Inspection on 16/01/06 for Craghall Residential Home

This inspection was carried out on 16th 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Craghall Residential Home 03/05/07

Craghall Residential Home 17/05/06

Craghall Residential Home 27/07/05

Craghall Residential Home 06/01/05

Craghall Residential Home 24/06/04

Craghall Residential Home 24/02/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Craghall Residential Home Matthew Bank Newcastle Upon Tyne Tyne & Wear NE2 3RD Lead Inspector Elaine Malloy Unannounced Inspection 16th January 2006 10:30 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 DS0000039863.V263206.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. DS0000039863.V263206.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Craghall Residential Home Address Matthew Bank Newcastle Upon Tyne Tyne & Wear NE2 3RD 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 284 6077 Wellburn Care Homes Limited Mrs Christine Barbrook Care Home 38 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (32) of places DS0000039863.V263206.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th July 2005 Brief Description of the Service: Craghall is a care home that provides personal care to 32 older people and 6 older people with dementia. The home is located in South Gosforth and has extensive well kept grounds and car parking space. The property was converted to a care home. A major refurbishment and extension was completed in November 2004. This included installation of a passenger lift, stair lift and ramped areas to aid access. There are 34 single and 2 double bedrooms, 30 of which have ensuite facilities. Four bathrooms and a shower room are provided. There is access by public transport. Local amenities and shops are available in Gosforth and Jesmond. DS0000039863.V263206.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 6 hours. Standards were inspected through discussion with management and residents, and examining records. The building was also inspected. Each area that the home was asked to improve at the last inspection was checked. What the service does well: Each resident has individual plans that show how their care needs will be met. There are suitable arrangements to meet resident health care needs. Residents said staff are respectful and maintain their privacy and dignity. A good range of social activities and outings is provided. Residents are supported to keep contact with family, friends and the local community. Residents are given choices and encouraged to make decisions in daily living. A varied menu with choice of meals is offered, and residents said the food is good. There are procedures and staff training to protect residents from abuse. The building is kept to a good standard and is clean and hygienic. The home is working towards meeting targets for the ratio of staff who have achieved care qualifications. Methods are used to monitor the quality of the service. Resident personal finances are safeguarded. DS0000039863.V263206.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? An experienced manager has been approved for registration and she is studying for a management qualification. Action had been taken on the majority of the previously required improvements: Completing full care needs assessment of new residents before admission. Making arrangements to ensure suitable supervision and care of residents with dementia. Devising care plans that address dementia, mental health and behaviours. Improving systems for controlled medication and providing medication training for senior staff. Having consistent care staffing levels. Developing the recruitment process for new staff. Testing the fire alarms weekly. DS0000039863.V263206.R01.S.doc Version 5.0 Page 7 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. DS0000039863.V263206.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 DS0000039863.V263206.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): 3 and 4. New residents have their care needs assessed before being admitted to the home. Action has been taken to ensure suitable supervision of residents with dementia. EVIDENCE: At the last inspection a Requirement was made for needs assessment to be fully completed for all prospective new residents, and for this assessment to cover all areas specified in the Standard. This had been addressed. Evidence was seen in the care records of the last resident admitted to the home. The home provides care for older people with dementia. At the last inspection a Requirement was made for arrangements to be made to ensure suitable supervision and care of these residents, including designated staffing. Action had been taken to address the issues. Residents with dementia are not strictly segregated within the home however there is designated space in one of the communal lounges. Care staff were being allocated to work with residents with dementia at staff shift handovers. DS0000039863.V263206.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 and 10. Residents have care plans that show how their needs are to be met. There are suitable arrangements for residents to receive health care services. The medication system and staff training has improved, but staff were still not signing for all medication administered. The home operates practices to maintain resident privacy and dignity. EVIDENCE: A sample of care records was examined. Residents assessments are regularly updated and care plans were in place for identified health, personal and social care needs. At the last inspection a Requirement was made for care plans to be devised that address dementia/mental health/behaviour. This had been addressed. Evidence was seen of relevant care plans for residents with dementia. Five GP practices are used. The District Nursing Service was visiting twice weekly, or more often if needed. Arrangements are in place to access the services of NHS and private podiatry, optician and dentists. Mental health care DS0000039863.V263206.R01.S.doc Version 5.0 Page 11 professionals are accessed as required. All contact with medical professionals is separately recorded in personal care files. Staff escort residents to hospital appointments. Moving and handling, continence and nutritional needs are assessed and plans devised where necessary. Individual’s dietary