Inspection on 13/02/06 for Crossways

This inspection was carried out on 13th February 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Crossways 24/10/06

Crossways 02/09/05

Crossways 03/02/05

Crossways 24/11/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Crossways 1 The Boulevard Sheringham Norfolk NR26 8LH Lead Inspector Mrs Marilyn Fellingham Unannounced Inspection 13th February 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 Crossways DS0000027294.V282356.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. Crossways DS0000027294.V282356.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Crossways Address 1 The Boulevard Sheringham Norfolk NR26 8LH 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) 01263 823164 01263 826185 Mr S Booth Mrs Dawn Clark Mr S Booth Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Crossways DS0000027294.V282356.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Crossways is registered as a private care home providing accommodation and personal care for up to twenty-three older people. It is sited within walking distance of all amenities close to the centre of the small seaside town of Sheringham and was originally two large, period houses dating from the turn of the century and has been restored, adapted and decorated to a high standard whilst retaining some of the original features and made into one property. There is a shaft lift to facilitate access to all floors and it has bedrooms situated on the ground, first and second floors. All bedrooms are single with a toilet and washbasin en-suite and four bedrooms also have en-suite bathing facilities. The design of some bedrooms gives service users additional living and sitting space and there is communal use of an adapted bathroom on each floor, a lounge, conservatory and large, dining room where all service users have their own dining table. The grounds, although not extensive, are kept tidy and provide small, safe areas to the side and rear of the property where service users can sit and parking to the side of the front of the property with space for a number of vehicles. Crossways DS0000027294.V282356.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over two and a half hours. A tour of the premises took place and staff and care records were inspected. Opportunity was taken to communicate with several of the service users, a few relatives and staff members as well as the management. What the service does well: What has improved since the last inspection? The care plans are much improved and the staff need to be commended for this. Records for assessment are now in place. A system has been set up for formal supervision and some supervisory sessions have taken place. New chairs have been provided throughout the home in all the communal areas. Crossways DS0000027294.V282356.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Crossways DS0000027294.V282356.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 Crossways DS0000027294.V282356.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): 4 Service users are confident that when they enter the home their needs will be met. EVIDENCE: The home now has a comprehensive system for assessment of service users prior to admission and records were seen for this activity. This assessment process is then used to formulate care plans for each individual admitted to the home. A service user who had recently been admitted to the home confirmed that he felt that he and his wife’s needs would be met and that they were lucky to be accepted into the home that was very good. Crossways DS0000027294.V282356.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9. Immense progress has taken place to ensure that the health care needs of the service users have been identified, met and evaluated. The administration and handling of medication is managed well. EVIDENCE: Individual care plans are available for all service users residing in the home, examination of six of these revealed that immense progress had taken place to ensure that all aspects of health, personal and social care needs were being identified and planned for. There was evidence to signify that the care was being evaluated and changed to meet the changing needs of all individuals. Those staff spoken to by the Inspector, felt that the care plans were much clearer and more easy to understand so that they felt that they could give the care that was prescribed. The Inspector found that the care prescribed was detailed and visits by other professionals such as G.P’s, community nurses, and continence advisors were recorded and any further changes to care added to plans of care. Crossways DS0000027294.V282356.R01.S.doc Version 5.1 Page 10 Risk assessments were in place especially related to individuals who were at risk of falling. Weights were being monitored and the care plans highlighted this activity and also recorded when specialist help had been sought. Training in techniques for the administration and handling of medication is on going and records were seen for this. The MAR charts appeared to be correctly used and indicated all given or refused medication, with the exception of two charts where some blanks were noticed and a recommendation is made. Crossways DS0000027294.V282356.R01.S.doc Version 5.1 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): 12. The home is developing its ability to provide options to satisfy service users social and recreational needs. EVIDENCE: The manager explained to the Inspector that he has started to provide extra staff in the mornings so that the residents can have uninterrupted time given to them so that they can enjoy one to one activities with the