Inspection on 05/10/05 for Conifers

This inspection was carried out on 5th October 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Conifers 09/01/09

Conifers 18/01/08

Conifers 13/07/07

Conifers 18/04/06

Conifers 09/06/05

Conifers 14/10/04

Conifers 11/05/04

Similar services:

Deepdene Care Centre

Ferndale Residential Care Home

David Gresham House

Elizabeth House

Elvy Court Nursing Home

Fontenay Nursing Home

Clairmont Residential Home

Cornford House

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

CARE HOMES FOR OLDER PEOPLE Conifers Seal Square Selsey Chichester West Sussex PO20 0HP Lead Inspector Ms J Hartley Unannounced Inspection 5th October 2005 12:30 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 Conifers DS0000046710.V255841.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. Conifers DS0000046710.V255841.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Conifers Address Seal Square Selsey Chichester West Sussex PO20 0HP 01243 606436 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) Family Care Private Company Limited Mr Martin Pelling Care Home 20 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (20) of places Conifers DS0000046710.V255841.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Only service users over the age of 65 years of age may be admitted to the home. The home may accommodate one service user under the age of 65 years. 9th June 2005 Date of last inspection Brief Description of the Service: Conifers is a care home providing personal care and accommodation for up to twenty service users in the category of dementia, over sixtyfive years. It is owned by Family Care Private Company Limited and managed by Mr Pelling. The home is located in Selsey and is close to shops and other amenities in this seaside town. The responsible person on behalf of the company is Mr Samarasekara. It is a detached property with accommodation on three floors. It consists of eighteen single rooms and one double room. There are sitting areas and a dining room. The exterior is well maintained with garden facilities accessible to service users. Conifers DS0000046710.V255841.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was carried out over a period of three hours. The inspector examined information held on the service file since the last inspection in June 2005, and read the previous two inspection reports, the Service User Guide and the Statement of Purpose During the inspection the inspector spoke to two service users. The inspector undertook a tour of the premises and looked at three care plans and two staff files. Various record books, policies and procedures were also examined. This report should be read in conjunction with the report of the announced inspection held on 9th June 2005. All the key standards, which should be inspected in a twelve-month period, are covered in these two reports. What the service does well: What has improved since the last inspection? What they could do better: Staff files need to be updated to meet the requirements set out in the Standards. The home has a quality monitoring system in place. This would be improved by including the views of service users and other stakeholders. A fitting plate on a bath chair hoist was found to be rusty. This should be addressed, as it could be a risk to infection control. Conifers DS0000046710.V255841.R01.S.doc Version 5.0 Page 6 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. Conifers DS0000046710.V255841.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 Conifers DS0000046710.V255841.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): 1, 5 Prospective service users, or their families, are given the information they need to make an informed choice about where to live. They are also invited to visit the home prior to admission whenever possible. Standard Three was inspected at the last inspection and found to have been met. Conifers does not provide intermediate care, therefore Standard Six does not apply. EVIDENCE: Conifers has an up to date Statement of Purpose and Service User’s Guide which was examined prior to the site visit to the home. Both documents contain the information required, including how to contact the Commission. Service users, (or their relatives), are given a copy of each prior to moving into the home. The manager stated and records confirm that when a referral is received, the referrer, and where possible the service user, are invited to visit the home. The manager also arranges to visit the service user in his or her own home or Conifers DS0000046710.V255841.R01.S.doc Version 5.0 Page 9 in hospital to gain more information for the initial assessment, and to explain the service to the prospective service user. Service users move in on an initial one-month trial basis. On the day of the inspection a relative of a prospective service user was visiting the home. Conifers DS0000046710.V255841.R01.S.doc Version 5.0 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): 7 Every service user has an individual care plan that clearly records health, personal and social care needs. Standards Eight, Nine and Ten were inspected at the last inspection and were found to have been met. EVIDENCE: Three service users’ care plans were seen during this inspection. They all clearly set out the action to be taken by care staff to ensure that all aspects of the health, personal and social care needs of service users are met. All care plans are reviewed monthly and signed by the manager. Short-term changes to care needs are recorded clearly and in detail. Due to the level of dementia experienced by service users, it is not always possible for the plan to be drawn up with the involvement of the service user. Conifers DS0000046710.V255841.R01.S.doc Version 5.0 Page 11 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): 14 The staff and management at Conifers promote service users’ autonomy and choice. Due to the level of dementia experienced by service users in the home, they are unable to handle their own finances. Standards Twelve, Thirteen and Fifteen were inspected during the last inspection and were found to have been met. EVIDENCE: The two service users spoken to during the inspection said that they are able to make choices about what time they go to bed, what clothes they wear and what they eat. Service users’ bedrooms showed evidence that they are able to bring personal possessions with them when they move into the home. The manager said that prior to admission, information is gathered from the service user and/or their relatives on personal likes and dislikes. Evidence of this was seen in service users’ files. The manager also said that when a service user is first admitted, the cook spends some time with them finding out about their food preferences. Details on how to contact Age Concern for independent advice and advocacy are on the information board in the hall of the home. Conifers DS0000046710.V255841.R01.S.doc Version 5.0 Page 12 Due to the level of dementia experienced by the service users at Conifers, they are unable to maintain control of their finances. Conifers DS0000046710.V255841.R01.S.doc Version 5.0 Page 13 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): None of the above standards were inspected during this inspection. Standards Sixteen and Eighteen were inspected during the last inspection and were found to have been met. EVIDENCE: Conifers DS0000046710.V255841.