Inspection on 05/09/05 for Culby House

This inspection was carried out on 5th September 2005.

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 6 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 19/09/06

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 32 Warwick Road Cliftonville Margate Kent. CT9 2JY Lead Inspector Christine Grafton Announced 05/09/05 at 14:00hrs 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 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 Stationary 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 H56-H05 S23181 Culby House V241665 050905 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Culby House Address 32 Warwick Rd, Cliftonville, Margate, Kent. CT9 2JY Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01843 298887 Mrs Jean Kelly Registered Care Home 3 Category(ies) of Mental Disorder registration, with number of places Culby House H56-H05 S23181 Culby House V241665 050905 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31/5/2005 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 4 children and has a separate lounge, dining room and bedroom accommodation for family use only. The residents have their own toilet and separate bathroom 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. Mrs Kelly is the main carer but there is a volunteer, who regularly helps out. The residents live independent lifestyles within a supportive environment. The environment is homely and well maintained. Culby House H56-H05 S23181 Culby House V241665 050905 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over half a day. The total time spent at the home was 3 hours 15 minutes. Additional time was spent in preparation and report writing. The inspection consisted of speaking with the registered provider/manager and the 2 residents, checking records and looking round communal areas of the home, plus one bedroom. The focus of this inspection was to check whether standards identified at the last inspection were being maintained and to see what progress had been made on meeting the requirements of that inspection. At the time of this inspection there were 2 residents and the care of both residents was case tracked. The outcome of this inspection indicates that the registered provider is committed to providing appropriate care for the residents in this small home. What the service does well: What has improved since the last inspection? What they could do better: The registered provider knows the residents well and provides the support they need to meet their care needs. However, the home’s record keeping does not Culby House H56-H05 S23181 Culby House V241665 050905 stage 4.doc Version 1.40 Page 6 provide the necessary protection for residents to make sure that information is not lost and that residents’ care is properly managed. The residents’ care plans need to be further developed to give a full picture of each individual. This should include all their various needs and wishes, the plans to achieve things identified in the care management assessments and any other care needs identified within the home’s own assessment process. The care plans devised since the last inspection do not have enough information yet. The care plans should follow on from a full assessment undertaken within the home and cover a range of needs, rather than just one part of the assessment (as is the current case). They should also show how the care is to be provided, listing the actions needed to achieve the desired outcomes. Any identified risks must show the strategies to be adopted to reduce risk and protect residents and other people. This whole process must start at the pre-admission stage for any new residents admitted to the home. As the registered provider is the sole carer she must do the training specified in the standards herself and keep regularly updated to remain competent, as she has no one to share these skills between. Training in care planning is needed to improve her understanding and to develop the care provided. Record keeping generally needs to be developed. The provider hopes to do this once she has completed her computer 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 H56-H05 S23181 Culby House V241665 050905 stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Culby House H56-H05 S23181 Culby House V241665 050905 stage 4.doc Version 1.40 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 standard(s) 2 & 3 Residents feel their needs are being met at the home, but there is no written assessment process to ensure that the needs of new residents can be met. EVIDENCE: There have been no admissions to the home since July 2004. Since the last inspection, a resident has moved out and the home now has a vacancy. It is therefore important that the home has a clear admission procedure to ensure that the needs of any new resident can be met in the home. This decision must be made and recorded before the new person moves in. The registered provider has still not formalised the pre-admission assessment process and the home does not yet have its own working care plans for each resident, although there has been some progress in starting these (see under section 2). The needs of the two current residents were described verbally and it was clear that the provider knows much about their personal and health care needs that is not currently recorded within individual care plans. Therefore there is no evidence to show that the care provided is thought through and planned, rather than given in a reactive way as needs arise, or changes occur. Culby House H56-H05 S23181 Culby House V241665 050905 stage 4.doc Version 1.40 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 standard(s) 6 & 9 The registered provider has made some progress in trying to introduce individual care plans for each resident. These do not yet