Inspection on 01/06/05 for Culliford House

This inspection was carried out on 1st June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Culliford House 08/07/09

Culliford House 09/07/07

Culliford House 24/07/06

Culliford House 04/10/05

Culliford House 25/02/05

Culliford House 17/08/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Culliford House Icen Way Dorchester Dorset DT1 1ET Lead Inspector Val Hope Unannounced 1st June 2005 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 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. Culliford House D55 S26789 CULLIFORD HOUSE V230659 010605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Culliford House Address Icen Way Dorchester Dorset DT1 1ET 01305 266054 01305 266259 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) Mrs R F Moors Mrs Suzanne Jackson CRH - Care Home only 25 Category(ies) of Old Age not falling within any other category registration, with number (OP) of places Culliford House D55 S26789 CULLIFORD HOUSE V230659 010605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 25th February 2005 Brief Description of the Service: Culliford House is situated close to the town centre of Dorchester and within easy proximity of shops and other amenities. The property is is a large elegant Victorian house retaining many period features. The house has been sympathetically extended and is set in its own attractive landscaped gardens with a large car park to the front of the property. This is a well established family-run home, in the ownership of Mrs R Moors (proprietor) since 1985. Suzanne Jackson is Mrs Moors’ daughter and the registered manager. Mrs Jackson is assisted by Mrs Ann Moors who is deputy manager. Culliford House is registered to accommodate a maximum of 25 elderly people. Accommodation is provided at ground, first and second floor levels of the home. A passenger lift affords level access throughout the home. Culliford House D55 S26789 CULLIFORD HOUSE V230659 010605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 1st June 2005 commencing at 09:50. The total time spent on this inspection was 6 hours. This included preparation time, a tour of the premises, inspection of records and discussion with five members of staff and 11 residents. The registered person, Mrs Rita Moors and her daughter Mrs Suzanne Jackson who is the registered manager assisted the inspector throughout the inspection. Of the 38 National Minimum Standards, 15 of the 18 Key Standards and 17 of the remaining 20 Standards were assessed. What the service does well: Culliford House continues to provide a good standard of care in elegant, comfortable and attractive accommodation. The bright and spacious communal areas comprising large lounge, conservatory and dining room provide pleasant and relaxing surroundings. The décor and presentation of all areas of the home is of a very high standard, there are 22 rooms in the home with three registered as doubles. These are mostly used as singles and are generous in size; four rooms measure at least 20 square meters. A passenger lift provides access to all floors and all bedrooms have en suite toilets and there are assisted use bathrooms for service users with impaired mobility. An exceptionally high standard of cleanliness was apparent; residents said this was always the case, a fact they clearly feel very proud of. All rooms have now been subject to total refurbishment and it is the policy of the home to redecorate/refurbish each room upon vacation. Residents are encouraged to bring with them their own favourite possessions where possible and all the rooms viewed were well personalised by the occupant. The provision of food is of a high standard; a good wholesome and varied menu is offered. Residents likes and dislikes are well-known and taken into account when menu planning. Meals are very well presented and served in pleasant and congenial surroundings in the dining room or privately in rooms where so wished. Residents said that they feel very well cared for and that the kindness of management and staff is “second to none”. The promotion of independence and the protection of privacy and dignity is something residents of the home clearly value, they said that they are treated with respect and their privacy and dignity is protected, particularly whilst personal care tasks are being Culliford House D55 S26789 CULLIFORD HOUSE V230659 010605 Stage 4.doc Version 1.30 Page 6 undertaken. The welcome and hospitality received by relatives and visitors is much appreciated by residents. Without exception, positive comments were received from residents including: “It is excellent her, I could not be better cared for everyone is so kind and I do as I please”; “They are always willing to help and no one minds”; “They work hard to make us comfortable, the food is excellent and my room and everywhere is always spotless”; “I could not be cared for better and feel glad I was able to move in, I love my room and the food is wonderful”. What has improved since the last inspection? 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 Culliford House D55 S26789 CULLIFORD HOUSE V230659 010605 Stage 4.doc Version 1.30 Page 7 contacting your local CSCI office. Culliford House D55 S26789 CULLIFORD HOUSE V230659 010605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Culliford House D55 S26789 CULLIFORD HOUSE V230659 010605 Stage 4.doc Version 1.30 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 standard(s) 1, 2, 3, 4, 5 and 6. The home’s Information Pack, which includes the Statement of Purpose, requires some amendment as it does not quite meet the standard and therefore residents are not fully informed. Prior to admission, the needs of each prospective resident are assessed to ensure the home will be able to properly meet them. Prospective residents and/or their representatives are encouraged to visit the home in advance of admission to assist them in making an informed choice. A formal signed agreement relating to the terms and conditions of residence safeguards and provides clarity for residents. The home does not provide intermediate care. EVIDENCE: A copy of