carers. Domestic duties have been reorganised in order to designate more time to pursuing recreational activities. Explanation of this new system was seen in the minutes of the last staff meeting. Those service users spoken to by the Inspector stated that they felt that their lifestyle in the home matched that of their expectations. Service users indicated that they chose what they wanted to do and felt that there were enough activities being offered to them to suit their needs. Those carers spoken with stated that there were more activities going on and that many of the service users wanted to participate in them. Crossways DS0000027294.V282356.R01.S.doc Version 5.1 Page 12 Crossways DS0000027294.V282356.R01.S.doc Version 5.1 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): 16,18. Arrangements for dealing with complaints are satisfactory. Service users appear to be protected from abuse. EVIDENCE: The procedure for making a complaint was examined by the Inspector; it was straightforward and easy to understand. Those service users spoken to stated that they would know who to make a complaint to, but felt they would never need to do this. Most of the concerns expressed by the service users are small issues that are dealt with on a day to day basis, this is because the manager/provider spends a lot of time in the home and every one including the staff find him most approachable. Records for training were examined and they confirmed that training in all matters related to the protection of vulnerable adults had taken place and was on going. Those staff spoken to confirmed this and they also were very positive about Whistle Blowing and all matters relating to abuse. Crossways DS0000027294.V282356.R01.S.doc Version 5.1 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): 19,24,26. Service users continue to live in a well-maintained and safe environment surrounded by their own possessions. The home is exceptionally clean, pleasant and hygienic. EVIDENCE: A tour of the home by the Inspector took place and all rooms inspected were found to be well maintained and in good decorative order throughout. All the rooms are neatly and pleasantly furnished with many of the service users having their own possessions around them. All those service users spoken with expressed their delight in their rooms and felt they met their needs and that they were very comfortable. The home itself was found to be exceptionally clean and tidy throughout. Crossways DS0000027294.V282356.R01.S.doc Version 5.1 Page 15 Crossways DS0000027294.V282356.R01.S.doc Version 5.1 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): 27,28,29,30. Staff at the home are employed in sufficient numbers to adequately meet the needs of the service users, especially in the mornings to facilitate more activities. The home enjoys a good record for retention of staff. The service users are protected by the home’s recruitment policy and practice. Staff have a good understanding of service users support needs. EVIDENCE: Examination of duty rosters confirmed that the home is adequately staffed and operates above the minimum level in the mornings to enable staff to engage in activities with the service users on a one to one basis. Service users spoken to indicated that they felt they were well looked after and were in safe hands. Training records supported this, on the day of inspection a training session for infection control had been arranged and staff confirmed that they were going to attend. All staff appear well trained and competent to carry out their jobs. Although no new staff had been employed recently the manager confirmed that he would always request two references and obtain all the appropriate Crossways DS0000027294.V282356.R01.S.doc Version 5.1 Page 17 checks including POVA before commencement of employment of any new member of staff. Crossways DS0000027294.V282356.R01.S.doc Version 5.1 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): 31,33,36. There is very clear leadership within the home. The home needs to activate a system for monitoring care. Staff are going to be appropriately supervised. EVIDENCE: The manager/provider takes a most active part in the running of the home; he is most competent and able to discharge his responsibilities fully. The staff are clear about their roles within the home. Discussion took place between the manager and the Inspector about the provision of a system for monitoring care given in the home; this is being Crossways DS0000027294.V282356.R01.S.doc Version 5.1 Page 19 addressed but is not functional at the moment and a requirement is made to ensure that this happens. A system for formal supervision has been introduced and the Inspector saw records for this and staff confirmed that they had, had, some sessions on this. Crossways DS0000027294.V282356.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 x x x x 4 X 4 STAFFING Standard No Score 27 4 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 1 x x 3 x x Crossways DS0000027294.V282356.R01.S.doc Version 5.1 Page 21 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 OP33 Regulation 24 Requirement The registered person shall establish and maintain a system for reviewing at appropriate intervals and improving the quality of care. Timescale for action 13/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations It is recommended that accurate records are made of all given or refused medication. Crossways DS0000027294.V282356.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Crossways DS0000027294.V282356.R01.S.doc Version 5.1 Page 23 - 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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