contain sufficient information to ensure that care is planned and structured to meet residents’ needs. There are no risk assessments, or risk management strategies in place to safeguard residents and other people. EVIDENCE: Since the last inspection, a care plan document has been devised, but it does not cover a full range of needs appropriate for people with mental health problems living within a residential care setting. The document has been copied from a care management assessment/care plan and contains things that are not relevant and lacks other things that should be included. It does not include assessment and management of risk, for example, there was a record of verbal aggression, but there were no records to show whether, or how this had been followed up. The discussion with the registered provider indicated that the care manager had been consulted and visited the resident to agree a way to overcome their frustration. This had not been recorded. Other significant events had occurred that had resulted in strategies being adopted that had not been recorded. Good record keeping is important as an integral part of care to make sure that things are not forgotten and are recorded as reference points to look back on and identify patterns of behaviour that require Culby House H56-H05 S23181 Culby House V241665 050905 stage 4.doc Version 1.40 Page 10 professional advice, or intervention. The registered provider would benefit from some training in care planning and agreed to pursue this. Both residents go out independently and in one case, where this had involved an element of risk, the registered provider described how an agreement had been reached with the resident about a way in which this could be managed. There is no longer any risk in this particular thing, but none of this had been recorded, which is a pity, as it would have provided supporting evidence of a risk that had been appropriately managed. Culby House H56-H05 S23181 Culby House V241665 050905 stage 4.doc Version 1.40 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 standard(s) none inspected on this occasion EVIDENCE: The key standards were inspected at the last inspection of 31st May 2005 and were all met. The reader is advised to refer to that report for evidence of compliance with these standards. Culby House H56-H05 S23181 Culby House V241665 050905 stage 4.doc Version 1.40 Page 12 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 standard(s) 19 & 20 Residents feel their healthcare needs are being met. Medication administration records need some improvement to protect residents. EVIDENCE: Most healthcare needs are recorded in the residents’ monthly summaries. These give some indication of how personal care needs are being met and refer to visits to doctors’ surgeries and contacts with other professionals, such as psychiatrists and a chiropodist. The home works with care managers and the local mental health team to support residents to maintain their health. Residents spoke about contacts with their care managers. One resident’s care manager had recently visited and the other resident spoke of seeing his care manager at a local centre. Both residents said that their health needs were being met. Medication administration records (MAR sheets) were seen. There had been a problem in obtaining one drug from the pharmacy that provides the home with its monitored dosage system. The drug had been obtained from a different pharmacy, but it had not been signed for on the MAR sheet as being administered. The registered provider said it had been given and this was apparent from checking the numbers of tablets left. The registered provider said that she would ensure that all drugs are signed for when administered in future. Culby House H56-H05 S23181 Culby House V241665 050905 stage 4.doc Version 1.40 Page 13 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 standard(s) 22 & 23 Residents know that their complaints will be listened to and acted upon. The registered provider knows what to do to protect residents from abuse, but record keeping needs to be improved to fully safeguard residents. EVIDENCE: The home’s complaints procedure is prominently displayed. Residents said they like living at the home and had no complaints. They both said they could speak to the registered provider or their care managers if they had any complaints. A resident said that the registered provider usually sorts out things if they have a worry. The registered provider has a copy of the local authority’s adult protection policy, protocols and guidance. She talked through the procedure she would follow if abuse was suspected and was able to identify the different forms of abuse. The procedure for dealing with verbal aggression by a resident was not being properly recorded. (See under standard 9 above). Culby House H56-H05 S23181 Culby House V241665 050905 stage 4.doc Version 1.40 Page 14 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 standard(s) 24 & 30 The standard of the environment within this home is good providing residents with an attractive and homely place to live. EVIDENCE: The residents’ lounge has recently been redecorated and new flooring provided. Residents are pleased with the result and said that they feel the room is very homely. They also have the sole use of a small private enclosed patio area with flowers and a water feature. The lounge has a fish tank, television, comfortable seating, plus dining table and chairs. Residents have their own drinks making facility. The vacant bedroom has been provided with new furniture. The areas of the home seen were clean, comfortably furnished, light and airy. Culby House H56-H05 S23181 Culby House V241665 050905 stage 4.doc Version 1.40 Page 15 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 & 35 The process for vetting the one person who