Inspection on 18/11/05 for Deeside

This inspection was carried out on 18th 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Deeside 26/09/08

Deeside 31/01/06

Deeside 21/06/05

Deeside 14/10/04

Deeside 22/04/04

Deeside 09/06/03

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 Deeside Alliston Way Southam Basingstoke Hampshire RG22 6SW Lead Inspector Craig Willis Unannounced Inspection 18th November 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Deeside DS0000038990.V266249.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. Deeside DS0000038990.V266249.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Deeside Address Alliston Way Southam Basingstoke Hampshire RG22 6SW 01962 847798 01962 846998 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) Hampshire County Council Mrs Carole Anne Haydock Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Deeside DS0000038990.V266249.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st June 2005 Brief Description of the Service: Deeside is registered to provide care and accommodation for 33 older people. The home is situated in a residential area of Basingstoke and is operated by Hampshire County Council. The home is organised on four wings, each with its own lounge and dining area. There are 33 single rooms, none of which have en-suite facilities. Disabled service users are able to access all areas of the home through the use of ramps and lifts. The home is within a quarter of a mile of local shops and bus services. Deeside DS0000038990.V266249.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection of the year April 2005 to March 2006. Key standards not covered in this report were assessed at the inspection of 21st June 2005. On this visit a Regulation Manager for the Commission for Social Care Inspection accompanied the inspector. Five service users were spoken with during the inspection and a tour of the building took place. The manager and one of the assistant unit managers helped the inspectors during the visit. What the service does well: What has improved since the last inspection? The manager has taken action to enable service users to make private phone calls by providing a cordless phone that can be used in bedrooms. The manager still plans to place a pay phone in the visitors’ room. Deeside DS0000038990.V266249.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. Deeside DS0000038990.V266249.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 Deeside DS0000038990.V266249.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): 2 and 6 Incomplete statements of terms and conditions of residence may leave some service users unsure of the cost of their service. EVIDENCE: The files of four service users were looked at. Of the four files viewed, all had a statement of terms and conditions of residence, although two of these documents did not contain any details of the cost of the placement at the home. This was identified as a problem at the last inspection and the requirement to take action is repeated in this report. The manager reported that Hampshire County Council held this information centrally and she would obtain an updated figure for all service users. The home does not provide any intermediate care. Deeside DS0000038990.V266249.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 and 10 The home has good care plans in place, which provide accurate information on how service users’ needs should be met. Staff treat service users well and respect their privacy. The medication systems in the home are generally good, although changes in the administration of night time medicines will offer greater protection to service users. EVIDENCE: The care plans of four service users were viewed. All these documents set out how the assessed needs of service users should be met and had been reviewed each month. The plans had been amended were necessary, for example to reflect the changing mobility needs of one service user, and had been signed by the service user. Service users spoken with said that they were aware of their care plans and were happy that the information they contained was accurate. Medication was stored in a locked medical room and in two lockable trolleys, one on each floor. The home had a copy of the Hampshire County Council medication procedure, although it was noted that the document made reference to the Registered Homes Act 1984. This should be amended to Deeside DS0000038990.V266249.R01.S.doc Version 5.0 Page 10 cover the requirements of the Care Standards Act 2000. The medication records had been fully completed and a controlled drug register was used. The records of three controlled drugs were checked and were found to match with the stock held. Two staff had signed the controlled drug register. All staff administering medication have received training. Four service users require medication early in the morning, which is administered by the night care coordinators. Currently, this medication is removed from the cassette it is dispensed in and placed in another container for the night care co-ordinator to administer. The manager said she would take action to ensure that medication is only administered from the container it is dispensed in, in order to comply with the Royal Pharmaceutical Society’s guidelines for the administration of medication in care homes. The manager reported that since the last inspection the pay phone had not been moved to a private area. The manager said she would like to install the phone in the visitors room, although in the meantime she has made the home’s cordless phone available to service users. While this interim measure has enabled service users to make private calls, they are still reliant on staff to gain access to the phone. Service users spoken with said that staff treat them well and respect their privacy. Deeside DS0000038990.V266249.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): 14 Service users are helped to exercise choice and control over their lives. EVIDENCE: Service users manage their own financial affairs where possible. Service users spoken with confirmed that they were able to bring their possessions into the home. Details of choices service users have made are included in their care plans. The manager kept a record of possessions brought into the home by service users. Deeside DS0000038990.V266249.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None The key standards were assessed in the inspection of 21st June 2005. EVIDENCE: Deeside DS0000038990.V266249.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): None The key standards were assessed in the inspection of 21st June 2005. EVIDENCE: Deeside DS0000038990.V266249.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 and 29 The needs of service users are met by the numbers, skill mix and qualifications of staff deployed. The home has robust recruitment procedures, which protect service users. EVIDENCE: The home generally has four staff in the morning, three in the afternoon, three in the evening and three overnight. On two or three occasions each week there were five staff working in the mornings. The home had a rota that indicates which staff had covered which shifts. This demonstrated that the manager ensures that there was a good skill mix on each shift, for example by pairing new staff with those with more experience. Service users spoken with said that there were sufficient staff working to meet their needs. The manager reported that there were ten staff with NVQ level 2 or above, with four staff starting the award in January 2006. The rotas indicated that staff without the NVQ award do not generally work together. The recruitment records of six members of staff were viewed. These records demonstrated that the manager obtained an enhanced Criminal Records Bureau disclosure and two written references prior to staff starting work in the home. It was noted that the application form and rehabilitation of offenders declaration for one member of staff was not signed because it was submitted electronically. The manager said she would ensure the member of staff signed these and any future electronically submitted forms were signed at interview. None of the records contained a declaration by staff that they were medically Deeside DS0000038990.V266249.R01.S.doc Version 5.0 Page 15 fit to carry out their duties. The manager said that these forms were held centrally and that she would obtain a copy for the home’s records. Deeside DS0000038990.V266249.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): 31, 33 and 35 A competent manager who fulfils her responsibilities runs the home. The quality assurance systems ensure the home is run in the best interests of service users and the financial interests of service users are safeguarded. EVIDENCE: The manager has an NVQ level four in social care and a City and Guilds award in management. She has undertaken regular training to update her skills and has many years experience of managing care homes. There are clear lines of accountability within the home. The manager reported that Hampshire County Council has recently introduced a ‘Managers Charter’, which includes an audit of the home’s environment and infection control procedures. The information from this audit will be used to develop a County plan for improvement. Hampshire County Council is also introducing a Quality Management System, which will form a comprehensive assessment of all aspects of the home’s performance and identify areas for Deeside DS0000038990.V266249.R01.S.doc Version 5.0 Page 17 improvement. The manager has developed a questionnaire of service users and relatives, specific to Deeside. This information is collated and used to plan improvements to the service. The manager reported that the home does not act as an appointee for any service users. Money is held in the safe on behalf of some service users for safekeeping. This money is individually stored and records are kept of transactions made on behalf of service users. The money of three service users was checked and found to correspond with the records. A record was maintained of all other personal possessions that were held for service users, such as passports and bankcards. Deeside DS0000038990.V266249.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 X 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 3 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X X Deeside DS0000038990.V266249.R01.S.doc Version 5.0 Page 19 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 OP2 Regulation 5 (1) (b) Requirement The registered person must ensure that each service user has a statement of terms and conditions of residence, which includes the level of fee for the service they receive. This requirement is repeated, as the previous time-scale of 31/8/05 was not met. Timescale for action 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Deeside DS0000038990.V266249.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Deeside DS0000038990.V266249.R01.S.doc Version 5.0 Page 21 - 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!