the home’s information pack was provided to the inspector. It is comprehensive and well presented but amendments need to be made; the Culliford House D55 S26789 CULLIFORD HOUSE V230659 010605 Stage 4.doc Version 1.30 Page 10 necessary amendments were outlined to the home in an email on 9th June 2005. The statement of purpose did not contain information relating to actual fire precautions and associated emergency procedures in place in the home and stated that care plans are reviewed three monthly when they are in fact, reviewed monthly to comply with standard 7. The home’s small pictorial brochure gives a good idea of the presentation of the home however it inaccurately states that the home is registered with DCC (Dorset County Council), the home was registered with the local authority (DCC) prior to 2002 and now only contracts with it. All documents should be amended to refer to Commission for Social Care Inspection (CSCI) and not its predecessor the National Care Standards Commission (NCSC). Care plan files demonstrated that assessments of need have been undertaken prior to admission to enable the home to prepare a plan of care to be implemented from the day of admission. Residents spoke of being able to visit the home prior to admission to assist them in making the decision whether to move in or not. Each resident has a terms and conditions agreement in place. Culliford House D55 S26789 CULLIFORD HOUSE V230659 010605 Stage 4.doc Version 1.30 Page 11 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 standard(s) 7, 8, and 10 Care plans are detailed and of a very good standard ensuring staff have the information they need to satisfactorily meet resident’s needs. The health needs of residents are well met and good multi disciplinary working takes place on a regular basis promoting and maintaining (where possible) good health. Residents are treated with respect and their privacy and dignity is promoted enhancing their quality of life. EVIDENCE: The care plans of three residents were examined. Discussion with staff found that they are very knowledgeable about residents care needs. The plans of care relating to specific care needs [e.g diabetes] contain input from specialist health professionals. Care plans are regularly reviewed and case notes, accident records and risk assessments cross-reference satisfactorily. Health professionals’ visits are satisfactorily recorded. Residents said they feel respected and that care tasks are undertaken in a way which ensures they are able to retain dignity. Culliford House D55 S26789 CULLIFORD HOUSE V230659 010605 Stage 4.doc Version 1.30 Page 12 Culliford House D55 S26789 CULLIFORD HOUSE V230659 010605 Stage 4.doc Version 1.30 Page 13 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 standard(s) 12, 13, 14 and 15. Social, cultural and recreational activities are dependent on individual preferences and the resident’s capacity for involvement. The activities provided by the home meets the expectations of residents. Residents are supported in maintaining contact with their friends, family and the community and they are helped to exercise choice and control over their lives promoting independence. A good wholesome varied diet is provided, meals are appetising and of good quantity and quality, assisting with the promotion and maintenance of health. EVIDENCE: Residents said that they have choice in all the routines of daily living. Several of the residents said they go out regularly whenever they feel like it. Residents said that there has been an improvement in the social activities programme provided; the home’s deputy and a designated carer have carried out individual assessments for social needs, which have been recorded. Visitors are made welcome at any reasonable time, are offered refreshments and arrangements can be made for relatives from outside the area to stay Culliford House D55 S26789 CULLIFORD HOUSE V230659 010605 Stage 4.doc Version 1.30 Page 14 overnight in the separate apartment on the top floor of the home. This is also available for use by relatives if a resident is seriously ill and/or dying. The standard of food provision, presentation and serving is high. There are two cooks, one of 20 years standing and both have recently achieved the Intermediate Food Hygiene Certificate. Culliford House D55 S26789 CULLIFORD HOUSE V230659 010605 Stage 4.doc Version 1.30 Page 15 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 standard(s) 16, 17 and 18 The home has a satisfactory complaints system, which is properly managed; residents are confident their concerns are listened to and taken seriously. The legal rights of residents are protected and they are enabled to participate in the civic process. Members of staff demonstrated a good knowledge and understanding of Adult Protection issues, this contributes to providing a safe environment to protect residents from abuse. EVIDENCE: No complaints have been made to the home or the Commission since the last inspection. Information given in the home’s information pack relating to complaints should advise that complaints may be made to the Commission for Social Care Inspection at any time, not just if they are dissatisfied with the home’s investigation of their complaint. Discussion with residents found that they were assisted to participate in the civic process if they wanted to and postal votes have been arranged for those who wish to vote in this way. Staff spoke of their training in adult protection issues. Culliford House D55 S26789 CULLIFORD HOUSE V230659 010605 Stage 4.doc Version 1.30 Page 16 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 standard(s) 19, 20, 21, 22, 23, 24, 25 and 26. On-going investment in both interior and exterior of the property ensures residents live in a safe, well maintained environment. There is ample indoor and landscaped outdoor space creating a relaxing, peaceful environment for residents. Adequate toilet, washing and bathing facilities are in place to meet the needs of residents. Residents have the specialist equipment they require to maximise their independence. Residents live in attractive, elegant, comfortable