Inspection on 07/02/06 for Culwood House

This inspection was carried out on 7th February 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Culwood House 26/09/08

Culwood House 09/04/08

Culwood House 20/04/07

Culwood House 28/07/06

Culwood House 24/05/05

Culwood House 10/01/05

Culwood House 17/08/04

Culwood House 28/03/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Culwood House 130 Lye Green Road Chesham Bucks HP5 3NH Lead Inspector Mike Murphy Unannounced Inspection 7th February 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 Culwood House DS0000022968.V282846.R01.S.doc Version 5.1 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. Culwood House DS0000022968.V282846.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Culwood House Address 130 Lye Green Road Chesham Bucks HP5 3NH 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) 01494 771012 webbej4572@aol.com Mrs Anita Larkin Mr Larkin Mr Chris Webb Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places Culwood House DS0000022968.V282846.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The number of persons for whom residential accommodation with both board and care is provided at any one time shall not exceed 14 (fourteen) The Home is registered to accommodate older people 24th May 2005 Date of last inspection Brief Description of the Service: Culwood House is a privately run care home providing personal care and accommodation for 14 older people. The home is located on the outskirts of Chesham about one mile from the town centre. The home was formerly a large family residence. There is dropping off space and limited parking at the front of the building. The rear garden is level and accessible, with mature shrubs and flowerbeds providing a pleasant environment and privacy for service users. The garden is well maintained. A part of the home is the private residence of the manager.The home is not purpose built and does not have a lift. All bedrooms are single and have en-suite facilities (WC and sink). Culwood House DS0000022968.V282846.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one inspector on a mid week morning and early afternoon in February 2006. The inspection methodology included discussion with the registered manager, staff and residents, review of documents (including care plans), a tour of the home and testing hot water temperatures. Since the announced inspection on 24 May 2005 and a follow up visit in August 2005 the registered manager had arranged for temperature regulation valves to be fitted to the hot water outlets in areas to which residents have access. The registered manager and an experienced care worker had attended a training course in first aid. The inspection finds that, at the time of this inspection, the residents at Culwood House expressed satisfaction with the care they received. They report that the registered manager and care staff are kind and considerate. The home has a warm and domestic atmosphere and residents appeared well cared for. However, the inspection also finds significant shortfalls in performance in a number of areas and the home is therefore failing to meet a number of the national minimum standards. Action to deal with this is listed in the requirements and recommendations. The inspector would like to thank the residents, manager and staff for their time and hospitality during the course of this inspection. What the service does well: What has improved since the last inspection? Temperature regulation valves have been installed in areas to which residents have access. Two staff have attended training in first aid. Culwood House DS0000022968.V282846.R01.S.doc Version 5.1 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. Culwood House DS0000022968.V282846.R01.S.doc Version 5.1 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 Culwood House DS0000022968.V282846.R01.S.doc Version 5.1 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, 4 and 5 The home has systems for conducting assessment of needs prior to admission. However, these are not recorded in detail and do not appear to meet the minimum standards. Resident’s needs may not, therefore, be appropriately assessed before accepting the offer of a place in the home. EVIDENCE: The process of pre-admission assessment is outlined in the service users’ guide. Enquiries are made to the registered manager. The registered manager makes contact with the prospective resident and their family to assess whether the home can meet the persons needs. Notes are made of the meeting. Where admission is agreed then the enquiry progresses to a trial admission where a more comprehensive assessment is undertaken and where both parties can decide if the home is likely to be able to meet the resident’s needs. At any point in the process information may be sought from other sources – most usually the person’s general practitioner or from hospital (where the prospective resident is an in-patient at the time of referral) – to inform the assessment and care plan. Culwood House DS0000022968.V282846.R01.S.doc Version 5.1 Page 9 Documentation of the process remains uneven and falls short of this standard. Records are summary notes rather than the detailed assessment outlined in standard 3.3. There are no reports, however, of the home having admitted someone whose needs it cannot meet. The registered manager has a clear view of the needs which the home can and cannot meet. This is based on his experience in managing the home over many years. The homes liases with local health services where required. The home has a group of experienced care staff who have worked together for some time. Service users are offered a one month trial visit which allows both parties to decide if the home is able to meet the persons needs and is happy moving in. The home does not accept emergency admissions. Culwood House DS0000022968.V282846.R01.S.doc Version 5.1 Page 10 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 and 8 The home liaises with GPs, district nurses and other local healthcare providers as required thus ensuring that residents healthcare needs are met. Weaknesses in care records however fail to support the provision of good quality care and residents may not, therefore, receive the full range of care they require. EVIDENCE: Two care plans were examined. The care plans consist of a range of documents for recording the process and contained the information outlined in schedule 3 (of Regulation 17(1)(a))including a photograph of the resident. However, the structure of care plans lacked coherence and they contained a number of documents which either duplicated information elsewhere, did not have the name of the resident (e.g. section entitled ‘preferred daily routine’ no name, no