Inspection on 06/03/07 for Driftwood House

This inspection was carried out on 6th March 2007.

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

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

Other inspections for this house

Driftwood House 23/05/07

Driftwood House 17/10/06

Driftwood House 17/02/06

Driftwood House 09/09/05

Driftwood House 05/04/05

Driftwood House 01/12/04

Driftwood House 08/11/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Driftwood House Lynn Road Hunstanton Norfolk PE36 5HL Lead Inspector Ruth Hannent Key Unannounced 6th March 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Driftwood House DS0000027358.V332768.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. Driftwood House DS0000027358.V332768.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Driftwood House Address Lynn Road Hunstanton Norfolk PE36 5HL 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) 01485 532241 01485 535037 Mr Roy Alfred Kent Not applicable Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Driftwood House DS0000027358.V332768.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th October 2006 Brief Description of the Service: Driftwood House is situated in a residential area, close to the sea front and town centre of Hunstanton. Originally a hotel, the building occupies a corner site in attractive grounds with a large car park and was adapted by previous owners as a residential care home. The registration category is for older people and accommodation is available in 18 single and 2 double rooms. At present all 20 rooms are being used for single occupancy. Fees £300 - £350 Driftwood House DS0000027358.V332768.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report completes a key inspection to the home that looks at all the key standards within the National Minimum Standards, Care Homes For Older People. The visit also included a follow up to ensure the requirements made at the previous inspection carried out in October 2006 had been met. A pre inspection questionnaire and some comment cards had been received for the October 2006 inspection and the information/comments from these have been included in this report. The Proprietor had also completed an improvement/action plan following the last inspection and this was also discussed and used as evidence within this report. Throughout the day residents, staff and visitors were able to offer information to help make a judgement on the service offered in this Home. Some records were looked at such as care plans, medication records, equipment serviced and personnel files. Due to the large amount of building works taking place the environment was not inspected fully but areas that had been completed appeared suitable. Overall the home has made some improvements but some management systems still need improving. What the service does well: What has improved since the last inspection? The last inspection identified poor care plans. The information now recorded on new care plans is informative and gives much clearer information tailored to the needs of each resident. Driftwood House DS0000027358.V332768.R01.S.doc Version 5.2 Page 6 The Home now record the clear information that is the result of a health professional visit and the action to follow. The Proprietor has managed to get three places for staff to achieve a recognised qualification in care that will begin in April. The person who is to become the Registered Manager has now achieved a recognised Management qualification. Criminal Records for all potential staff are now carried out and no one is left unsupervised until that document is returned. 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. Driftwood House DS0000027358.V332768.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 Driftwood House DS0000027358.V332768.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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents do not move into this Home if the needs of the person cannot be met. EVIDENCE: A recent assessment form was seen of a lady admitted since the last inspection and although completed the information was limited. The manager has just started to use a new system for care plans and is about to introduce the assessment format that is part of the care plans just purchased. (The Home has not taken a new resident since the new care plans were introduced but future potential residents will have a more comprehensive assessment, guided by the new, more detailed format). There is no evidence to say a resident has been wrongly placed at this home. Driftwood House DS0000027358.V332768.R01.S.doc Version 5.2 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. 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 residents do now have care plans that give relevant information to ensure care needs can be met. Residents’ health care needs are met. The residents are protected by the procedures for medication within the Home. Resident’s are treated with respect, dignity and privacy. Driftwood House DS0000027358.V332768.R01.S.doc Version 5.2 Page 10 EVIDENCE: All care plan files are now stored in a suitable locked trolley. All residents have a new care plan with details clearer with more comprehensive information that gives person centred details of each resident. The Senior staff team have recently completed the information, along with the residents by transferring existing record information and completing documents not in place before. One resident spoken to was aware of the new care plans but others were a little bewildered about them. (As these are new formats the monthly reviews on each one have yet to take place). The staff team need to continue in the way they have been by developing the care plans and by reassuring staff that they are a tool to be used that will benefit both resident and staff with care delivery. The health care needs are met by the local GP practise. The district nurses are regular visitors and great support is offered by the local pharmacy who will chase up late prescriptions. The pharmacist is also planning a visit within the next two weeks to audit all medication and future training in medication is planned shortly after that for all senior staff to attend. It was also noted that a GP visit had been recorded in the care plan with clear information about the visit and the action required by the home. The medication for all residents is held in a suitable, locked and chained to the wall trolley. The Manager has a cycle throughout the month of audit, return, reorder and delivery. On occasions the Home has had problems in getting the prescriptions from the surgery which can mean a delay in someone getting their medication. The Pharmacist chases the surgery on behalf of the Home but some form of Management system needs to be in place with the surgery to ensure no one goes without medication. (Recommendation). The inside of the trolley is in order with colour coded blister packs for each time of administration, the eye drops were all dated and the manager automatically removes the drops on a monthly basis to ensure no opened drops go over the four week period. All medication charts are completed correctly and details highlighted in colour. Although the existing staff know the residents there are no photographs in the records, nor a sample signature of all the staff responsible for signing. Both these suggestions are added safety systems. (Recommendation). Throughout the visit it was noted that doors of residents were knocked upon before entry. The conversations overheard were polite and respectful. Residents can have a phone in their room if they so wish and noted was the post passed to a relative, unopened to then share with her mother. No rooms are shared bar one that is a double room with a married couple sharing at this time. Driftwood House DS0000027358.V332768.R01.S.doc Version 5.2 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. 