Inspection on 21/06/05 for Deeside

This inspection was carried out on 21st 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 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 18/11/05

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 RG22 6SW Lead Inspector Craig Willis Unannounced 21.06.05 09:40 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. Deeside H54 S38990 Deeside V231061 21.06.05.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Deeside Address Alliston Way, Southam, Basingstoke RG22 6SW 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) 01256 323334 Hampshire County Council Mrs Carole Anne Haydock CRH 33 Category(ies) of OP Old Age registration, with number of places Deeside H54 S38990 Deeside V231061 21.06.05.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: There are no additional conditions of registration. Date of last inspection 14.10.04 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 H54 S38990 Deeside V231061 21.06.05.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five hours. The inspector spoke with three of the service users on the day and received comment cards from eleven service users prior to the inspection. Two care staff and two assistant unit managers were spoken with during the course of the inspection. What the service does well: What has improved since the last inspection? Action has been taken to make sure the fire protection systems in the home are improved and protect service users. Carpets in some of the bedrooms have been replaced, ensuring that the home is safe and hygienic. Deeside H54 S38990 Deeside V231061 21.06.05.doc Version 1.30 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 H54 S38990 Deeside V231061 21.06.05.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 Deeside H54 S38990 Deeside V231061 21.06.05.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) 2 and 3 The system for assessing the needs of service users before they move into the home is good and assures service users their needs will be met. Missing and incomplete statements of terms and conditions of residence may leave some service users unsure of the cost of their service. EVIDENCE: The files of six service users were viewed during the inspection, all of which contained a needs assessment completed by the duty manager before admission to the home. Each file also contained a copy of the assessment completed by the care manager. Service users spoken with confirmed that the home was able to meet their needs. Of the six files viewed, two did not have a statement of terms and conditions of residence and two did have this document but it did not include details of the fee payable. Two of the files contained a costed statement of terms and conditions, which set out the services that would be provided at the home, the room that would be occupied and the rights and responsibilities of service users and the provider. Deeside H54 S38990 Deeside V231061 21.06.05.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, 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 with respect, although privacy when making phone calls is not maintained. Access to health services and the medication systems in the home are good and protect service users. EVIDENCE: The files of six service users were viewed during the inspection. All of the files contained a care plan that set out how the assessed needs of the service users should be met. Service users spoken with confirmed that they had been involved in drawing up and reviewing the plans and that the information in them was accurate. All of the plans were reviewed each month and changes had been made where applicable. Since the last inspection the care plan of one service user has been updated to include details of how staff should respond to verbal aggression. Service users spoken with confirmed that their health needs were met and they were able to see a GP when they needed and attend hospital Deeside H54 S38990 Deeside V231061 21.06.05.doc Version 1.30 Page 10 appointments. Service users’ files contained details of health appointments they had attended, including any advice given by the practitioner. Medication was stored in a locked trolley and medication administration records had been fully completed. A separate locked cabinet was available for controlled medication and two staff had signed administration records for these medicines. The balance recorded matched the balance held and records were available of medication returned to the pharmacist. All staff administering medication had received assessed training. The payphone on the first floor of the home has been lowered to make it more accessible, although it was still not in an area where service users could make a private call. One of the comment cards received from service users said they would like a payphone downstairs. The Assistant Unit Manager reported that there were plans to install a payphone in the downstairs visitors room, although they were unsure when this would happen. Service users spoken with said that staff treated them well and respected their privacy. 11 service users completed a comment card prior to the inspection, 8 of which said they felt well cared for at the home. None of the respondents said they did not feel well cared for. Deeside H54 S38990 Deeside V231061 21.06.05.doc Version 1.30 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 standard(s) 12, 13 and 15 Food in the home is adequate, providing choice and a balanced diet and there is a good range of activities for service users to participate in. The arrangements for service users to receive visitors are good, with the home making visitors feel welcome. EVIDENCE: Of the 11 comment cards received from service users, 8 said the home provided suitable activities and 3 said they sometimes provide suitable activities. Organised activities included arts, crafts, bingo, reminiscence sessions, visiting musicians and games. Service users spoken with confirmed that they were able to receive visitors at any time. One service user commented that visitors “are made to feel welcome and can always have a coffee or tea”. The visitors’ policy states that they are welcome at any time between 8am and 10pm and arrangements can be made with the manager for visits outside these hours. 