Inspection on 24/07/06 for Culliford House

This inspection was carried out on 24th July 2006.

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 04/10/05

Culliford House 01/06/05

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 Inspection 24th July 2006 10:00 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 Culliford House DS0000026789.V305330.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 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 DS0000026789.V305330.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Culliford House Address Icen Way Dorchester Dorset DT1 1ET 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) 01305 266054 01305 266259 Mrs R F Moors Mrs Suzanne Jackson Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Culliford House DS0000026789.V305330.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th October 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. Fees range from £370 to £650per week. Culliford House DS0000026789.V305330.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken on Monday 24th June 2006. The total time spent on this inspection was 7.5 hours. This included preparation time consisting of examination and note taking relating to the pre inspection questionnaire completed by the home, analysis of comment cards from Residents, GP’s, Relatives and Health and Care professionals received by the inspector prior to the inspection. In addition, examination of the Commission’s service history for the home, planning a timetable for the day, a tour of the premises, inspection of records and discussion with Suzanne Jackson registered manager and her deputy Ann Moors, 3 members of staff, 14 residents, one visiting Social Worker and 2 visitors to the home. On the day of the inspection there were 21 people accommodated in the home [including 1 in hospital]. The main purpose of this inspection was to review the home’s progression in implementing requirements and recommendations from the previous inspection report. Additionally, the purpose was also to assess the home’s compliance with key National Minimum Standards for Older People. Surveys and comment cards were received from 12 residents, 11 relatives/friends, 2 General Practitioners and 1 Social Care & Health Care Manager. 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 en suite 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 throughout all areas of the home; residents spoken with said this was always the case. All rooms have now been subject to total refurbishment in recent years and it is the policy of the home to redecorate/refurbish each room upon vacation. Culliford House DS0000026789.V305330.R01.S.doc Version 5.2 Page 6 Residents are encouraged to bring with them their own possessions and all the rooms viewed were well personalised by the occupant, a number of residents had brought their own beds into the home in addition to favourite pieces of furniture, pictures and ornaments. 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 carried out. The continued commitment to providing formal training for all social care workers is commended. 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 contacting your local CSCI office. Culliford House DS0000026789.V305330.R01.S.doc Version 5.2 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 Culliford House DS0000026789.V305330.R01.S.doc Version 5.2 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): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prior to admission, the needs of each prospective resident are assessed to ensure the home will be able to properly meet them. The home does not provide intermediate care. EVIDENCE: The care records of 3 recently admitted residents were examined. There was evidence that prospective residents care needs are assessed prior to admission and they are assured that the home is able to meet their identified care needs. Culliford House DS0000026789.V305330.R01.S.doc Version 5.2 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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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. There are satisfactory arrangements for managing medication in the best interests of residents. EVIDENCE: The care plans of 5 residents were examined. The plans of care relating to specific care needs contain input from specialist health professionals where appropriate. 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 Culliford House DS0000026789.V305330.R01.S.doc Version 5.2 Page 10 respected and that care tasks are undertaken in a way that ensures they are able to retain dignity. There are policies and procedures in place relating to medicines. 15 members of staff have received formal training in the management of medicines, only those who have completed the training are permitted to administer medication. The ordering, storage and administration of medicines is well managed and records were found to be up to date with the exception of 2 medicines not having been signed as administered on the Medication Administration Record on the day of the inspection. This was immediately rectified by the person who administered the medication. Residents retain control of their medication where they so wish subject to the risk assessment process. One resident retains responsibility for one of his/her prescribed medicines [Migril (Controlled Drug) 1 x daily, no more than 6 in one week, first prescribed 19/5/06]; the home had provided 6 tablets to the resident the first week but then no more. It was not known if the resident had actually taken any and the resident had not requested a further week’s stock. It was recommended that the home contact the GP and seek advice as it was clear the resident was not taking the medication as prescribed by the GP; this was done prior to the inspector leaving the home. Residents said that they feel well cared for and that staff are helpful and kind and undertake their duties in a willing and respectful manner. Comments received from residents included: “All the carers are delightful and work very hard to keep us as happy as possible”, “I came here by recommendation and I have not been disappointed, they have helped me settle in well and I am very comfortable and content”, “I have no real complaints”, “I can do as I please, I do not have to join in anything if I don’t want to and I am quite happy with what is provided” and “I did not want to have to come here no one wants to lose their home, but I think I did well getting in here”. Culliford House DS0000026789.V305330.R01.S.doc Version 5.2 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): All the above Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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. Individual assessments for social needs have been recorded and a record of entertainment/activities is held. Residents said that their visitors are always made welcome and are offered refreshments; arrangements can be made for relatives from outside the area to stay overnight in the separate apartment on Culliford House DS0000026789.V305330.R01.S.doc Version 5.2 Page 12 the top floor of the home. This is also available for use by relatives if a resident is seriously ill and/or dying. There was evidence that a good varied and wholesome menu is provided and that alternatives are provided upon request. The vast majority of residents spoken with said that they were very satisfied with the food provision and that there is always discussion relating to food at residents meetings. Their likes and dislikes appear to be well known to the main cook who has worked in the home for over 20 years. Comments received included: “No one ever cooks it like you do for yourself but I do