CARE HOMES FOR OLDER PEOPLE
Coniscliffe Rest Home 37 - 43 Grosvenor Place Jesmond Newcastle Upon Tyne Tyne & Wear NE2 2RD Lead Inspector
Deborah Haugh Announced Inspection 16th January 2006 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 Coniscliffe Rest Home DS0000000437.V262407.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. Coniscliffe Rest Home DS0000000437.V262407.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Coniscliffe Rest Home Address 37 - 43 Grosvenor Place Jesmond Newcastle Upon Tyne Tyne & Wear NE2 2RD 0191 281 2553 0191 281 8690 coniscliffe@highfield-care.com 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) Southern Cross Home Properties Limited Mr Terence Lillico Care Home 43 Category(ies) of Dementia - over 65 years of age (12), Old age, registration, with number not falling within any other category (31) of places Coniscliffe Rest Home DS0000000437.V262407.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 15th September 2005 Brief Description of the Service: Coniscliffe is a care home that provides personal care to 43 older people and older people with dementia. The Home is located in Jesmond, a residential area of Newcastle upon Tyne and is a conversion of five large terraced houses. There is a range of local shops and amenities within walking distance and the area is well served by public transport. Coniscliffe Rest Home DS0000000437.V262407.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The announced inspection took place on 16/01/06 from 9.30 until 3.15pm. The Registered Manager, Mr Terry Lillico was on duty during the visit. There were 35 service users at the time of the visit. Staffing levels were checked. Time was spent looking around the home to check the cleanliness, maintenance and decoration during the visit. Prior to the inspection questionnaires were provided to service users and relatives. 13 questionnaires were completed by service users and some people shared their views during the inspection. Time was also spent observing the contact between the service users and staff. Four relative/Visitor questionnaires were completed and views were sought from visitors during the day. Three care plans were examined. Arrangements for the administration and management of medication were checked. Recruitment, training, service users finances that are looked after by the home and quality assurance were also examined. What the service does well:
All of the service users spoken with spoke highly of the care they receive and comments included; ‘Very nice here.’ ‘Its smashing here.’ ‘I like to read.’ ‘There’s a board which tells you what’s on the menu.’ ‘There’s always a choice.’ I would talk to Sam or Terry if I was unhappy.’ ‘The food here is excellent.’ ‘I would talk to the girls if I was unhappy.’ All of the service user questionnaires indicated that they felt safe, felt well cared for and that staff treated them well. Staff were observed to have good relationships with service users and people liked to share jokes. Staff were sensitive, responsive and discreet. Visitors and questionnaire comments included; - ‘The staff are kind and caring.’ Coniscliffe Rest Home DS0000000437.V262407.R01.S.doc Version 5.0 Page 6 - ‘Activities are organised by the home but these do seem intermittent. I wonder if items like magazines, newspapers, even drawing materials … could be constantly in lounges so that residents could be just encouraged to reach out and use them. I would like the residents to have more stimulation. I think the introduction of dolls has been a great success for some residents.’ (See NMS 12) - ‘X is very settled here. The staff are great. I can speak to Terry or Sam anytime.’ - ‘ No problems.’ - ‘This home is excellent, no problems here, always good care.’ All of the relative/visitor questionnaires indicated that they were made welcome, could visit in private and kept informed. Service users and staff spoke highly of the support of the Registered Manager Mr Lillico and the other seniors. Mr Lillico encourages service users and staff to fulfil their potential. One service user has won a competition to have her painting put in the Southern Cross calendar. The home has being quality assured and obtained a certificate ISOAQR in medication. This is commendable. In the past the home has been awarded a prize for the Newsletter. The care plans are positive and look at a range of service users needs. Links with other professionals are in place. Relationships with other professionals are positive. New activities introduced in the home are suitable for people with dementia. The introduction of doll therapy has been planned and sensitively handled with consultation with all concerned. The Activities Co-ordinator is getting to know the service users and was knowledgeable about their interest and hobbies. The home is flexible to requests from service users such as a request to go out for a drink or go for a walk. The staffing levels are maintained and appropriate to meet the needs of the service users. What has improved since the last inspection?