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): 19, 20, 26 Conifers provides a safe well maintained environment that is clean, pleasant and hygienic. The decoration of the home is mainly of good standard but some areas require attention. There remains an issue with the siting of the laundry but a policy is in place to minimise risk. Some rust was found on a fitting plate of a bath chair hoist, this needs to be addressed, as it could be an infection control risk. Communal space available includes a lounge, dining room and conservatory. The lounge is a smoke-free environment. EVIDENCE: The location and layout of the home was found to be suitable for its stated purpose. On the day of the inspection it was clean, tidy and free from offensive odours. Furniture and decoration are homely, and lighting is domestic in character and sufficiently bright. The areas mentioned in the last report that are in need of redecoration, (one stairway, one bathroom and two bedrooms), have not all been attended to. All other areas in the home are well decorated and well maintained. Since the last inspection the redecoration of Conifers DS0000046710.V255841.R01.S.doc Version 5.0 Page 15 the lounge has been completed, and the lighting in the lounge has been improved. Conifers has a lounge, dining room and conservatory for the use of service users. There is adequate space and facilities for a variety of social, religious and cultural activities to take place. The grounds are well maintained, accessible to service users, and are enclosed to minimise the risk of service users accidentally wandering out of the homes’ garden. The fitting plate of a bath chair hoist is starting to rust; this needs to be addressed, as it could be an infection control risk. Access to the laundry is through the kitchen, although there is a policy in place informing staff to use a route outside the building to the laundry. Mr Samarasekara is planning an extensive refurbishment of the property, which when complete, will address this issue. Conifers DS0000046710.V255841.R01.S.doc Version 5.0 Page 16 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): 28, 29 Conifers has a minimum ratio of fifty per cent trained members of staff with NVQ level two or equivalent. The recruitment policy is thorough but the manager needs to ensure that all records required by the regulations are kept on staff files. Standards Twenty Seven and Thirty were inspected during the last inspection and were found to have been met. EVIDENCE: Records seen of staff qualifications indicated that the home has met the requirement that fifty per cent of care staff have an NVQ level 2, (or above), or an equivalent qualification. Case tracking of staff files highlighted that some files do not include proof of identification, although the manager would have seen proof of identification to apply for CRB and POVA checks. In one case only one reference was on file. The manager explained that this was due to the difficulty of obtaining references from abroad. The manager should keep photocopies on staff files and ensure that two written references are received prior to employment starts. The home has a thorough recruitment procedure that includes an informal discussion with the manager prior to an interview. Staff also undertake trial shifts prior to permanent employment. Conifers DS0000046710.V255841.R01.S.doc Version 5.0 Page 17 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): 31, 33 The manager is of good character and is able to discharge his duties in full. The home has a quality monitoring system in place to measure its’ success at meeting the aims and objectives and statement of purpose. The system should be expanded to include seeking the views of service users and professional involved in their care. Standards Thirty Five and Thirty Eight were inspected during the last inspection and were found to have been met. EVIDENCE: Training and qualification records seen show that the manager has the qualifications and experience needed to run the home. He has continued to update his knowledge, skills and experience whilst managing the home. Conifers DS0000046710.V255841.R01.S.doc Version 5.0 Page 18 Evidence was seen during the inspection that the home has a quality monitoring system in place that includes sending a questionnaire to relatives and monitoring complaints and compliments. The system should be expanded to include seeking the views of service users and professionals such as social workers, GP’s and nurses. It is also suggested that a formal system is put in place to review policies, procedures and practices on a regular basis. Conifers DS0000046710.V255841.R01.S.doc Version 5.0 Page 19 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 X X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 3 X X X X X 2 STAFFING Standard No Score 27 X 28 3 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X X X Conifers DS0000046710.V255841.R01.S.doc Version 5.0 Page 20 Yes 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 OP26 Regulation 23 Requirement The rust found on a fitting plate of a bath chair hoist, needs to be addressed, as it could be an infection control risk. The registered person must ensure that staff files contain all records required by the Care Homes Regulations. see Schedules two and four. Outstanding from last inspection. (Previous timescale of 9/08/05) The registered person should expand the current quality monitoring system to include seeking the views of service users and other stakeholders. Timescale for action 05/12/05 2. OP29 19 05/12/05 3. OP33 24 05/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Conifers DS0000046710.V255841.R01.S.doc Version 5.0 Page 21 1. OP19 That the areas of the home specified within this report are redecorated. Conifers DS0000046710.V255841.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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. 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