Inspection on 19/09/06 for Culby House

This inspection was carried out on 19th September 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Culby House 29/07/08

Culby House 18/07/07

Culby House 05/09/05

Culby House 31/05/05

Culby House 21/01/05

Culby House 24/06/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

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

CARE HOME ADULTS 18-65 Culby House Culby House 32 Warwick Road Cliftonville Margate Kent CT9 2JY Lead Inspector Christine Grafton Key Unannounced Inspection 19 September 2006 10:00 th Culby House DS0000023181.V306065.R01.S.doc Version 5.2 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 Culby House DS0000023181.V306065.R01.S.doc Version 5.2 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 Adults 18-65. 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. Culby House DS0000023181.V306065.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Culby House Address 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) Culby House 32 Warwick Road Cliftonville Margate Kent CT9 2JY 01843 298887 Mrs Jean Kelly Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Culby House DS0000023181.V306065.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th September 2005 Brief Description of the Service: Culby House is a small family style home occupying a terraced property with three bedrooms for residents use on the first and second floors. Residents have their own lounge/diner overlooking a small enclosed patio area to the back. The registered provider/manager, Mrs Kelly, lives at the home with her four children and has a separate lounge, dining room and bedroom accommodation for family use only. The residents have one toilet and a bathroom for their use and there are separate facilities for the family members. The home is situated in a residential area of Cliftonville, close to shops and other communal facilities. Parking is on-street. Mrs Kelly is the main carer but there is a volunteer, who regularly helps out. Information provided by the provider in the pre-inspection questionnaire on 17th May 2006 indicates that the weekly fees are £303.25. Culby House DS0000023181.V306065.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report takes account of information obtained from various sources, including a visit to the home, written information provided beforehand by the registered provider/manager and surveys completed by the three residents. An unannounced visit took place on 19th September 2006 between 10.00 hours and 12.50 hours and consisted of talking to the provider/manager, the three residents, looking round the home and checking some records. The care of all three residents was case tracked. What the service does well: What has improved since the last inspection? What they could do better: The provider needs to continue the work achieved since the last inspection in improving the overall record keeping of the home to protect residents’ best interests. All records should be properly dated and kept up to date. This is particularly important where risks are apparent, for instance, any risky activities that residents may wish to pursue should be fully discussed with them and any actions agreed documented and regularly reviewed. This makes sure that risks are properly managed to safeguard the residents and promote independence. Culby House DS0000023181.V306065.R01.S.doc Version 5.2 Page 6 The provider indicated that she had started the process for police checks to be carried out for the two new volunteers. These must be completed to show that residents are being properly safeguarded. The provider has a basic care qualification and has undertaken various short training courses to update her knowledge, but she does not have the management qualification that is expected of a person in charge of a residential care home. She has previously made a commitment to do the management and care qualification recommended in the standards. So far she has not achieved this because of the cost implications on the viability of this small home, but promised to continue her search to find a suitable way for her to do the training. 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. Culby House DS0000023181.V306065.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Culby House DS0000023181.V306065.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements have been made to the home’s admission process to make sure that prospective residents’ needs can be met upon moving in. EVIDENCE: At the last inspection, the provider was asked to formalise the admission procedure to make sure the needs of any new resident can be met in the home. Since then a new resident has been admitted to the home. The new person had visited the home before moving in and the provider had obtained some faxed information with basic details about the person’s needs. This covered general health, personal care needs, family relationships and independence. A care plan had been written providing additional information indicating that the person’s care was being thought through and planned. It had been a quick admission and much of the information in the care plan had been gathered following admission. The provider gave a good verbal account of the person’s needs. Following discussion, the provider agreed to add more detail in the care plan about the person’s mental health and to include a risk assessment. This was promptly addressed and evidence was subsequently seen to confirm it had been completed. Culby House DS0000023181.V306065.