Inspection on 02/11/05 for Arran House

This inspection was carried out on 2nd 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Arran House 15/05/07

Arran House 14/02/06

Arran House 24/02/05

Arran House 23/07/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Cumbrae House 10 Church Lane Guisborough TS14 6RE Lead Inspector Jackie Herring Announced Inspection 2nd November 2005 09:30 Cumbrae House DS0000060456.V261706.R01.S.doc Version 5.0 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 Cumbrae House DS0000060456.V261706.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 Adults 18-65. 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. Cumbrae House DS0000060456.V261706.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Cumbrae House Address 10 Church Lane Guisborough TS14 6RE 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) 01287 280511 01287 280522 Mrs Jane Dexter-Smith Mr R Dexter-Smith Brenda Anne Harland Care Home 7 Category(ies) of Learning disability (7), Mental disorder, registration, with number excluding learning disability or dementia (7) of places Cumbrae House DS0000060456.V261706.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Core and Cluster Home 4 places at Arran House The Manager, Mrs Brenda Harland, should attain (by 2005) a qualification, at level 4 NVQ in care and management, or suitable alternative. 24th February 2005 Date of last inspection Brief Description of the Service: Cumbrae was registered June 2004 as a core and cluster arrangement with Arran House, which had previously been registered, offering up to seven places for adults with both a learning disability and a mental health problem. Cumbrae has three single bedrooms one of which is on the ground floor. Arran House can accommodate four people in single rooms, one of which is situated on the ground floor with an ensuite facility. There is a small lounge available on the third floor. Both houses offer domestic, homely accommodation with ground floor lounges and well appointed kitchens/dining areas. Cumbrae and Arran House are situated near the centre of Guisborough and close to local amenities. Cumbrae House DS0000060456.V261706.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an announced inspection and took place over one inspection day, five inspection hours in total. Pre inspection documentation was completed and returned prior to the inspection, as were resident surveys and relative surveys. Discussions took place with residents, the manager and staff and a small number of records were examined including staff files, maintenance records and medication records. The inspector was only able to engage two residents in discussion about life within Arran House and Cumbrae House. It was agreed that the next inspection would take place at a time when more residents would be home to enable more in-depth discussion. What the service does well: What has improved since the last inspection? There have been a number of developments since the last inspection, with the manager having successfully completed NVQ 4 in Care, improved auditing of records, the review and update of the Statement of Purpose although this needs to be more service specific and continued work for staff to obtain their National Vocational Qualifications. There have been improvements to the environments at Arran House with a full kitchen refurbishment. Cumbrae House DS0000060456.V261706.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. Cumbrae House DS0000060456.V261706.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cumbrae House DS0000060456.V261706.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 Whilst a detailed service users guide was available and contained information to enable prospective service users it was about the whole organisation rather than specifically about Arran and Cumbrae Houses. EVIDENCE: The Statement of Purpose had been reviewed and updated since the last inspection and contained all of the required information. The information was not service specific to Arran and Cumbrae; it also included organisational information and included details about Miltoun and Brunswick House. It was recommended that a briefer more service specific Statement of Purpose be reviewed, which accurately reflects information about the specific registered homes and their individual structures and management arrangements. Cumbrae House DS0000060456.V261706.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 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 these standards were examined during this inspection. EVIDENCE: Cumbrae House DS0000060456.V261706.