Inspection on 03/06/05 for Culrose

This inspection was carried out on 3rd 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

Culrose 09/11/07

Culrose 20/06/06

Culrose 23/11/05

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 IP21 4NS Lead Inspector Susan Golphin Announced 03 June 2005 09:30 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. Name I55 s59073 Culrose v222497 200405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Culrose Address Norwich Road Dickleburgh Diss Norfolk IP21 4NS 01379 741369 01379 741369 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) 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 Name I55 s59073 Culrose v222497 200405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Twenty (20) Older People, not falling into any other category, may be accommodated. Date of last inspection 11 January 2005 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. Name I55 s59073 Culrose v222497 200405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine announced inspection that took place between 9.30am and 3.30pm. The inspection included a short tour of the premises and the grounds. A sample of records and procedures were also seen . During the inspection there was the opportunity to talk to three residents and three staff. The residents seen said that they are very satisfied with their care. Fifteen comment cards from relatives and residents said they were happy with the care service, only one expressed a concern about the service . In their first year of ownership the new providers have begun to make considerable improvements to the premises and the service provision. What the service does well: What has improved since the last inspection? The home has had new owners since April 2004 and considerable improvements have been made to the premises and also to some of the practices and routines. The improvements to date include-: • Wider range of options offered at meal times, and residents commented on nice choice of fresh fruit juices and cereals available every day . • Decoration and complete refurbishment of three rooms. • Upgrade and replacement of kitchen equipment including fridges and freezers. • Complete renovation of garden areas and pathways to the rear of the premises providing shaded seating under mature trees and attractive roped walkways. Residents said that the garden and pathways are very pleasant and much improved. Name I55 s59073 Culrose v222497 200405 Stage 4.doc Version 1.30 Page 6 • • • • The fire protection/ alarm ; call bell, and emergency lighting systems have all been replaced, which ensures that residents health and safety are protected. Sitting rooms and dining room refurbished and redecorated. Increase in training opportunities for staff and this was confirmed during the discussions with staff. Staff, relatives and residents said that all the improvements are seen as positive commitment by the owners to develop good personal service in a family style and homely setting. 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. Name I55 s59073 Culrose v222497 200405 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Name I55 s59073 Culrose v222497 200405 Stage 4.doc Version 1.30 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 standard(s) 1,3 The information about the home is clear and concise so that prospective residents and their representatives can make an informed choice. The home have a satisfactory assessment process in place, and all prospective residents needs are assessed by the home prior to admission. EVIDENCE: One relative confirmed that information about the home and the service provision had been made available to them before the admission so that they were able to make an informed choice about the accommodation. Three resident’s files contained assessments of need carried out by placing agencies and the staff of the home, they provide a clear account of individual healthcare needs. Reviews are carried out on a regular basis, residents, their families and representatives are asked to sign up to the agreed plan of care. Name I55 s59073 Culrose v222497 200405 Stage 4.doc Version 1.30 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 standard(s) 7,8,10 All residents have a plan of care which provides staff with the information they need to meet residents healthcare needs. The staff have a good understanding of residents needs. Personal care is offered in such a way as to promote individual dignity and privacy. EVIDENCE: Three care plans were seen on the day and discussed with the key carers. The information in the plan is clear and provided details of risk assessments and medical care and changes in need. Throughout the day staff were observed assisting residents with their personal care and meals in a relaxed and respectful way. During the discussions the care staff demonstrated a good understanding of residents needs. Name I55 s59073 Culrose v222497 200405 Stage 4.doc Version 1.30 Page 10 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) 12,15 Resident’s dietary needs are well catered for with balanced and nutritious food options available. Group activities are in place throughout the week but there are plans in place to develop and offer more individual sessions. EVIDENCE: During the discussions residents said that the meals and choices on the menu had improved over the last year and spoke enthusiastically about more choices of cereal for breakfast and fresh fruit juices. Others commented on the range of light meals that are available at teatime. One resident likes to take their teatime meal later in the evening and this request is happily met by the staff. A range of social activities take place on a regular basis and residents said they enjoy some of the word search games and quizzes. The management are exploring some of the more individual activities which residents have expressed an interest in including activities and recreational events outside the home. ( see recommendation) Name I55 s59073 Culrose v222497 200405 Stage 4.doc Version 1.30 Page 11 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) 16,18 The home have a satisfactory complaints process in place with evidence that complaints are