clean and hygienic surroundings suited to their needs and with their own belongings around them for their comfort. A very high standard of cleanliness is maintained for the comfort and safety of residents. Culliford House D55 S26789 CULLIFORD HOUSE V230659 010605 Stage 4.doc Version 1.30 Page 17 EVIDENCE: The home meets with the requirements of Dorset Fire and Rescue Service and Environmental Health Department. Fire precautionary measures were satisfactory the home’s fire risk assessment is routinely reviewed. An Occupational Therapist assessment of the premises has been carried out. Regulators have been fitted to baths to reduce risk of scalding and there is an ongoing programme to install radiator guards to reduce risk of injury. Priority to fitting guards is on a risk assessment basis. A very high standard of cleanliness is maintained and the laundry room has been subject to refurbishment and upgrade. Policies and procedures are in place in relation to infection control and the management of laundry. Residents looked very well groomed in well-presented clothing and commented upon improvements they feel have taken place in relation to organisation of laundry services. Culliford House D55 S26789 CULLIFORD HOUSE V230659 010605 Stage 4.doc Version 1.30 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29 The home employs enough staff to meet the needs of residents and to ensure their safety and comfort and the good condition of the premises. Procedures for the recruitment of staff are robust and designed to minimise the risk of unsuitable staff being employed. EVIDENCE: There is a strong and stable staff team at Culliford House. Staff rotas were viewed and considered sufficient to meet the needs of residents accommodated. The records of the most recent recruit to the staff team were examined, all the necessary checks had taken place and the file contained copies of all the documents required by regulation. Residents hold management and staff in high regard; the inspector received many comments relating to the kindness and effectiveness of staff. Culliford House D55 S26789 CULLIFORD HOUSE V230659 010605 Stage 4.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36, 37 and 38 The staff team is led by an experienced and competent manager; this assures residents that they are well cared for. The manager is supported well by senior staff in providing clear leadership and effective management, giving residents confidence that their best interests are being served. Organisation of administrative tasks and quality monitoring systems are in place to ensure residents benefit from an efficient administration. Management practices, records and policies and procedures are in place to promote and safeguard the health, safety and welfare of residents. EVIDENCE: Culliford House D55 S26789 CULLIFORD HOUSE V230659 010605 Stage 4.doc Version 1.30 Page 20 Mrs Jackson, registered manager has extensive experience in running a care home and has achieved NVQ level 4 in Management and Care. Mrs Moors (junior) is in the process of completion of the same qualification. The staffing structure within the home is very clear with all staff demonstrating an awareness of their roles and responsibilities. For the most part records required by regulation were found to be in place, notification of significant events and monthly registered provider reports have been submitted as required. The exception was that there was no evidence to show that prospective residents had been advised in writing that as a result of a needs assessment, the home the home was able to meet their needs. Individual staff supervision sessions are planned and carried out, records were in place able to demonstrate this. A wide range of risk assessments have been carried out in relation to individuals and aspects of the premises, these have been recorded. There are a range of health and safety policies and procedures in place all of which are subject to annual review. Discussion with staff found that they are familiar with and knowledgeable about health and safety issues. Periodical testing of the home’s systems and equipment is consistently undertaken. Routine servicing, maintenance and staff training is ongoing. The fire records were examined and it was found that fire precautionary measures are satisfactory and that training for staff in what to do in the event of fire is up to date. Culliford House D55 S26789 CULLIFORD HOUSE V230659 010605 Stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 1 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION 3 3 3 3 3 4 2 4 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 x x 3 2 3 Culliford House D55 S26789 CULLIFORD HOUSE V230659 010605 Stage 4.doc Version 1.30 Page 22 NO 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 1 Regulation 4 Schedule 1.11 14.1.d Requirement The statement of purpose must include a description of the fire precautions and emergency procedures in the care home The home must confirm in writing to the resident that as a result of the assessment process, the home is able to comprehensively meet their needs. Timescale for action 30/9/05 2. 37 30/9/05 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. 5. Refer to Standard 1 1 1 16 25 Good Practice Recommendations The statement of purpose should advise that care plans are reviewed on a monthly basis. All documents should be amended to refer to Commission for Social Care Inspection (CSCI). The homes information pack should be amended as per details forwarded to the home on 9/6/05. The homes complaints procedure should advise residents that complaints may be made directly or at any stage, to the Commission for Social Care Inspection. Complete the programme of fitting radiator guards by August 2006 (ongoing). D55 S26789 CULLIFORD HOUSE V230659 010605 Stage 4.doc Version 1.30 Page 23 Culliford House Culliford House D55 S26789 CULLIFORD HOUSE V230659 010605 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Unit 4 New Fields Business Park Stinsford Road Poole, Dorset BH17 0NF 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. 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