needs are also communicated to catering staff, including special diets and likes/dislikes. The home’s medication records were examined. At the last inspection the following Requirements were made: (a) There must be no unexplained gaps to signatures within medication administration records. There was improvement to the recording of medication though some occasional gaps were still evident to signatures. (b) An audit must be completed of Controlled Drugs and entries to the CD Register to rectify errors, including stock balances. A Pharmacist and the Manager had carried out the audit. (c) Two staff signatures must be recorded for all entries to the Controlled Drug Register. Two staff were signing for each entry in the register. (d) Arrangements must be made for all staff who administer medication to undertake medication training. Senior staff only administer medication and all had now completed medication training. Personal care and medical examination/treatment is carried out in private, either in the resident’s bedroom or the treatment room. There is a pay telephone in a small lounge for resident use and some residents have their own telephones in bedrooms. Mail is given unopened and staff/relatives support residents in dealing with any correspondence. Staff check how residents prefer to be addressed and preference for gender of carer. No male carers are employed at present. Systems are in place to make sure that residents wear their own clothes. Clothing is labelled and there is named laundry baskets and lingerie bags. There are two double bedrooms in the home. One was currently used for single occupancy. Two relatives share the other room that has an en-suite facility, and they have declined screening. The Inspector talked with a number of residents who confirmed that staff are respectful and maintain their privacy and dignity. DS0000039863.V263206.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, 13, 14 and 15. Residents are offered a range of social activities and outings. Contact with family, friends and the local community is supported. Residents are given choices and encouraged to make decisions in daily living. Variety and choice of meals is offered and residents said the food is good. EVIDENCE: Residents’ social needs are assessed including details of their background, social interests and preferred routines. Social care plans are then devised. There is a forward planned monthly activities programme and a social diary is completed daily. Examples of recent activities were exercise classes, sing-along, ball games, quiz, art class, bingo, manicures, aromatherapy hand massage, and card games. There had been two outings this month, shopping in Eldon Square and tea at a local pub. Visiting entertainment is usually planned monthly. Photographs are taken of social events and outings. Residents told the Inspector that they enjoyed activities and have opportunities to out. The home has a visiting policy. Family and friends can visit at any reasonable time and are welcome to attend events and individual reviews of care. Contact DS0000039863.V263206.R01.S.doc Version 5.0 Page 13 is also maintained through correspondence and telephone calls. Some use is made of local amenities. Visitors from the community include clergy, and children from a local school whom occasionally entertain/dance. A volunteer had recently been appointed; the full recruitment process was followed. At the last inspection there was an outstanding Recommendation for information on advocacy services to be made available to residents and their relatives/friends. This had been provided. Nutritional needs are assessed and resident weights are monitored. The home has a 3-week seasonal menu. This was currently being revised, as some meals were less popular. Choice of dishes is offered. Completion of preference sheets was discussed. Residents had last met with the Cook in October 2005 to discuss meals. Residents spoken with said the food is good. No residents at present require assistance with feeding or feeding aids. Staff provide support to residents where necessary with meals by prompting and cutting up food. A number of residents choose to take meals in their bedrooms. DS0000039863.V263206.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): 16 and 18. The home needs to keep details of all complaints received. There are procedures and staff training to protect residents from abuse. EVIDENCE: Two complaints had been received in the period since the last inspection. The record of one complaint was available and this had been dealt with appropriately. The other complaint was sent to the company’s head office and investigated by the Care Director; information needs to be kept at the home. Residents spoken with said they had no cause for complaint, but would speak to management if they were unhappy. There are policies and procedures on prevention of abuse. Staff have received in-house training on abuse and whistle blowing (informing on bad practice). Protection of Vulnerable Adults training was being organised for all carers. There have been no allegations of abuse. Residents told the Inspector that they felt safe living at the home. DS0000039863.V263206.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 and 26. The building is maintained to a good standard. The home was clean and hygienic. EVIDENCE: In the period since the last inspection there had been ongoing maintenance and redecoration. The dining room was decorated and the floor was sanded and re-varnished. There were plans to replace the stair carpet leading to the kitchen. All parts of the home seen were appropriately decorated, furnished and equipped. Some bedroom doors were not closing fully; these had been reported for repair/adjustment. The home was clean. There are policies and procedures on control of infection. Hand washing facilities with liquid soap and paper hand towels are provided in toilets, bathrooms, sluice, laundry and the kitchen. Hand washing in bedrooms was discussed. Staff are provided with disposable aprons and gloves. There has been in-house training on infection control and additional training from the home’s training provider was being considered. DS0000039863.V263206.