date no signature of staff member completing it), were blank pages (i.e. care record ‘general’ and care record ‘medical’), contained a list of medicines which may not be up to date (the current medicines administration record (‘MAR’) should be the most reliable source of such information) or had sheets of questionable value (e.g. ‘Out-Patient referrals’ (not out-patient Culwood House DS0000022968.V282846.R01.S.doc Version 5.1 Page 11 attendances)). It seemed as if new sheets had been added over the years without reference to the overall structure leading to a confusing end product. At the same time some useful additions had been made in the autumn of 2005 namely, a basic ‘falls assessment’ and ‘nutritional screening’ sheets. Daily entries were very brief. There was no evidence of systematic review and updating of care plans. The matter was discussed with the registered manager and it was suggested that the structure be reviewed and rationalised. A recently admitted resident discussed her experience with the home. She said that the she found the staff to be very caring and the registered manager to be very kind. The discussion included a number of other matters which were briefly discussed with the registered manager afterwards. The home liases with residents GPs, district nurses and other local services in meeting residents’ healthcare needs. The home has recently introduced a basic falls risk assessment and nutritional screening form which should alert staff to residents at risk. Record of resident’s weights could be attached to the nutritional screening sheet. There were no pressure sores at the time of the inspection – the residents in this home are fairly active. Psychological health is monitored through observation and conversation with residents. The home was advised to make further contact with the falls assessment team with regard to reassessing the risk of falls to a recently admitted resident and advising more generally on falls risk assessment and management. A local pharmacy deals with all pharmacy needs. A chiropodist visits every six weeks. Residents use a local dentist in Chesham when required. Opticians would be sought as required by the resident and the family. One resident said that she was not allowed out of her room because of the risk of falling. The registered manager said that this appeared to be a misunderstanding. The home had received the advice of the falls team who had expressed satisfaction with its arrangements in respect of this matter. The resident was a relatively new admission and it was felt that once she had regained her confidence that she would then spend more time in the lounge with others. Culwood House DS0000022968.V282846.R01.S.doc Version 5.1 Page 12 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): 14 The home aims to accommodate resident choice where possible although it does not promote the availability of appropriate local advocacy services. This may disadvantage residents who might benefit from external support in clarifying or expressing their wishes. EVIDENCE: The registered manager said that the home endeavours to accommodate residents choices wherever possible. The home does not manage the financial affairs of residents – families are required to make appropriate arrangements. No information on advocacy is available. Residents may bring personal possessions to the home with them if they wish. Access to personal records would not be denied to a service user wishing to see their files. Culwood House DS0000022968.V282846.R01.S.doc Version 5.1 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): Standards in this section were not assessed on this unannounced inspection EVIDENCE: Culwood House DS0000022968.V282846.R01.S.doc Version 5.1 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): 19 and 26 The home is an older style building with a pleasant garden which is much appreciated by residents. The quality of the interior décor is variable however, and the home needs an ongoing programme of refurbishment in order to maintain a pleasant and safe environment for residents. EVIDENCE: The home is a detached residence set in reasonably secluded grounds on the main road between Chesham and Bovingdon. It is accessible by car and bus. There is a small drop off and parking space at the front, and pleasant, level gardens to the rear. Bedrooms vary in size. The home is also the private residence of the registered manager and this mixed use is reflected in its overall domestic ambience. It does not have a lift and is therefore only suitable for residents who are ambulant. The quality of the interior décor varies. Since the last inspection a bedroom has been redecorated, hot water temperature regulatory valves have been fitted, a bathroom has been redecorated and work relating to compliance with the recommendations of the fire service completed. To the knowledge of the registered manager there are Culwood House DS0000022968.V282846.R01.S.doc Version 5.1 Page 15 no outstanding issues from fire and environmental health officers visits in 2005. The grounds are well maintained and residents find the garden a pleasant place to sit in warm weather. At the time of this inspection the premises were generally clean, reasonably tidy and odour free. Some areas are due for redecoration, in particular chipped paintwork in the corridors. The lounge was warm and bright, and residents resting there after lunch expressed satisfaction with the home. One resident said that she was not allowed out of her room because she might fall (there was a history of a fall prior to admission). The registered manager said that this was a misunderstanding, that the falls team appeared satisfied with the environment when they had recently visited, and that the resident would be supported in joining others when her confidence returns. Culwood House DS0000022968.V282846.R01.S.doc Version 5.1 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): Standards in this section were not assessed on this unannounced inspection EVIDENCE: Culwood House DS0000022968.V282846.R01.S.doc Version 5.1 Page 17 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 and 38 The home does not have a systematic approach to quality assurance or health & safety matters. This has led to oversight of some health & safety matters which could compromise the welfare or safety of residents. EVIDENCE: The home does not have a systematic approaches to quality assurance. It is also the private residence of the registered manager and he is therefore frequently around the home during the day and available to residents, relatives and staff. It does not have a development plan. Developments occur as required in liaison with the registered proprietor. Self-monitoring and feedback is