dealt with openly and promptly. Arrangements are in place for protecting residents from abuse. Training is in place so that staff have an understanding and knowledge about protecting vulnerable adults. EVIDENCE: From the records there have been no formal complaints made since the last inspection. There is a complaints / suggestions box in the reception area of the home and the management are actively encouraging residents and families to be more involved in and feel able to contribute to the running of the home. Name I55 s59073 Culrose v222497 200405 Stage 4.doc Version 1.30 Page 12 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) 19,20,24 The standard of the environment within this home is good and continues to be upgraded and improved providing the residents with a homely place to live. EVIDENCE: A short tour of the premises was undertaken and three service users rooms and the communal rooms were seen on the day. All were decorated and furnished to a good standard. One double room has recently been completely refurbished and decorated also to a good standard . The garden area at the rear of the home has been extensively improved and now provides shaded seating and pathways around the building which residents can use in safety. Part of the path at the side of the garden has a rope walk way and rose arbour. On the day of the inspection the home was clean and hygienic and well maintained. The manager and staff have a good understanding and knowledge about infection control and the prevention of cross infection. Name I55 s59073 Culrose v222497 200405 Stage 4.doc Version 1.30 Page 13 The new owners of the home have a five year business plan in place to continue upgrading and improving the premises which will improve the personal and communal space for residents. The plan also includes upgrading and improving the washing and bathing facilities. The registered providers are to be commended for the major investment and improvements being made to the home .( see recommendation) Name I55 s59073 Culrose v222497 200405 Stage 4.doc Version 1.30 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 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) 27,30 The staff have a good understanding of the residents needs, and this is clear from the positive relationships between residents and staff. Residents needs are met by sufficient numbers of staff with a range of skills and experiences in the care of older people. Improved systems are in place for promoting training opportunities for staff EVIDENCE: The duty rota submitted with the pre inspection information confirms that there are sufficient numbers of staff on duty to meet current needs. Residents spoke warmly of the support and help they receive and gave examples of individual kindnesses shown to them by staff. Improved training opportunities are in place and during the discussions with staff it was said that mandatory training has been completed , including sessions on first aid, fire protection basic food hygiene and manual handling. Three staff hold an NVQ qualification and others will be undertaking training this year. Name I55 s59073 Culrose v222497 200405 Stage 4.doc Version 1.30 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 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) 31,37,38, The registered providers and manager have a clear development plan for the home which is being effectively communicated, and shared with residents, relatives and staff. The homes policies and procedures promote the safety of the residents and clear practice guidance for staff. The home maintain safe working practices which comply with relevant legislation and safety procedures. EVIDENCE: The new owners are promoting an open style of management and are looking at ways in which residents and staff and relatives can be involved in the ongoing development of the home. There is a quality assurance process in place and the outcome of recent surveys will be displayed as soon as possible. The management are reviewing ways in which the care practice can be reviewed through self appraisal processes with the staff group. Name I55 s59073 Culrose v222497 200405 Stage 4.doc Version 1.30 Page 16 The policies and procedures for the home have been reviewed in April of this year. The information and guidance is available to the staff. Work on the pre set valves for hot water and the radiator guards is work in progress as part of the overall development plan and is nearing completion. Staff receive regular mandatory training to ensure the safety and well being of the residents. The home has recently been subjected to major refurbishment to replace all the safety and alarm call systems Name I55 s59073 Culrose v222497 200405 Stage 4.doc Version 1.30 Page 17 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 3 x 3 x x 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 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 x x x 3 x x 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 Standard No 16 17 18 Score 3 x 3 3 x x x x x 3 3 Name I55 s59073 Culrose v222497 200405 Stage 4.doc Version 1.30 Page 18 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 Regulation none Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 12 19 31 Good Practice Recommendations It is recommended that the management continue to develop the recreational interests of the residentswhich offers both individual and group activities. It is recommended that the management continue to improve and develop the environment for residents safety and comfort. It is recommended that the management continue to look at ways in which the residents and relatives can be involved in the development of the home and promote the open style of management. It is recommended that the management give priority to the installation of the pre set hot water valves and radiator guards as part of the overall development of the premises . 4. 38 Name I55 s59073 Culrose v222497 200405 Stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection 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 Name I55 s59073 Culrose v222497 200405 Stage 4.doc Version 1.30 Page 20 - 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!