Inspection on 04/10/05 for Culliford House

This inspection was carried out on 4th October 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 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 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 Announced Inspection 4th October 2005 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Culliford House DS0000026789.V255809.R01.S.doc Version 5.0 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.V255809.R01.S.doc Version 5.0 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.V255809.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st June 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 DS0000026789.V255809.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection commenced at 10:30 am on the morning of Tuesday October 4th 2005. The total time spent on this inspection was 5.5 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 Mrs Rita Moors, Mrs Suzanne Jackson, Mrs Anne Moors, three members of staff and 13 residents. On the day of the inspection there were 20 people living in the home. For information relating to core standards not assessed on this occasion please read the previous inspection report of 1st June 2005. 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 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. The continued commitment to providing formal training for all social care workers is commended. Comments received by the inspector included: “It is lovely here, I am well cared for, my room is lovely and the food is very good”; “Everyone is very Culliford House DS0000026789.V255809.R01.S.doc Version 5.0 Page 6 kind, I am slow these days but no one rushes me, I do as I please and I am very satisfied”; “If you cannot look after yourself at home then this is the place to be”. 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.V255809.R01.S.doc Version 5.0 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.V255809.R01.S.doc Version 5.0 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): 1 Comprehensive information is provided to prospective residents to assist them with making an informed decision as to whether Culliford House would be a suitable home for them. EVIDENCE: An information pack is provided to all prospective residents and/or their relatives or representative. Copies are made freely available in the main entrance hall of the home. Culliford House DS0000026789.V255809.R01.S.doc Version 5.0 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, 9 and 10 Care plans would benefit from further expansion to ensure all identified needs can be fully and satisfactorily met. Shortfalls in record keeping relating to medication issues and lack of policies and procedures relating to application of creams and instillation of eye drops have the potential to place residents at risk. 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 were very knowledgeable about residents care needs. The plans of care relating to specific care needs [e.g diabetes] contain input from specialist health professionals. However, the same level of information was not in the care plan of a resident noted as having epilepsy and there was no risk assessment setting out how staff would identify the onset of an episode or what to do in that event. Care plans and risk assessments in place were reviewed on a monthly basis. Shortfalls were identified in relation to medication issues. Where creams had been prescribed in two cases, there was no written instruction as to the Culliford House DS0000026789.V255809.R01.S.doc Version 5.0 Page 10 location creams were to be applied to - either on the Medication Administration Record or the persons care plan. One prescribed cream was not recorded on the Medication Administration Record at all. Medication [Senna} had been signed as administered on two occasions when clearly it had not been required or given – it could not have been, none was in stock. There were no written procedures in place to provide staff with instructions for the instillation of eye drops and application of creams. With the exception of one member of staff all have received certificated training in relation to medication issues. Culliford House DS0000026789.V255809.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 13 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. 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 the top floor of the home. This is also available for use by relatives if a resident is seriously ill and/or dying. Culliford House DS0000026789.V255809.R01.S.doc Version 5.0 Page 12 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): NONE OF THE ABOVE STANDARDS WERE ASSESSED ON THIS OCCASION. EVIDENCE: Culliford House DS0000026789.V255809.R01.S.doc Version 5.0 Page 13 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): 21, 22, 23, 24, 25 and 26 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 throughout the premises for the comfort and safety of residents. EVIDENCE: An Occupational Therapist assessment of the premises has been carried out. Residents rooms were well-personalised. No unpleasant odours were detected and residents commented upon the high standard of the accommodation provided. The programme of fitting radiator guards remains ongoing. Ongoing redecoration continues, it is the policy of the home to assess and redecorate and refurbish each room upon vacation as necessary. Replacement of carpets and other furnishings also takes place as deemed necessary. Culliford House DS0000026789.V255809.R01.S.doc Version 5.0 Page 14 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 STANDARDS WERE ASSESSED 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. A comprehensive training plan is in place to ensure safe care practice protects residents. 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. It is intended to implement a ‘sickness cover rota’ to ensure there are always carers available in the event of staff sickness. The records of the most recent recruit to the staff team was examined; all the necessary checks had taken place and the file contained copies of all the documents required by regulation. It remains the case that residents hold management and staff in high regard, comments received by the inspector attested to this. Staff training during 2005 included Manual Handling, Health and Safety, Fire Protection, Food Hygiene and ongoing NVQ training. Culliford House DS0000026789.V255809.R01.S.doc Version 5.0 Page 15 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): 35 Appropriate procedures and practice provide protection and safeguard residents’ finances. EVIDENCE: The home handles small amounts of cash on behalf of five residents accommodated. Associated records are kept. Culliford House DS0000026789.V255809.R01.S.doc Version 5.0 Page 16 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 3 X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 x COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 x X X 3 3 3 4 2 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 X X X X 3 X X x Culliford House DS0000026789.V255809.R01.S.doc Version 5.0 Page 17 Are there any outstanding requirements from the last inspection? NO 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 OP7 Regulation 15 Requirement Care plans must contain specific instruction relating to identified health needs [eg epilepsy] with input from specialist health professionals and an associated risk assessment. Procedures must be put into place for the application of creams and instillation of eye drops. Instruction for the application of creams must specify the area to be creamed. Accurate records must be kept in relation to the administration of all medication to include creams and eye drops. Timescale for action 20/11/05 2 OP9 13[2] 30/10/05 3 4 OP9 OP9 13[2] 13[2] 30/10/05 04/10/05 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 Refer to Standard OP25 Good Practice Recommendations Complete the programme of fitting radiator guards by August 2006 (ongoing). DS0000026789.V255809.R01.S.doc Version 5.0 Page 18 Culliford House 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. 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