Inspection on 23/11/05 for Culrose

This inspection was carried out on 23rd November 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

Culrose 09/11/07

Culrose 20/06/06

Culrose 03/06/05

Culrose 11/01/05

Culrose 29/06/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Culrose Norwich Road Dickleburgh Diss Norfolk IP21 4NS Lead Inspector Ms Ginette Amis Unannounced Inspection 23/11/0 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 Culrose DS0000059073.V254632.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. Culrose DS0000059073.V254632.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Culrose Address Norwich Road Dickleburgh Diss Norfolk IP21 4NS 01379741369 01379740186 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) Jean Whitten Care Ltd Miss Leanne Prest Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Culrose DS0000059073.V254632.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Twenty (20) Older People, not falling into any other category, may be accommodated. 3rd June 2005 Date of last inspection Brief Description of the Service: Culrose is a converted and extended detached property in the village of Dickleburgh. The home can accommodate up to twenty older people in sixteen single and two double bedrooms on the ground and first floors. Three single bedrooms have en suite facilities. The home has a dining room and two lounges, one of which can be used for service users who wish to smoke. There is car parking to the front and gardens to the rear of the property. Culrose DS0000059073.V254632.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Wednesday 23rd November 2005 from 11.00 am to 14.10 pm. The care home’s owners were not present and the manager was on sick leave. The deputy manager was in charge of the care home and was courteous and helpful in offering as much information as she could to aid the inspection. Other members of staff were observed going about their duties and spoken with. The file of 4 residents were examined and 3 of the people concerned were interviewed in private. Other residents were spoken with informally. The views of residents have helped inform the content of this report. During the course of the day, staff training in first aid was in progress and for this reason the dining room was not used by residents. Those residents who were spoken with fully understood why this was happening and expressed no objection over being served lunch in their room so as to facilitate the trainer. What the service does well: What has improved since the last inspection? Some areas had been redecorated. Radiators throughout the care home had for the most part been covered. A new shower room had become available. Members of staff described the care home as “a much better place” since it came into new ownership. Culrose DS0000059073.V254632.R01.S.doc Version 5.0 Page 6 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. Culrose DS0000059073.V254632.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 Culrose DS0000059073.V254632.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): 1,3,6 Useful information about the care home was made available to current and prospective residents of Culrose. Assessments of residents’ needs were undertaken prior to admission and those offered only a short stay were subject to the same form of assessment as those seeking a permanent home. EVIDENCE: One resident while being interviewed produced her copy of the care home’s ‘Service User Guide’ This contained information about the care home, its services and staff group as well as the terms of residence/contract and complaints’ procedure. Another resident, staying at Culrose to recuperate following an accident at home described how the manager had visited her to assess her needs, “asked me lots of questions about how I felt and what I needed”. An assessment of health, personal care and social needs was documented in each of the 4 residents’ files examined during the course of the inspection. Culrose DS0000059073.V254632.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): 7,8,9,10 Residents’ files were generally well maintained and contained useful information as to the care needs of residents. In some cases more information would have been helpful while in another recording should have been limited to significant information only. While medication randomly checked had been appropriately administered storage facilities were not ideal. Residents felt confident of the kindliness and respect of members of staff. EVIDENCE: Residents’ files contained evidence of their needs having been assessed. In addition, monthly reappraisals and more detailed periodic reviews had been documented. Records regarding weight and fluid intake were meticulously maintained. Records relating to risk assessment and moving and handling were in some cases less helpful while some other, unnecessary details were recorded. Recommendations were made to address this. Medication was mainly delivered by monitored dose system and all members of staff had received training in administration of medicines. A system of risk assessment was in place to ascertain if residents could administer their own medication but at the time of this inspection none of the residents were doing Culrose DS0000059073.V254632.R01.S.doc Version 5.0 Page 10 so. The provisions for storing medication were not ideal, being cramped and lacking facilities to store controlled drugs or medication in need of refrigeration. A requirement and recommendation were made accordingly. All residents spoken with offered praise for the staff group and expressed their utmost confidence in them, one saying “They’re such a nice pleasant lot, all of them. The cook is lovely too and the managers are always helpful.” Culrose DS0000059073.V254632.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, 13, 15 Residents were generally content with their lifestyles. Most residents were satisfied with the amount of activities organised by the care home. The food, its quality, quantity and choices available were much appreciated. EVIDENCE: Residents spoken with expressed general content with their life style. One resident alluded to the content of her room, how very personal it appeared saying how her relatives had been permitted to arrange things just to her liking. Another said, “Its just a little thing but I mentioned to night staff how much I hate drinking out of a mug and from the next morning I got a cup and saucer.” Residents described their trips out with relatives and also on outings organised by the care home. A trip to Banham Zoo with staff was described as “great fun”. One resident though felt there were few activities and a recommendation was made for events to be more positively advertised and records kept and for some one-to-one activities to be promoted. All residents were particularly appreciative of the food at Culrose. One said, “The only complaint I could make is that there’s too much good food!” Another said she knew that drinks could be accessed at any time, day or night. Culrose DS0000059073.V254632.