By end of January 2006 53 of care staff will be trained to a minimum of NVQ Level 2, which exceeds the standard. The standard required is 50 by 2005. All but one of the requirements made at the last inspection have been addressed. Medication changes have improved and good systems put in place. Hazards identified regarding a cracked bath, covering an electric socket and moving and handling training for staff addressed (October 2005). The home has new vertical blinds, a new entrance carpet and reception lounge carpet. New chairs have been purchased and add to a homely feel. New
Coniscliffe Rest Home DS0000000437.V262407.R01.S.doc Version 5.0 Page 7 flooring has bee provided in the dining room and a proposed new kitchen floor will be provided. 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. Coniscliffe Rest Home DS0000000437.V262407.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Coniscliffe Rest Home DS0000000437.V262407.R01.S.doc Version 5.0 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 3 was assessed and met at the last inspection. NMS 6 is not applicable. EVIDENCE: Coniscliffe Rest Home DS0000000437.V262407.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): 7,8, 9 & 10 Care plans are in place and staff have the information to meet service users needs. The health needs of service users are met and multi disciplinary working is taking place. The arrangements for the administration of medication are satisfactory. Resident’s dignity is respected. EVIDENCE: 7) Three service user care records were examined. Care plans look at a range of needs based on ‘Activities of Daily Living’. People’s preferences are included in the guidance to staff and staff were able to describe the approaches and their knowledge of service users. These are updated on a monthly basis. Risk assessments and risk management plans are in place. Supplementary reports and charts are also recorded. There is a system of initial and six monthly reviews of service users care. The arrangements for service users finances
Coniscliffe Rest Home DS0000000437.V262407.R01.S.doc Version 5.0 Page 11 must also be assessed i.e. personal monies, ability, risks, and representative’s support. Care plans must be put in place where appropriate. 8) Service users have access to a range of health professionals. Assessments are in place for pressure sore management, nutrition, falls, moving and handling and continence. Improvements are noted in some of the plans. 9) The requirements from the last inspection regarding medication have been addressed. A full audit was completed at the last inspection. 10) Service users questionnaires and comments said that they felt their privacy was respected and that staff treated them well. Visitors confirmed this. Staff receive training in Customer Care. Care plans document service users preferred name and this is used. Physical care and medical examinations are conducted in private. Coniscliffe Rest Home DS0000000437.V262407.R01.S.doc Version 5.0 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): 12,14 & 15 (NMS 13 were assessed and met at the last inspection). Service users are able to join in a variety of activities. Service users have control over their lives. Dietary needs of residents are well catered for with a balanced and varied selection of food available that meets resident’s tastes and choices as well as special dietary needs. EVIDENCE: 12) Service users are able to participate in a regular programme of arts and crafts, newsletter discussion groups, karaoke sing-a-longs, board games, bus outings, library service, chairobics. There are visits to a local bingo hall, pubs, theatres, shops, museums, church services and Jesmond Dene. Other activities are entertainers and singers. One person is going to celebrate her 100th birthday and one of the lounges has been set aside and the Sheriff invited to present the Queens Telegram. Entertainment is planned to celebrate the occasion for all of the service users. The Registered Manager continues to introduce activities for people with dementia and seeks training and guidance from University of Stirling, Dementia North and Newcastle General Hospital Challenging Behaviour Team.
Coniscliffe Rest Home DS0000000437.V262407.R01.S.doc Version 5.0 Page 13 The introduction of Doll Therapy following appropriate consultation and guidance is having good outcomes for some of the service users. The Registered Manager is committed to providing and reviewing the activities and occupation for service users. 14) Within the context of risk assessments service users are able to maximise their control over their lives. People are able to bring their own possessions with them and handle their own affairs. 15) Service users spoke positively about the food. The inspector shared lunch with service users. Lunch was unhurried and service users are able to have a choice and alternatives to the menu. The lunch choice was corned beef pie or fish Mornay with mixed vegetables creamed and croquet potatoes. Bread and butter pudding, custard, fruit and ice- cream were for dessert. Excellent information is available in the kitchen regarding service users nutritional needs, weights (loss of weight is highlighted and addressed) and preferences. The cook is competent and knowledgeable about the dietary needs of older people. The catering arrangements exceed the standard. The inspector observed several service users being assisted or encouraged to eat at lunchtime. This was done sensitively and discreetly. Staff sat with people and helped them. The atmosphere in the dining room was relaxed. Service users are able to have their meals in another lounge/diner or their room, which some people prefer. Coniscliffe Rest Home DS0000000437.V262407.R01.S.doc Version 5.0 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 & 18 were assessed and met at the last inspection EVIDENCE: Coniscliffe Rest Home DS0000000437.V262407.R01.S.doc Version 5.0 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): 19, 21 & 26 Service users live in a home, which is suitable for their needs. Improvements have been made to improve the quality of life for service users. Infection control measures protect service users. EVIDENCE: A tour of the premises with the Registered Manager found the home to be clean, well maintained and decorated. The home has new vertical blinds, a new entrance carpet and reception lounge carpet. New chairs have been purchased and all add to a homely feel. New flooring has been provided in the dining room and a new kitchen floor will be provided. The manager still intends to develop the rear garden for the benefit of the service users. Adequate numbers of bathrooms and toilets are provided for the current number of service users living in the home. However a walk-in shower would
Coniscliffe Rest Home DS0000000437.V262407.R01.S.doc Version 5.0 Page 16 be of benefit to service users in the interest of choice and personal hygiene. One of the toilet seat frames has areas where the paint has worn and this must be repaired or replaced. The Registered Manager is hoping to introduce printed and illustrated name plaques on bedroom doors following consultation with service users and/or their representatives. Infection control measures are robust. The laundry was clean and well organised. Delicate bags were suggested for hosiery or small items for individual rooms for laundry collection. Coniscliffe Rest Home DS0000000437.V262407.R01.S.doc Version 5.0 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): 27- 30 Staffing numbers are appropriate to the assessed needs of the residents, size and layout and purpose of the home at all times. Service users are protected from potential harm as robust recruitment systems are in place. Service users are cared for by staff that are trained and competent. EVIDENCE: 28 & 30) Staff must receive training for the safe moving and handling of service users. The home has exceeded National Minimum Standards for NVQ Level 2 training for care staff at 53 by end of January 2006. (Required level is 50 ). Five staff are to commence NVQ level 3 and 2 newly recruited staff will commence NVQ Level 2. Staff have also received training in the following - Protection of Vulnerable Adults (POVA) & Whistle Blowing - Fire safety - Moving and handling - Control of Substances Hazardous to Health (COSHH) - Oral Hygiene, Pressure Areas, Infection, Continence, Diabetes, Death & Dying. - Healthy Eating for the Elderly, Basic Food Hygiene, - Preventing Accidents, Health & Safety, First Aid.