regularly helps at the home has been satisfactorily completed to safeguard residents, but this must be extended to cover any other volunteers (including family members) who help out. The registered provider is committed to her own personal development and works positively with residents to improve their quality of life. Further training is necessary to fully meet some of the standards. EVIDENCE: The registered provider is the manager and sole carer in this small home. A volunteer regularly helps out and a police check has been obtained since the last inspection. Police checks and protection of vulnerable adults register (POVA) checks must be carried out for anyone else who might occasionally help out in supervising or caring for residents. An eighteen year old family member is sometimes left to supervise residents for short periods while the registered provider is out. There was no evidence of any risk assessment having been carried out, or of the procedure to be followed if an emergency should occur. The registered provider is committed to training, has recently completed an adult literacy course and is currently attending a basic computer skills course. She aims to continue with the next level in computer studies and said that once this is completed, she would pursue other short courses to update her care practice, knowledge and skills. Culby House H56-H05 S23181 Culby House V241665 050905 stage 4.doc Version 1.40 Page 16 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39, 41 & 42 This home is generally well run, but improvements are needed in the record keeping to ensure that residents’ best interests are safeguarded. EVIDENCE: The registered provider has a good relationship with the residents, who said that she is supportive and listens to their views. The provider talks to residents about any proposed changes in the home and makes sure they understand, for example, the decorating of the lounge. Residents had completed comments cards prior to the inspection, which were put in sealed envelopes. They said the provider had encouraged them to say what they like about the home and if there is anything they feel could be improved. A notice of inspection was displayed and the residents were fully involved in the inspection. The provider spoke of her plans for the future of the home and it is clear that she has a vision to improve the service she provides. None of this is documented yet but the provider has recorded her aims and has written policies and procedures that are appropriate for this small three-bedded home. Record keeping generally is an area that needs further attention as previously stated throughout this report. Culby House H56-H05 S23181 Culby House V241665 050905 stage 4.doc Version 1.40 Page 17 The registered provider has a current first aid certificate and has attended a basic food hygiene course in the past. The home’s fire safety procedures include: domestic smoke detectors in the hall, on landings and in one bedroom, fire extinguishers on each landing and a fire notice displayed on the inside of the residents’ lounge door. Residents are not allowed to smoke in bedrooms. The provider stated that the gas fires and boiler are checked annually. Culby House H56-H05 S23181 Culby House V241665 050905 stage 4.doc Version 1.40 Page 18 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 2 2 x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score x x x 2 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Culby House Score x 2 2 x Standard No 37 38 39 40 41 42 43 Score x x 2 x 2 2 x H56-H05 S23181 Culby House V241665 050905 stage 4.doc Version 1.40 Page 19 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 YA2 Regulation 14 Requirement Timescale for action 30/11/05 2. YA6 15 3. YA9 13(4) 4. YA20 13(2) An assessment must be undertaken prior to admission and the registered person must confirm in writing to the person that their needs can be met at the home. A full assessment must be completed following admission and a care plan drawn up. (Previous requirement 21/1/2005 & 31/5/2005 not met and carried forward). Each resident must have an 30/11/05 individual care plan showing how their needs in respect of health and welfare are to be met. Plans to be kept under review and updated as needs change. (Previous requirement 21/1/2005 & 31/5/2005 - some action taken, but requirement carried forward). Individual risk assessments must 30/11/05 be recorded for each resident, showing management strategies and any other actions to be taken to minimise risks and hazards. (Previous requirement 21/1/2005 & 31/5/2005 not met and carried forward). Medication administration 20/9/2005 records must be signed for each Version 1.40 Page 20 Culby House H56-H05 S23181 Culby House V241665 050905 stage 4.doc drug administered. 5. YA34 18 & 19 Any person who works at the 30/11/05 home to supervise or care for residents must be properly vetted (CRB/POVA checks) and trained. (To include family members). Trainees must be appropriately supervised. The registered person must 30/11/05 ensure that the homes records contain all the details specified in schedules 2, 3 & 4. 6. YA41 17 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. Refer to Standard YA35 YA39 YA42 Good Practice Recommendations The registered provider should undertake training in care planning and pursue an NVQ level 3 and/or level 4 in care, plus level 4 in management. That the annual development plan for the home is documented. That food hygiene training is updated. Culby House H56-H05 S23181 Culby House V241665 050905 stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection 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 H56-H05 S23181 Culby House V241665 050905 stage 4.doc Version 1.40 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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