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): 16, 18 Residents were confident any concern or complaint they might raise would be swiftly and appropriately dealt with. Policies and procedures along with awareness training were being made available to staff regarding the protection of vulnerable adults from abuse. All members of staff had been CRB checked. EVIDENCE: Copies of the complaints procedure had been given to all residents. Residents expressed great confidence in the manager and deputy saying “you could talk to them about anything” and would have “no fear at all” of raising any kind of complaint or concern. The need to protect vulnerable adults from abuse was a topic covered during staff induction and as part of their NVQ accreditation. Whistle-blowing procedures were contained in the ‘staff room file’ along with other important good practice information. Culrose DS0000059073.V254632.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): 19, 21 and 26 Culrose is generally clean, comfortable and well maintained. Considerable work to raise environmental standards has already been undertaken to a good standard. There remain some works yet to be completed. In particular, the providers must ensure that hot water temperatures are governed to safe levels in all residents’ rooms. EVIDENCE: Culrose presented as a clean, comfortable and safe environment. Good progress had been made in attending to the need to cover radiators, with only a few still remaining to be covered. Some redecoration had also been recently completed and a new, well-appointed shower room was available for use. Some refurbishment and redecoration had yet to be completed but this falls within a general plan to upgrade the premises. The need to ensure safe hot water temperatures in residents’ rooms remains a priority. (There was no evidence available to say this had been attended to – and although hot water did not run excessively hot the deputy manager was unaware of any work Culrose DS0000059073.V254632.R01.S.doc Version 5.0 Page 14 having been undertaken to fit regulatory valves) A recommendation was made for the larger bathroom to be made more comfortable. Culrose DS0000059073.V254632.R01.S.doc Version 5.0 Page 15 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): 27, 30 The staff team was small but effectively deployed. EVIDENCE: The staff rota and training records indicated that residents’ needs were being met by a small but effective staff team. NVQ accreditation had been gained by a good proportion of care staff, and others were in the process of doing so. The care home had access to a small bank of regular relief staff. Recently, the night shift had been raised to 2 waking staff on duty instead of just one. The manager had been in post for a number of years and her deputy also was experienced. Culrose DS0000059073.V254632.R01.S.doc Version 5.0 Page 16 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): 33,35,38 A small amount of cash was retained in safe keeping at the care home for residents and adequate records kept of transactions. The health and safety of residents and staff was promoted. Progress must be made to produce evidence of having consulted with residents and their relatives over their views, satisfaction and any planned future developments at the care home. EVIDENCE: In the absence of the care home’s manager it was not possible to fully assess all the above standards. Questions relating to quality assurance remained unanswered and a requirement was subsequently made for work in this area to be advanced. Some residents have cash held for them by the care home in safekeeping and adequate records of transactions were kept. Information regarding personal Culrose DS0000059073.V254632.R01.S.doc Version 5.0 Page 17 effects insurance was contained in the service user guide and a certificate of public liability insurance was displayed in the foyer. The fire officer last inspected the care home in May 2005 when no issues were raised. Fire fighting equipment was regularly serviced and the next service was scheduled for the following week. All staff had had regular training in fire fighting. The environmental health officer last inspected in July 04 and gave a very positive report on aspects of cleanliness and safety. Culrose DS0000059073.V254632.R01.S.doc Version 5.0 Page 18 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 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X X X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 3 Culrose DS0000059073.V254632.R01.S.doc Version 5.0 Page 19 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 OP9 Regulation 13(2) Requirement Provision must be made for the safe storage of controlled drugs and medication requiring refrigeration Preset valves to control hot water temperatures in residents’ rooms must be installed Evidence must be produced to show that residents and their relatives are consulted about their views of life at the care home Timescale for action 31/01/06 2 1 OP21 OP33 4(a) 24 (1) 31/03/06 30/06/06 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 Refer to Standard OP7 Good Practice Recommendations Greater attention should be paid to completing the detail of risk assessments, moving and handling guidance for staff in residents care plans. Only significant information regarding bowel movements need be recorded. If possible, a more spacious, secure storage area should be found for medication DS0000059073.V254632.R01.S.doc Version 5.0 Page 20 2 OP9 Culrose 3 OP12 4 OP21 The activities organised by the home should be advertised to all residents to avoid doubt and disappointment and records kept of activity events as they occurred. Some one-to-one activities might be introduced for those who are unlikely to enjoy group events. The larger bathroom could be made more comfortable and attractive. Culrose DS0000059073.V254632.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Culrose DS0000059073.V254632.R01.S.doc Version 5.0 Page 22 - 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!