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): 27, 28, 29 and 30. There are sufficient staffing levels to meet the needs of the number of residents. The home is working towards meeting the standard of carers who have achieved care qualifications. Improvements have been made to the staff recruitment process. The staff training programme should be updated, and more staff need training in caring for people with dementia. EVIDENCE: At the time of the inspection there were 36 residents, 32 category Older People and 4 category Older People with Dementia. At the last inspection a Requirement was made for care staffing levels of 5 carers across the waking day and 3 carers at night to be consistently maintained. This had been actioned and was evidenced from staff rotas. Existing staff provide cover for absence/vacancies. 6 staff have completed NVQ care qualifications at either Levels 2 or 3, and 2 further staff were enrolled to study. The home has 15 carers and is working towards meeting the standard of 50 of carers achieving NVQ qualifications. There were currently staff vacancies for Team Leaders, Night Carer and Domestic/Laundry Assistant. Thes posts had been advertised. A sample of staff DS0000039863.V263206.R01.S.doc Version 5.0 Page 17 recruitment information was examined. At the last inspection there was an outstanding Requirement for references for new staff to be obtained from appropriate sources. There was also an outstanding Recommendation for gaps to employment history to be explored, and documentary evidence to be maintained of discussion and decision-making as a result of any traces on Criminal Records Bureau checks. Each of these issues had been addressed. At the last inspection a Requirement was made for all care staff to be provided with training in caring for people with dementia. This had not been fully addressed as not all carers have completed this training. There is a staff training programme however this was not up to date. Training in recent months had included induction for new staff, medication, dementia, supervision, health and safety and risk assessment, managing resources and the law and legislation. DS0000039863.V263206.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): 31, 33, 35, 36 and 38. There is now a Registered Manager who is experienced and working towards achieving a management qualification. She needs to be provided with supernumerary hours each week to fulfil management responsibilities. The home uses methods to monitor the quality of the service. Resident personal finances were recorded appropriately. There is a schedule for staff to receive individual supervision, and supervisors have completed training. Fire safety checks need to be carried out consistently. DS0000039863.V263206.R01.S.doc Version 5.0 Page 19 EVIDENCE: The Commission for Social Care Inspection approved Mrs Christine Barbrook as the Registered Manager for the home in October 2005. She has 7 years experience working in care, including 4 years in a senior/management capacity. She has completed NVQ Level 3 care qualification and is studying for the Registered Manager Award. Upon completion she will commence NVQ Level 4 in care. Mrs Barbrook is allocated 16 hours per week that are supernumerary to the care rota. These hours are for her to carry out management responsibilities. In the past month she had not had any supernumerary time due to covering on the rota to meet minimum carer levels. Wellburn Care Homes, the company that owns the home is accredited with the ‘Investors In People’ quality system. The home carries out surveys with residents that ask questions on staffing, car, comfort, activities, laundry, food, rights, privacy, independence and health and safety. Resident and relative, and staff meetings are held. A senior manager visits at least monthly and completes a report on the conduct of the home. Use of audits to monitor quality should be considered. Resident personal finance records were examined. A book is maintained with individual pages for each resident. This was suitably recorded with two signatures for each entry. Receipts are obtained and numbered to correspond to the transaction. At the last inspection there was an outstanding Requirement for a schedule of staff supervision to be devised that meets the standard of six supervisions annually. This was now in place. The Deputy Manager and all Team Leaders have completed supervisory training and will be taking some responsibilities for providing individual supervision. Staff are provided with training in safe working practices. Records of fire safety checks, tests and instructions were examined. At the last inspection there was an outstanding Requirement for fire alarms to be tested on a weekly basis, and monthly checks and tests of emergency lighting and fire equipment to be conducted and recorded. The alarms had been tested weekly, however the last check of emergency lighting and fire equipment was Novemeber 2005. Staff were being provided with monthly fire instructions. DS0000039863.V263206.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 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 3 X 2 DS0000039863.V263206.R01.S.doc Version 5.0 Page 21 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 OP9 Regulation 13(2) Requirement (Outstanding Requirement) There must be no unexplained gaps to signatures within medication administration records. (Outstanding Requirement) All care staff must be provided with training in caring for people with dementia. (Outstanding Requirement) Monthly checks of emergency lighting and fire equipment must be conducted and recorded. The Registered Manager must be provided with consistent supernumerary hours to fulfil management responsibilities. Timescale for action 16/01/06 2 OP30 18(1)(c) 16/04/06 3 OP38 23(4) 16/01/06 4 OP31 18(1)(a) 16/01/06 DS0000039863.V263206.R01.S.doc Version 5.0 Page 22 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 2 2 Refer to Standard OP16 OP30 OP33 Good Practice Recommendations The home should keep details of all complaints received. The staff training programme should be brought up to date. Audits should be introduced as part of the quality monitoring system. DS0000039863.V263206.R01.S.doc Version 5.0 Page 23 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 © 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 DS0000039863.V263206.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!