4 of the returned service users’ comment cards said they liked the food, 4 said they sometimes like the food and 3 said they did not like the food. Service users spoken with said they thought the food was adequate and that choices and alternative meals were always available. Minutes of the service users’ meetings indicated that service users were consulted on the quality and variety of food and changes had been made to menus as a result of the meetings. Deeside H54 S38990 Deeside V231061 21.06.05.doc Version 1.30 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 standard(s) 16 and 18 The home has suitable complaints and adult protection procedures and service users know what to do if they have a complaint. Service users are confident their complaints will be taken seriously. EVIDENCE: The home has a complaints procedure in place, which sets out the details of who would investigate a complaint, the time within which a complainant could expect a response and the contact details of the Commission for Social Care Inspection. The complaints record was seen and no complaints had been made since the last inspection. Service users spoken with said that they knew what to do if they wanted to make a complaint and felt their complaint would be taken seriously. The home has adult protection procedures in place and staff spoken with demonstrated a good understanding of issues of abuse and action they should take if they suspected an abusive situation. Deeside H54 S38990 Deeside V231061 21.06.05.doc Version 1.30 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 standard(s) 19, 24 and 26 The systems for keeping the home clean and hygienic are good and maintain a safe environment. Service users’ bedrooms are safe and comfortable and have been personalised to make them more homely. EVIDENCE: Since the last inspection action has been taken to comply with requirements made by the fire authority. A letter from the fire officer was seen, confirming that the outstanding requirements had been complied with. The home has also replaced the carpets in two bedrooms since the last inspection to resolve unpleasant odours. The assistant unit manager reported that the carpet in one other room was due to be replaced later in the week of the inspection due to an unpleasant odour. Three bedrooms were seen during the inspection, all of which had been personalised by the service user and were clean and well maintained. Service Deeside H54 S38990 Deeside V231061 21.06.05.doc Version 1.30 Page 14 users spoken with said that their bedrooms were fitted with all of the equipment they need. The home was clean and hygienic throughout. There were separate laundry facilities which did not require soiled laundry to be taken through food preparation or storage areas. Deeside H54 S38990 Deeside V231061 21.06.05.doc Version 1.30 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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 and 30 The needs of service users are generally met by the number of staff working and the training staff have received, although systems to cover staff absences need to be improved. EVIDENCE: The home had a rota indicating which member of staff had worked which shifts. Staff numbers for carers were generally 4 in the morning, 3 in the afternoon and 2 in the evening / overnight. There had been some occasions when only 3 staff had been on duty in the morning due to sickness and leave and the assistant manager reported that on these occasions the duty manager covered some of the care duties. Staff spoken with said that there were occasions when they had to serve meals in two dining rooms, which could lead to some delays. One of the service users’ comment cards reported that staff were rushed at times. The manager reported that the home planned to introduce 3 carers awake overnight and not have a manager asleep in the home on-call. One of the staff on duty overnight will be a Night Care Co-ordinator and 3 staff had been recruited to perform this role. The manager reported that the training of these staff included completing the initial assessment of service users in case of an emergency admission to the home overnight. The training records indicated that all had completed courses in moving and handling, adult protection, fire safety, first aid, food hygiene, use of hoists and risk assessment. 6 staff have completed the NVQ level 2 in care and 5 staff Deeside H54 S38990 Deeside V231061 21.06.05.doc Version 1.30 Page 16 are due to complete the qualification this year. Staff spoken with said that they felt they had received the training they need to do their job. Deeside H54 S38990 Deeside V231061 21.06.05.doc Version 1.30 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 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) 38 The systems for maintaining the health, safety and welfare of service users and staff in the home are good and protect service users and staff. EVIDENCE: Staff have received fire safety training twice in the last year and have taken part in an evacuation of the building. Regular checks of the fire alarm and extinguishers have been made by staff and all fire systems have been serviced by contractors. The home had a current gas safety certificate and servicing certificates for the lift, hoists, bath chairs and the alarm call system. Fridge and freezer temperatures were recorded daily and assessments had been completed for chemicals used in the home. Accidents and injuries to service users and staff were recorded and reported where necessary. Deeside H54 S38990 Deeside V231061 21.06.05.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x x 3 Deeside H54 S38990 Deeside V231061 21.06.05.doc Version 1.30 Page 19 Yes 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 2 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. The registered person must make arrangements for service users to hold telephone conversations in private. This requiremant is repeated as the revious time-scale of 30/11/04 was not met. Timescale for action 31/8/05 2. 10 16 (2) (b) 31/8/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Deeside H54 S38990 Deeside V231061 21.06.05.doc Version 1.30 Page 20 Commission for Social Care Inspection 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 H54 S38990 Deeside V231061 21.06.05.doc Version 1.30 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. 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