Inspection on 31/01/06 for Deeside

This inspection was carried out on 31st January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Deeside 26/09/08

Deeside 18/11/05

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 Peter J McNeillie Unannounced Inspection 31st January 2007 09:00 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 Deeside DS0000038990.V323458.R01.S.doc Version 5.2 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.V323458.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Deeside Address Alliston Way Southam Basingstoke Hampshire RG22 6SW 01962 847798 01256 346042 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.V323458.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th November 2005 Brief Description of the Service: Deeside is purpose built care home owned and managed by Hampshire County Council and is registered to provide care and accommodation for 33 persons who are at least 65 years of age. The home is situated in a residential area of Basingstoke close to local shops and public transport with easy access to Basingstoke town centre and the M3 motorway. Accommodation is arranged 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 and garden through the use of ramps and lifts. Deeside DS0000038990.V323458.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report was produced after taking into consideration a number of sources of evidence/information including a visit to the home, reading previous inspection reports, notifications of death, illness and any other advent that the Commission for Social Care Inspection should be notified under Regulation 37. Reports covering management visits to the home as required under Regulation 26, examining service users assessments/care plans, staff recruitment/ training records, policies / procedures, health and safety arrangements and comments by management, staff, service users and the results of an in house service user satisfaction survey. This key unannounced visit was the first inspection for the year 2006/07 and took place on 31/01/07 between the hours of 09.00 am and 2.15 pm. During this inspection the inspector who was assisted by an assistant manager had the opportunity to discuss living and working in the home with a number of residents and staff both individually and in groups. The results and findings contained in this report which looked at all of the key standards for care homes for older persons will determine the frequency and type of future inspections. Current fees are £392.00 per week. What the service does well: What has improved since the last inspection? Since the last inspection the terms and conditions given to residents now includes the full costs of the service they are receiving. The practice of pre dispensing night time medication has ceased this makes the whole procedure much safer. Deeside DS0000038990.V323458.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Deeside DS0000038990.V323458.R01.S.doc Version 5.2 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.V323458.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Terms and conditions of residence that include costs are available for all residents. The previous requirement has been complied with. The home has a system of assessing and identifying residents needs which ensures residents safety and that their assessed needs can be met. Intermediate care is not provided. EVIDENCE: Following the last inspection a requirement was made that terms and conditions of residence issued to residents must include all costs. A random sample of four residents records viewed by the inspector confirmed the previous requirement had been complied with. All of the files viewed included an external care management assessment as well as an in house assessment of individual health/nutritional needs and a Deeside DS0000038990.V323458.R01.S.doc Version 5.2 Page 9 risk assessment. . The records also confirmed residents were normally only admitted in a planned manner. External health care professionals would also be consulted and contribute to assessments if appropriate. Residents confirmed they were consulted and contributed to the assessment process but there was no written confirmation on files viewed to confirmed this The assistant manager gave a verbal undertaking she would address this shortcoming as soon as possible. Records also confirmed assessments of need and risk for all residents are reviewed on a regular basis and care plans adjusted if required. Respite care is not available in the home. Deeside DS0000038990.V323458.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for planning care are clear ensuring that the health, personal care and medication needs of residents are met and their privacy and rights respected. EVIDENCE: A sample of four residents records chosen by the inspector were viewed and a number of residents spoken with individually and in groups. Blank copies of a satisfaction survey sent out by C.S.C.I. were readily available in the home but no responses had been received. All of the residents spoken with expressed total satisfaction with the care they were receiving and the manner in which it was delivered. Comments such as “lovely here”” better that a hotel” ”the tops” ”we want for nothing”. They also confirmed they were consulted about the contents of their individual care plan and the assessments on which the plan was based but there was no written evidence seen to confirm this. The assistant manager gave a verbal undertaking she would address this shortcoming as soon as possible. Deeside DS0000038990.V323458.R01.S.doc Version 5.2 Page 11 Care