carried out informally. Policies and procedures are not routinely reviewed and updated. Action on CSCI requirements and recommendations has been sluggish and timescales are either not met or requirements or recommendations are not fully achieved within timescale. The registered manager always informs residents about CSCI inspections and facilitates private interviews with residents. Culwood House DS0000022968.V282846.R01.S.doc Version 5.1 Page 18 The home does not manage residents finances. This is a matter for relatives where a resident is unable to do so themselves. The home has a Health and Safety policy. The date of last review is not recorded. The policy provides general advice to staff on the duties of employers and employees, moving and handling, electricity, safety signs, kitchen safety, laundry/cleaning safety, and general safety. The guidance is not specific to the home. Staff were trained in moving and handling in October 2005. The bath hoist and mobile hoist are regularly maintained. The registered manager believes that the home is now fully compliant with fire requirements and that all work in connection with the most recent fire inspection has been carried out. Fire alarms are regularly tested and records maintained in a diary by the door. The names of staff attending fire drills are not recorded. The fire procedure, description of fire extinguishers and location of fire extinguishers is outlined in the staff handbook. The emergency lighting was replaced in 2005. A contract is in place for regular maintenance of fire equipment. A fire risk assessment was not carried out in 2005. There is a first aid box in the kitchen. This was examined and considered inadequate. Some contents were out of date. A new first aid box of appropriate size should be obtained. The contents should be listed and checked weekly. The registered manager and one other staff member completed training in first aid in 2005. The registered manager believes that the home is now fully compliant with food hygiene requirements and has taken account of all of the advice of the most recent visit of an environmental health officer. Staff training in food hygiene took place in January 2005. Accidents are recorded using HSE accident records. Staff have not received training in infection control and the home does not have an infection control policy. In drawing up a policy the registered manager might find it helpful to talk to a control of infection specialist nurse. It did not have a copy of the Department of Health guidelines on the control of infection in residential and nursing homes. The registered manager reported that they would be guided by the advice of the general practitioner. A record of a service having been conducted on the gas boiler was not available. The registered manager belives that this is due in early 2006. PAT testing is carried out annually – next due in April 2006. The electrical wiring was checked in March 2005. There is still work outstanding from that inspection – in connection with the electricity supply to the garden. The home has a contract with ‘Allclear’ for the removal of clinical waste. The home did not have information on Legionella control for its hot water storage. The environmental health department should be able to advise on appropriate action on this. Culwood House DS0000022968.V282846.R01.S.doc Version 5.1 Page 19 Radiators are covered. Window restrictors are in place. Culwood House DS0000022968.V282846.R01.S.doc Version 5.1 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 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 2 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 X X X X X X 2 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X N/A X X 2 Culwood House DS0000022968.V282846.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? Yes 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 The registered manager is required to establish a programme of staff training in the home’s system of assessing care needs and of planning, recording and reviewing care.(PREVIOUS TIMESCALE OF 31 JANUARY 2005 NOT MET) The registered manager is required to review and rationalise the home’s present care plan documents (including assessment and daily progress notes) and develop a more coherent document. The registered manager is required to develop a staff training programme for 2006. (PREVIOUS TIMESCALEs OF JANUARY 31 and August 31 2005 NOT MET) The registered manager is required to develop or adopt a method of quality assurance for the home. (PREVIOUS TIMESCALE OF JANUARY 2005 AND OCTOBER 2006 NOT MET) The registered manager is required to ensure that the home DS0000022968.V282846.R01.S.doc Timescale for action 30/04/06 2 OP7 15 30/04/06 3 OP30 18(1) 30/04/06 4. OP33 24 15/05/06 7. OP38 12 & 13 05/03/06 Culwood House Version 5.1 Page 22 8 OP38 13(4) 9 OP38 13(3) 10 OP38 13(4) 11 OP38 13(4) conforms to relevant health & safety legislation. (PREVIOUS TIMESCALE OF NOVEMBER 2004 AND 30 SEPTEMBER 2005 NOT MET) The registered manager is required to ensure that there is a suitable first aid box available to staff at all times and that its contents are checked weekly and replenished as required. The registered manager is required to ensure that the home has an infection control policy and procedure and that staff receive appropriate training in infection control The registered manager is required to ensure that it has up to date and satisfactory maintenance records on its gas, electricity and other technical systems. The registered manager is required to ensure that it can demonstrate that it is conforming to current good practice on the prevention of Legionella in its hot water and shower systems. 01/03/06 15/05/06 30/04/06 12/03/06 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. Refer to Standard OP7 OP9 OP16 Good Practice Recommendations Care plans to be reviewed and kept up to date with current needs recorded It is recommended that a senior member of care staff attend a training course (such as the Aylesbury College Certificate in the Safe Handling of Medicines) on medicines It is recommended that the complaints procedure be DS0000022968.V282846.R01.S.doc Version 5.1 Page 23 Culwood House 4. OP36 amended so as to assure complainants that all complaints, oral and written, are investigated to the same standard. It is recommended that the registered manager establish a programme of individual staff supervision and appraisal Culwood House DS0000022968.V282846.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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 Culwood House DS0000022968.V282846.R01.S.doc Version 5.1 Page 25 - 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. 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