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans include a risk assessment element and provide the information necessary to meet residents’ needs. Residents are encouraged to take control of their own lives and maintain their independence EVIDENCE: The provider has continued to work hard to address previous inspection requirements and develop suitable care plans for people with mental health problems. Care plans have now been properly formulated for each resident providing some useful information. The quality of the three care plans varied, one contained all the necessary information and although the other two lacked some details, overall they were adequate. Following discussion at the site visit, the provider acted swiftly to add a few more details and to make sure the care plans are properly dated. Evidence was provided showing that the care plans now give a good overview of personal needs and the assistance required to meet the aims specified. Risk assessments have been added to the monthly reviews, which are more detailed. Daily records are recorded in individual Culby House DS0000023181.V306065.R01.S.doc Version 5.2 Page 10 diaries, providing brief details. The information is then expanded in the monthly review records that give some indication of decision-making and show how some risks are managed. All three residents go out into the local community independently and make their own decisions about their day-to-day lives. One of the residents manages their money completely independently and where the provider offers support with residents’ finances, proper records are kept and residents sign for any monies received. From discussion with the provider it was apparent that she is aware of certain activities residents pursue that involve a degree of risk and some risk assessments had been documented. However, these had not been fully completed for some evident risks. The provider described strategies she has in place to address those risks that had not been recorded in the care plans. This was rectified by 24th September and evidence has been seen to confirm this. Culby House DS0000023181.V306065.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the 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, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged and supported to pursue their own interests, maintain community links and lead independent lifestyles. Daily routines are flexible and residents enjoy their meals. EVIDENCE: Residents spoke about their daily activities, including going out to the local shops, cafes, pubs, library and visiting friends. They confirmed they could come and go as they please. None of the residents currently attend any further education classes, but one resident goes to a church drop in centre once a week and a care plan indicated that one had some involvement in a work activity. A resident spoke about contacts with a relative and of outings to another town several miles distance away. Residents are only allowed to smoke in their own lounge. Although one resident does not smoke, discussion with each resident indicated that they are Culby House DS0000023181.V306065.R01.S.doc Version 5.2 Page 12 all satisfied with this arrangement. The residents said there are not many home rules but understood the need to ensure fire safety rules are adhered to and agreed that the rules and daily routines suit them. Residents spend time in their lounge or their bedrooms as they wish. One resident sometimes goes out in the evenings, but the other two prefer to stay in and watch television. A resident confirmed that their privacy is respected and that other people in the house usually knock on their bedroom door and wait to be invited in. The residents each commented that the food is good. The provider confirmed that she knows residents’ food likes and dislikes and involves them in choosing the menus. Records of food provided had lapsed and the provider agreed to reinstate them. Evidence of the meals provided between 20th and 28th September was subsequently submitted, indicating a well-balanced, nutritious diet. Culby House DS0000023181.V306065.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate support is provided to ensure that residents’ personal and healthcare needs are met. Medication procedures are suitable for a small home of this size. EVIDENCE: Each resident’s care plan indicates the level of support needed to maintain their personal hygiene and the monthly review records contain details of any problems that may have occurred with this and how they have been dealt with. Healthcare needs are recorded and show when visits have been made to see doctors, psychiatrists, or other healthcare professionals, such as a dentist. Residents indicated that they had no current healthcare problems, although one spoke about a recent dental problem that had been resolved. The provider has completed a medication course and demonstrated an understanding of the drugs residents are currently prescribed. A monitored dosage medication system is in use and records of administration were signed for, with no gaps. Medication storage was checked and has previously been judged as adequate for a small home of this size. Culby House DS0000023181.V306065.R01.S.doc Version 5.2 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents know that their complaints will be listened to and acted upon. Procedures for protecting residents from abuse are clearly understood. EVIDENCE: The home’s complaints procedure is prominently displayed. All three residents said that they like living at the home and had no complaints. The new resident confirmed they knew the complaints procedure. All three residents said they would speak to the provider if they had a concern and it was clear from their comments that they felt confident she would address any concerns raised. One resident said that the provider listens to them and is very understanding. The provider said there have been no complaints since the last inspection. The provider has a copy of the local authority’s adult protection policy, protocols and guidance. At the last inspection, the provider talked through the procedure she would follow if abuse were suspected. Improvements have been made in recording risk assessments. Culby House DS0000023181.V306065.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment in this home is good providing residents with an attractive and homely place to live. EVIDENCE: The residents’ lounge was seen to be comfortably furnished, well decorated, clean and homely. Residents’ bedrooms are individually decorated and furnished and contain all the necessary furniture and fittings. Bedrooms have been personalised with residents’ own possessions and they said they like their rooms. All areas of the home seen on this occasion were clean, light and airy. The provider said she has an ongoing redecoration programme and the hall was in the process of being redecorated. Culby House DS0000023181.V306065.