to sit in and I can see what is going on”. The communal living areas were well decorated and maintained. Maintenance work undertaken on the homes equipment and facilities by the handyman as well outside contractors had been recorded appropriately. The manager confirmed that a redecoration programme was about to be carried out in the home. Cheveley is clean, tidy and free from unpleasant odours. There were appropriate systems in place for infection control. Cheveley House DS0000031184.V291630.R01.S.doc Version 5.1 Page 16 The homes infection control policies and procedures were written in accordance with relevant legislation and professional guidance. Staff confirmed that they had received appropriate training in infection control and a record of this training had been kept on their personnel file. Cheveley House DS0000031184.V291630.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 27 NMS 28 NMS 29 and NMS 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Cheveley House through its recruitment, employment and training procedures were ensuring that only suitably qualified care staff were employed. Staffing levels at the home were sufficient to meet the current assessed needs of the residents. EVIDENCE: From a review of the staff rota provided it was noted that staff were being deployed in sufficient numbers as to ensure the current needs of the 21 residents were being met. A resident commented, “care staff were very good and were always around when needed”. Another resident commented, “sometimes the care staff appeared to be very busy and that there was not enough care staff on duty”. From written information provided by the home to the Commission for Social Care Inspection it was noted that the home had provided an extra 117 care hours more than the guidance of 536 care hours per week as suggested by the Residential Care Forum to meet the current needs of the residents. It is essential though that the home does not fall below a minimum of five care staff on duty during the waking day as identified at the last inspection to ensure that residents needs are met. Cheveley House DS0000031184.V291630.R01.S.doc Version 5.1 Page 18 The home’s manager as well as external senior management must thoroughly and regularly review the deployment of care staff and care hours throughout the home to ensure that staffing levels at peak times meet the needs of the different groups of residents living at the home. There was a commitment to training for all staff at the home and currently over 80 of the homes care staff were qualified at NVQ level 2 in care or above. Staff had received appropriate induction training and there was also a rolling training programme operating in the home providing training for staff in moving and handling, first aid training, the safe handling and administration of medication and working with dementia training. Records were being maintained of all training being given in the home and individual records of training were being kept on the staffs files. Permanent staff or agency staff employed at the home had being recruited in accordance with the homes policies procedures and that of Durham County Councils. All of the appropriate employment checks prior to starting to work at the home had been undertaken and the result of these checks had been recorded appropriately. Cheveley House DS0000031184.V291630.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 31 NMS 33 NMS 35 and NMS 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Cheveley House has a positive and well lead management structure ensuring that the home promotes the health, safety and welfare of both residents and Staff EVIDENCE: There were clear lines of management, accountability and support systems to be found within the home. Formal supervision sessions were being given to all members of the care staff and ancillary staff. Cheveley House DS0000031184.V291630.R01.S.doc Version 5.1 Page 20 Records of staff supervision sessions were being maintained securely and staff confirmed that they had received copies of their supervisions. From discussions with staff it was confirmed that they were aware of the management structure within the home and outside of the home. Comments received from residents, relatives and visitors during inspection were positive; “staff were kind and considerate to their relative and nothing was too much trouble for them to do” and “the care staff were always there to help”. Minutes were being kept of the regular residents meetings and the responses to the points raised by residents during these meeting from the manager were also being kept. Regular fire alarm tests and fire drills had been undertaken at the home and records were being maintained accordingly. Records were also been were being maintained of when equipment had been serviced and who had undertaken and completed the work. Cheveley House DS0000031184.V291630.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 3 3 3 3 Cheveley House DS0000031184.V291630.R01.S.doc Version 5.1 Page 22 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. Standard Regulation Requirement Timescale for action 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 It is recommended that when the new care plans have been fully implemented that an audit of the care plans be undertaken to ensure that there are no inconsistencies in their content particularly in the areas of bathing and weight management. Cheveley House DS0000031184.V291630.R01.S.doc Version 5.1 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.V291630.R01.S.doc Version 5.1 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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