enjoy it, I get enough and have to watch my weight!”, “It is good home cooked food, nothing exotic or daring but sufficient for my needs”, “The food is varied, good sized portions and satisfying” and “It is better than I expected because it is not easy trying to please 20 odd different people – I am happy with it – no complaints”. Culliford House DS0000026789.V305330.R01.S.doc Version 5.2 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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system, which is properly managed; residents are confident their concerns are listened to and taken seriously. Policies, procedures and staff training contribute to providing a safe environment for residents. EVIDENCE: The home had appropriate complaint policy and procedures in place; a copy is available within the homes information packs that are always on display in the hallway of the home. All complaints, no matter how minor in nature, are taken seriously and investigated; this was evidenced by the complaints log which demonstrated that 13 were made within the last 12 months and had been satisfactorily dealt with in line with the policy and procedure. All the residents spoken with confirmed that they felt able to bring any matter to the attention of the management and were confident their concerns would be listened to, fairly dealt with and any action to rectify matters implemented. Care workers have received training in adult protection and policies and procedures are in place, however, there was evidence that on a recent occasion the home had not acted in accordance with the home’s own policy and procedure. Culliford House DS0000026789.V305330.R01.S.doc Version 5.2 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): All the above were assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. 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. Culliford House DS0000026789.V305330.R01.S.doc Version 5.2 Page 15 A very high standard of cleanliness is maintained for the comfort and safety of residents. 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 the ongoing programme to install radiator guards is in the process of fitting the last radiator guard to reduce risk of injury. 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 wellpresented clothing and commented positively upon laundry services. A room has recently been refurbished to a very good standard, for use as a treatment room/hairdressing salon. Culliford House DS0000026789.V305330.R01.S.doc Version 5.2 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): All the above Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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. In addition to the registered manager and her deputy there are 17 care workers, 1 cook, 1 care worker/cook, 1 cleaner, 1 relief and a volunteer ‘handyman’. Staff rotas demonstrated that there are 4 carers on duty in the mornings 3 afternoon and evenings and 2 awake at night. Staff rotas viewed were considered sufficient to meet the assessed needs of residents accommodated. There was evidence that Criminal Records Bureau checks had been obtained for all workers and the volunteer. The records of the most recent recruits to the staff team were examined, all the necessary checks had taken place and files contained copies of all the documents required by regulation. It was recommended that when references are received the date is recorded to accurately demonstrate they were received prior to commencement of work. Culliford House DS0000026789.V305330.R01.S.doc Version 5.2 Page 17 Residents hold management and staff in high regard; the inspector received many comments relating to the kindness and effectiveness of staff. The majority of comments received from residents and relatives expressed satisfaction with the staffing levels, although 3 relatives comment cards indicated that staffing levels were perceived to be insufficient at evenings and nights. Discussion with residents ascertained that they did not feel there were routinely any problems. Comments received from residents included: “On occasion if three or four people want something at once we might have to wait a little but it has never been disastrous”, “The girls are extremely kind and patient one day I might be ok but another day I might take three times longer but they never rush me”, “On occasion I feel they are busy so I try not to take up too much of their time as someone else may have to wait” and “Overall, they come promptly, they can’t be in several places at once!”. Staff training during the last 12 months included Manual Handling, Health and Safety, Fire Protection, Food Hygiene and ongoing NVQ training. This forms the basis of the home’s staff training programme and during this coming year first aid and more adult protection training is planned. Of the 20 care staff, 10 have NVQ level 2 or above and 14 hold a current first aid certificate. Culliford House DS0000026789.V305330.R01.S.doc Version 5.2 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): 31,32, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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. Culliford House DS0000026789.V305330.R01.S.doc Version 5.2 Page 19 EVIDENCE: Mrs Jackson, registered manager has extensive experience in running a care home and has achieved NVQ level 4 in Management and Care. The Deputy Manager of the home also has the same qualification and in the absence of the manager on maternity leave has been in day to day charge of the home. Mrs Jackson attends the home at least one full day in addition to being constantly available and undertaking a range of management tasks off the premises. 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 home manages petty cash for 4 residents, appropriate records are kept with a running total of the cash in their credit. All monies are safely locked away. Individual staff supervision sessions are planned and carried out, records were in place able to demonstrate this; it was recommended that all persons undertaking supervision should receive training in this topic. Mrs Jackson stated that she has been trying to locate formal supervision training. 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 satisfactory and that training for staff in what to do in the event of fire is up to date. Culliford House DS0000026789.V305330.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 3 3 3 3 4 3 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 3 x 3 Culliford House DS0000026789.V305330.R01.S.doc Version 5.2 Page 21 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 OP9 Regulation 14 Requirement The registered person must ensure that the Medicine Administration Record is signed at the point of administration. Timescale for action 24/07/06 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 2 3 4 Refer to Standard OP9 OP18 OP29 OP36 Good Practice Recommendations Where it is clearly known that a resident who self medicates is not taking their prescribed medication, the GP should be informed. The home should act in accordance with the stated policies and procedures, or amend them to reflect actual practice. When references are received the date should be recorded in order to be able to ensure the home can demonstrate. they were received prior to commencement of work. Persons undertaking supervision sessions should receive training in this topic. Culliford House DS0000026789.V305330.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole 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. Extracts may not be used or reproduced without the express permission of CSCI Culliford House DS0000026789.V305330.R01.S.doc Version 5.2 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!