Coniscliffe Rest Home DS0000000437.V262407.R01.S.doc Version 5.0 Page 18 - Dealing with confusion (planned training for Dementia) Challenging Behaviour, Bullying, Restraint Customer Care (planned) Alcohol and Drugs 29) Four staff recruitment records were sampled. Suitable systems and checks were found. Two references, Police and Protection of Vulnerable Adults checks and staff identity are in place. Sixteen staff Criminal Records Bureau certificates were checked and in place. Coniscliffe Rest Home DS0000000437.V262407.R01.S.doc Version 5.0 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): 31,33, 35 37 & 38 The Manager is experienced and is supported by the senior staff in providing clear leadership throughout the home, with all staff demonstrating an awareness of their roles and responsibilities. However categories of registration must be adhered to. Southern Cross is developing quality assurance systems. Arrangements for the management of service users own personal money protects service users. Records are maintained appropriately however the handover book does not. Service users are protected from robust health and safety arrangements. EVIDENCE:
Coniscliffe Rest Home DS0000000437.V262407.R01.S.doc Version 5.0 Page 20 31) The Registered Manager has completed the Registered Managers Qualification and is awaiting his certificate. Mr Lillico has also completed D32 and D33 NVQ Assessors Award. The Registered Manager has admitted a service user who the home is not registered for. This is not acceptable. An application for a variation of registration to reflect the admission of identified service user must now be applied for. 33) Southern Cross Care Homes Ltd acquired Highfield Care Homes and is developing quality assurance arrangements. The home informal quality assurance checks, which include monthly medication audits, Regulation 26 visits by the Company’s representative. Two policy and procedures are discussed each month at staff meetings. 35) Service users money, which is looked after by the home, is securely stored. Only the Registered Manager, Deputy and Administrator have access. Care plans must be put in place where service users require assistance with finances. Southern Cross is looking to open separate individual bank accounts for service users. 37) The home continues to record confidential information about service users in a Staff Handover Book. The record should refer to the service users individual care record for staff to read. 38) There were no hazards isdentified at this inspection but a toilet seat frame must be replaced/repaired as the front metal bars have very little paint left. An electric wiring certificate must be obtained and a copy sent to CSCI. Coniscliffe Rest Home DS0000000437.V262407.R01.S.doc Version 5.0 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X 2 X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X 2 2 Coniscliffe Rest Home DS0000000437.V262407.R01.S.doc Version 5.0 Page 22 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 OP31 Regulation 12 & 17 Requirement The Registered Manager must not admit service users who are outside of the categories of registration. An application for a variation of registration to reflect the admission of identified service user must be applied for. Confidential information must not be recorded in the Staff Handover Book. OUTSTANDING 23/09/05 Obtain an electric wiring certificate and provide a copy to CSCI. Repair/replace toilet seat frame (top floor bathroom wc) The arrangements for service users finances must be assessed i.e. personal monies, ability, risks, and representative’s support. Care plans must be put in place where appropriate. Timescale for action 16/01/06 2 OP37 17 16/01/06 3 OP21OP38 23(2) 31/03/06 4 OP7 15 31/03/06 Coniscliffe Rest Home DS0000000437.V262407.R01.S.doc Version 5.0 Page 23 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 OP21 Good Practice Recommendations Consider providing a walk in shower as a replacement for the damaged bath on the ground floor. Coniscliffe Rest Home DS0000000437.V262407.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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