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Procedures are in place to make sure that people who occasionally provide care to residents are properly vetted. The registered provider is committed to her own personal development and continues to work well with the residents to improve their quality of life. The pursuit of further training would further benefit residents. EVIDENCE: The provider is the main carer in this small home and is assisted from time to time by a volunteer who has been police checked. The provider stated that two family members have also recently started to help out occasionally and she has sent for the forms for them to complete their criminal records bureau checks. There is a written procedure for volunteers to follow in emergency. The provider has recently completed a computer course. Other training she has completed this year includes a Basic Food Hygiene and Nutrition Awareness course and a Health & Safety in the Workplace course for which certificates were seen. The provider stated that she is committed to training to update her care practice, knowledge and skills, but has been unable to access further training to gain a higher national vocational qualification (NVQ) level Culby House DS0000023181.V306065.R01.S.doc Version 5.2 Page 17 recommended at previous inspections. It was clear from discussion that she has a good understanding of the mental health needs associated with the residents currently being cared for. Culby House DS0000023181.V306065.R01.S.doc Version 5.2 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The provider has developed a management style that suits this small home. Improvements in the record keeping must be maintained to fully safeguard residents’ best interests. EVIDENCE: The provider has been running this small home since 1994 and has an NVQ level 2 in care. At previous inspection visits, she has indicated her commitment to pursue further training to achieve an NVQ level 3 in care and to go on to a level 4 in management and care. However, as this is a small home with limited income, the provider stated that the cost of funding these courses would have a financial implication on the home’s viability. She has been trying to access help with the funding, but so far this has not materialised. She stated her intention to continue to pursue this. From discussions at this and Culby House DS0000023181.V306065.R01.S.doc Version 5.2 Page 19 previous inspection visits, it is clear that the provider has the experience necessary to run this small home appropriately. At the last inspection visit, the provider had outlined her plans for the future of the home to improve the service she provides for residents. Since then, she has had to change those plans, but spoke of other things that have occurred to compensate for this. The provider and residents both confirmed that any planned changes to the home are discussed. The provider has written policies and procedures that are appropriate for a small three-bedded home. Most of the required records are in place, but some had not been dated or kept up to date (such as the record of food provided). The provider acted swiftly to address this. Since the last inspection, the provider has updated her food hygiene certificate and she stated that her first aid training update has been booked for 5th October 2006. Other health and safety training completed has previously been referred to. The provider spoke about a fire talk she had given to the residents in June following which she had asked them to write down what they would do in the event of fire. She had kept their answers and the exercise had been recorded in their monthly review records. Residents also confirmed this. Domestic smoke detectors are fitted in the hall and on landings and there are fire extinguishers on each landing. A fire notice is displayed on the inside of the residents’ lounge door. Residents know they are not allowed to smoke in their bedrooms. Culby House DS0000023181.V306065.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 x 2 3 3 x 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 x 32 x 33 x 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 x 2 3 2 2 x Culby House DS0000023181.V306065.R01.S.doc Version 5.2 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 YA34 Regulation 18 Requirement Timescale for action 30/11/06 2. YA41 17 An enhanced CRB disclosure and POVA check must be obtained for any new volunteers and trainees must be appropriately supervised. (Carried forward from 05/09/05). The home’s records must contain 30/11/06 all the details specified in the regulations and must be kept up to date. 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. 3. 4. Refer to Standard YA6 YA9 YA35 YA37 Good Practice Recommendations That care plans are dated initially and then dated each time they are reviewed and changes occur. To continue with the development of residents’ risk assessments and to make sure that strategies to reduce risks are properly recorded. Volunteers to be appropriately trained and any training undertaken to be documented, including induction training. The registered provider should undertake training in care planning and pursue an NVQ level 3 in care followed by an DS0000023181.V306065.R01.S.doc Version 5.2 Page 22 Culby House 5. YA39 NVQ level 4 in management and care. (Carried forward from previous inspections). To document the annual development plan for the home (carried forward from 05/09/05) and to formalise the home’s quality monitoring process (e.g. results of residents’ surveys). Culby House DS0000023181.V306065.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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 Culby House DS0000023181.V306065.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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