plans and separate night care plans, which were reviewed monthlycontained information on how identified needs including any special needs were to be met. Residents confirmed any personal care was given in private and staff always knocked and waited before entering their bedroom. The inspector observed this practice. Residents are not able to make and receive phone call in total private. There is a portable handset/phone available but residents must ask staff to use it. A public call box, which is sited next to, a lift in a corridor has also been provided but any person using it would be overheard. It is understood the manager has brought this matter to the attention to external managers but the problem continues to exist and seriously compromises resident’s privacy and the right to make and receive telephone calls in private. Some residents had made arrangements to have their own telephone installed. Files seen and comments made by staff confirmed consultation with a range of external health care professionals such as doctors, district nurses, geriatricians, and continence advisors. Medication administration records are clear and show that medicines are given when required by trained staff and disposed of it line with the homes medication policy. Medication is stored safely and securely. Two residents are able to administer their own medication following a risk assessment. Staff confirmed residents were free to choose their own GP and there are currently up to 40 plus doctors from 8 local practices visiting. Other health care such as care managers, community psychiatric nurses, physco-gerriatrician and personal services such as chiropodists, dentists and opticians are also provide. Assistance in accessing any service in the community was available. Deeside DS0000038990.V323458.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service The social activities, family contacts and the provision of varied and nutritious meals were well managed and reflected service users interests and choices. EVIDENCE: A selection of in house and community based activities was available. Residents confirmed they were consulted about the type of activities available and they had a choice as to whether or not to participate. In house activities on offer include, quizzes, discussion groups, library, keep fit, arts and crafts, cake decorating, musical therapy, bingo, visiting entailers and reminisance in which two staff had been especially trained. The residents enjoy a number of community activities, theatres, shopping, visits to garden centres and general sight seeing trips. One resident remarked “There is always something to do, I have no time to feel old or ill.” Residents confirmed they were fully consulted either individually or in groups sometimes at a residents regular meeting on all aspects of living in the home. They confirmed and were able to exercise choice in all aspects of their lives i.e., when to get up and go to bed, mealtimes and where meals are taken. Deeside DS0000038990.V323458.R01.S.doc Version 5.2 Page 13 Visitors are welcome at all times, residents confirmed they were able to meet with and talk with any visitor they wished in private. The quality, quantity, presentation and choice of food served came in for particular praise from the residents. A full and varied menu based on individual likes, dislikes and was available. The cook speaks to each resident on a daily basis and establishes the person’s choice for meals the following day. The inspector in checking the daily menu confirmed that there was a wide selection of food available and observed that the midday meal was well presented and served in a calm unhurried manner. At the time of the inspection no residents from minority ethnic groups with special dietary needs were resident. Assistance with feeding is available. Deeside DS0000038990.V323458.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear policies and procedures in place which ensures residents are protected from abuse. The complaints procedure was satisfactory with evidence that residents feel their views will be acted upon. EVIDENCE: A corporate Hampshire County Council Adult Protection policy/procedure designed to Safeguard vulnerable residents from abuse was available as were records to confirm all staff had received training. Records viewed, management and staff spoken with confirmed they had received training in recognising abuse and demonstrated they knew what to do should they witness or suspect the abuse of any resident. The homes complaints procedure was which was also included in the service users guide included information on how to contact The Commission for Social Care Inspection was seen as was a record of complaints. Residents spoken to stated they felt comfortable in discussing any concerns they had with the homes management and confident any matters raised would be dealt with fairly and promptly. Deeside DS0000038990.V323458.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A safe, well maintained, clean and suitably furnished home is provided for residents which meets their needs. EVIDENCE: A tour of the home indicated it was safe, well maintained and meeting residents individual and collective needs. Furniture was comfortable and homely and in keeping with the décor. Residents commented how satisfied they were with the accommodation. All areas of the home were accessible to residents including the garden. The home was clean, hygienic and free from adverse odours. An infection control policy and procedure is in place. All staff have access to aprons, gloves and antiseptic hand gel. Deeside DS0000038990.V323458.R01.S.doc Version 5.2 Page 16 The home recognises the needs of some residents to smoke and consequently has provided a separate room fitted with an extractor fan. An annual maintenance programme for both the building, fixtures and fittings and furniture is in place. Deeside DS0000038990.V323458.