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the 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, 16 The lifestyle of residents within Cumbrae and Arran Houses is very much individualised and is underpinned by appropriate social and recreational activities as well as the opportunities for personal development. Residents’ benefit from maintaining personal relationships and have their right respected. EVIDENCE: Discussion took place with the manager, a senior care worker and a care worker regarding recreation and personal development opportunities for residents. A number of the residents attend day care facilities, one of the residents attends college and a further resident works in a local shop. During discussions, it was evident that every effort is taken to support residents to increase their personal growth and independence. For example, where possible, resident care for their bedrooms, do washing and ironing and assist fully in the meal preparation. Other examples included planned programmes aimed toward increasing independent use of public transport, which for one resident has built up over time and they are now using the bus independently, whilst another resident is attending college and doing courses on literacy and life skills. Cumbrae House DS0000060456.V261706.R01.S.doc Version 5.0 Page 11 Details of holidays was discussed with one group of residents who like to go to Scarborough, another group who like to go to Blackpool, and for the younger men, a holiday at the Carlton Outdoor centre. There has been a very active programme of activities and outings including going out for bar meals, birthday celebration and trips to Flamingo Land. Both houses are part of the natural local community and the residents access all of the local amenities and facilities. Residents do have their keys to their own rooms and they were consulted about whether the inspector could visit them. During the inspection one relative visited, who was taking his son home for overnight leave, which happens on a weekly basis. He confirmed that relatives were kept up to date with any changes that there are regular phone calls and that he is always welcomed into the house and knows the staff personally. He said, “there is a real sense of family and there is good support”. He also said, “communication is excellent”. A copy of the menus was made available prior to the inspection and it was confirmed through discussion with staff that there were involved in the menu planning. Satisfaction with meal provision will be discussed with residents at the next inspection. Cumbrae House DS0000060456.V261706.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Residents receive personal and health care support appropriate to their needs and preferences, which ensure their privacy and dignity is respected and independence promoted. The medication systems are in the main robust, some additions to the records keeping would enhance this further. EVIDENCE: Life within both houses as with the other houses in the company, is one in which individuality; independence and choice are the underpinning believes. This was demonstrated through discussion with a relative and staff, where a flexible approach to life was described. Individual routines were described which were dependant upon daily life commitments such as college, work and attendance at day facilities. One resident said, “I am happy here, I am more relaxed and I can have a say, I believe I am listened to”. Progress in regard to personal care needs was discussed and staff described how they supported individual residents to take pride in themselves. Staff said that resident went to the GP if needed, attending clinics and had support from Consultant Psychiatrist, Social Workers, Community Psychiatric Nurses and outreach workers. The staff views were that the Multi Disciplinary Team very well supports the houses and they were very positive relationships. Cumbrae House DS0000060456.V261706.R01.S.doc Version 5.0 Page 13 A random sample of medication records was examined and the systems were managed effectively, there was the need however to review the system for manager medication when residents go on leave as the system currently used operates secondary dispensing. It was agreed that this would be discussed with the pharmacist and it was confirmed that immediate action would be taken to address this. It was also confirmed that staff undertake appropriate training to undertake the responsibility of administration of medication. Cumbrae House DS0000060456.V261706.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Robust procedures are in place to protect residents from abuse and there is an effective complaint procedure in place. EVIDENCE: The manager and staff were aware of the complaints procedure and knew about the topic of protection of vulnerable adults. They confirmed they had received up to date training on the topic of abuse and were clear about the actions they would take. Residents spoken to did not have any concerns and one relative said, “we have no worries or concerns, if did would speak with the staff”. Cumbrae House DS0000060456.V261706.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Residents of both houses benefit from a well-maintained, comfortable and homely environment in which to live, although some improvements could be made to Arran House. EVIDENCE: Both House offer clean and homely environments for the residents and were most certainly conducive to meeting the needs of the residents. They were observed to be clean, odour free and homely with sufficient internal communal space and there was a real sense of comfortable family homes. Currently at Cumbrae House, the laundry area is contained within a locked cupboard in the only bathroom. A request was made to review this current arrangement and to move the laundry into the kitchen with risk assessments and control measures in place. Approval was given for this following the inspection after consultation with one of the Regulation Managers. Resident’s spoken to said they were happy with the houses and the homely environment they had, one resident said, “I like it here because it is small and there are not many of us”. Cumbrae House DS0000060456.V261706.R01.S.doc Version 5.0 Page 16 Some refurbishment was needed in Arran House, particularly to the hallway in which the floor was showing signs of wear and could potentially be a tripping hazard. It was also identified that the lounge did not have an opening window, this worked had already been planned and the window is going to be replaced. Other planned worked included a new bathroom and shower, which would increase choice for residents. The kitchen had recently been renewed and was very tasteful and homely. Cumbrae House DS0000060456.V261706.