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs are met by sufficient numbers of well trained and supported staff who are recruited and selected using a procedure designed to protect all service users. EVIDENCE: At the time of the inspection there were six members of care staff (including two assistant managers) one cook, three domestics and one laundry operative on duty. The number of staff on duty were able to meet the resident’s needs. The staffing records of four members of staff were viewed. Records indicated all staff are recruited and selected in accordance with a homes recruitment and selection policy and procedure which involves, the completion of an application form, an interview the signing of a rehabilitation of offenders declaration and satisfactory Criminal Bureau Records, Protection of Vulnerable Adult, medical and reference checks are carried out, On commencement of employment all staff are subject to a corporate in house induction course and a probationary period following which all staff are encouraged/expected to participate in a National Vocational Qualification (N.V.Q.) training programme. Deeside DS0000038990.V323458.R01.S.doc Version 5.2 Page 18 Currently 67 of care staff are trained to at least N.V.Q. level two with a further three due to complete their course in February 2007. In addition records seen indicate all staff are involved individually designed programmes covering the administration of medication, food hygiene, moving and handling, first aid, health and safety, infection control and the protection of vulnerable adults, any other subjects as determined by residents needs. The staffing records of three members of staff were viewed, and records indicated all staff are recruited and selected in accordance with a homes recruitment and selection policy and procedure. This involves, the completion of an application form, an interview, signing of a rehabilitation of offenders declaration and a satisfactory Criminal Records Bureau check. Protection of Vulnerable Adult, medical and reference checks are also carried out. Residents were full of praise for their carers commenting they were always cheerful, willing to help, respectful and appeared to know what they were doing. Deeside DS0000038990.V323458.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38.Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is well managed, the manager is qualified and experienced and has cared for older people for a number of years. Comments made residents suggest that nothing is too much trouble for the staff and management, and every effort is made to meet their changing needs and to improve the service. EVIDENCE: The service is well managed by the manager who is experienced in the care of older people and qualified to N.V.Q. level 4 in social care and a City and Guilds award in management. Comments made by residents suggest that nothing is too much trouble for the staff and management, and every effort is made to meet their changing needs and to improve the service. Deeside DS0000038990.V323458.R01.S.doc Version 5.2 Page 20 There are clear lines of accountability within the home all staff were fully aware of there responsibilities. Staff and management confirmed staff meetings and one to one personal supervision takes place on a regular basis and this was also confirmed by examining the records. Residents are consulted formally with evidence of regular residents’ meetings and the completion of a satisfaction survey the results of which are used to plan improvements to the service. A sample of records relating to money held by the manager on behalf of residents was checked. Receipts were available and the cash balances held reconciled with the records seen. The inspector observed no immediate obvious hazards to health and safety during the inspection. Cleaning materials and chemicals were securely stored. Protective clothing, supplies of hand disinfectant gel and gloves were available to staff. A health and safety policy and procedure was in place. Control of substances hazardous to health (COSHH) assessments, risk assessments, equipment servicing and accident records were available as were records to confirm all staff have receive training in the techniques of moving and handling first aid health and safety and the procedures to follow in the event of fire, including evacuation. The home has a laundry procedure and a washing machine, which is capable of disinfecting soiled items. All of the hot water supplies to baths were fitted with thermostatic controls set at 43 degrees centigrade and all radiators and hot pipes were covered. Deeside DS0000038990.V323458.R01.S.doc Version 5.2 Page 21 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Deeside DS0000038990.V323458.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No 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 OP10 Regulation 12(4) Requirement The registered person must ensure that all residents are able to make and receive telephone calls in private. Timescale for action 31/03/07 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.V323458.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V323458.R01.S.doc Version 5.2 Page 24 - 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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