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Robust recruitment and selection procedures and regular training opportunities ensure that residents are appropriately supported and protected by a competent and supervised staff team. EVIDENCE: A random sample of staff files was examined and they contained all of the required information. Staff members were clear about their job roles. There was the impression of a very happy staff team and it was observed that people were valued and personal growth and development encouraged. Training was described in the pre inspection records and included training such as, Adult abuse and no secrets, diabetes, safe handling of medicines, non-abusive psychological and physical interventions. The staff supervision systems was discussed and it was confirmed that this was being carried out by staff who were interviewed. Staff received client specific training as well as mandatory training and NVQ training. It was confirmed through and examination of the pre inspection questionnaire that currently 40 of the staff are trained to NVQ level two, however a further three staff members have commenced level 2 and two have commenced level 3. Cumbrae House DS0000060456.V261706.R01.S.doc Version 5.0 Page 18 A minimum of two staff are on duty at Arran House during the day, and one member of staff on sleep over during the night. One member of staff is on duty through the day at Cumbrae and again one staff member is on sleep over. The shift system was discussed and the staff currently work 24 hour shifts at Cumbrae, which was thought to benefit the residents however staff at times thought this was too long as there were not breaks. It was however confirmed that this system was being monitored and reviewed. It was also clear through discussion with staff, the residents and one relative that the staff had a very sound understanding of mental health needs. One relative said, “The staff have the skill and knowledge and are genuinely caring”, “The staff are very professional and obviously extremely skilled”. A resident said, “This is the best place I have been, there are really good staff and they give a good level of help”. Cumbrae House DS0000060456.V261706.R01.S.doc Version 5.0 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 42 Resident’s benefit from well managed houses, which provides consistently high standards with sound leadership and support to the staff team ensuring residents needs are met. EVIDENCE: A suitably qualified person is in post who has the skill and experience to manage Arran and Cumbrae Houses, and there are good support systems in place from within the company. During the inspection, staff were interacting positively with the two residents and who were at home at the time of the inspection and it was very clear from the observations that good staff/resident relationships had been developed. One staff member said, “The house runs very well, the residents get a lot from living here, and also have a lot of 1:1 care, there are great relationships, a lot of love and empathy and everything is geared up for the residents welfare”. Another staff member said, “It’s just like a normal family home, it’s very open everyone can express their own opinions”. Cumbrae House DS0000060456.V261706.R01.S.doc Version 5.0 Page 20 Details of Health and Safety were made available through the pre inspection questionnaire and these were found to be up to date and it was confirmed that all staff receive an individual copy of the policies and procedures, which was evidenced during the inspection. Health and Safety had previously been discussed at the Miltoun inspection and the same arrangements are in place, with a key individual is responsible for taking care of the Health and Safety of both houses. Staff were fully aware of checks, such as weekly fire checks and drills and confirmed that these were carried out. Policies and procedure were observed to be accessible to staff and residents should they be required. Cumbrae House DS0000060456.V261706.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Cumbrae House Score 3 3 2 3 Standard No 37 38 39 40 41 42 43 Score 3 X X X X 3 X DS0000060456.V261706.R01.S.doc Version 5.0 Page 22 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 YA20 Regulation 13 Timescale for action The medication system should be 02/11/05 reviewed to include appropriate procedures for handling of medication for when residents go on leave. Requirement 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 Refer to Standard YA1 YA24 Good Practice Recommendations The statement of purpose should be reviewed and be service specific to Arran and Cumbrae Houses. The planned refurbishment programme should be continued and should include action to be taken in respect of the hallway floor at Arran House. 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