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. Residents do have a lifestyle that satisfies their social, religious beliefs and interests. Choice and control over their lives is encouraged by the Home. Meals are served with choice, are wholesome and enjoyed by the residents. EVIDENCE: Although there is not a designated staff member to carry out activities the Home does ensure that residents are occupied in some form. It was noted when walking the building how involved with the residents the proprietor and his wife are. The residents interact with them very well and the residents speak highly of them. Comment cards received for the last inspection talk of a great staff team. Some residents read, some sit outside in the nice enclosed garden. One lady was keeping an eye on the builders and enjoying watching the building progress. The Home also receives a visit from the church on a Driftwood House DS0000027358.V332768.R01.S.doc Version 5.2 Page 12 Sunday and Communion for those who wish monthly. Throughout the walk round it was noticeable how happy people appeared. During the day three visitors were seen with two able to talk about their relative and how they were cared for within the Home. Everyone appeared relaxed with lots of cheery conversations taking place. People felt welcomed and included. Resident’s rooms are personalised and hold small items of resident’s furniture. Photographs are on display and main areas show photographs of life within the Home. Choice is noted through meal availability and which drink is preferred. Residents were asked where they would like to sit and if they required anything like a magazine or paper. The meal on the day of the visit was liver or fish fingers with potatoes and two vegetables. Residents spoken to all praised the meals. One lady who had not been so well feels it is down to the good food that she has now improved. The choice of what resident’s would like is asked the day before to ensure the correct amount is cooked. The lunchtime meal was unhurried and residents appeared to enjoy what they had. Driftwood House DS0000027358.V332768.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and their families can be assured that their complaints/concerns will be listened to and acted upon. Residents are protected from abuse once the whole staff team have the full training and knowledge. EVIDENCE: The Home has not had complaints but does deal with concerns seriously. There is a complaints procedure on the wall in the entrance and one lady stated I can talk to staff and they will sort out my problem. The Commission has not received any complaints to date. The Home has a little way to go to train all staff on the protection of vulnerable adults but the plans are in place to update this training. The staff spoken to, who were in the building during the last inspection know who to talk to if they have any concern that potential abuse could be happening but is was not clear if they recognised the signs. (Recommendation). Driftwood House DS0000027358.V332768.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Due to building works and records not easily found. These standards were difficult to inspect. Some areas are safe and some are not. The areas that can be are clean, pleasant and hygienic. EVIDENCE: Since the last inspection the Home building works have started. The Home is disrupted at this time with major alterations and new rooms being built. Although the new build will be an improvement the site in certain parts of the building are still part built. The owner has not completed any risk assessments while the home is partly a building site. Some regular servicing has not been carried out such as the fire extinguishers that were over the 12 month date for servicing (Requirement) and until the building works are completed some Driftwood House DS0000027358.V332768.R01.S.doc Version 5.2 Page 15 rooms are still without radiator covers. (Requirement x 2) The Owner/Responsible person has assured the Inspector that the building works will be completed by the summer/autumn and that all the building requirements will be in place Therefore the requirements will be extended and be met in the autumn. As some of the requirements are now outstanding and the need to get the building works completed hinders the requirements being met a comprehensive risk assessment should be in place to cover all areas of risk during this time. (Requirement x 2) The cleaners are doing their best to keep the Home clean while the building disruption is happening. There were no unpleasant odours and all linen is now sent to an outside laundry with only personal clothing washed in the temporary laundry. Driftwood House DS0000027358.V332768.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ needs are met by the correct numbers of staff who have various skills to meet those needs. Staff are beginning to achieve a qualification which will increase the numbers of qualified staff to ensure resident’s are cared for by safe hands. The recent change in the personnel procedures ensure that resident’s are protected by the recruitment of new staff. Training needs to be improved to ensure all staff have the knowledge and are competent to do the job required. EVIDENCE: The staff on the day of the visit appeared sufficient to meet the needs of the residents. (1 Senior and 2 carers with the proprietor and his wife also around and are also involved with the day to day care). All residents spoken to said the staff cared for them well and that they were happy with the care provided. The last inspection (Oct 06) residents comment cards also stated that staff cared for them well. Driftwood House DS0000027358.V332768.R01.S.doc Version 5.2 Page 17 The Proprietor has just secured some places on the NVQ programme that begins within the next four weeks. This will ensure that the amount of qualified staff should reach 50 . During the last inspection it was noted that not all staff had a CRB check for this employment. The proprietor has now sent all the forms to CRB for those staff members and is awaiting their return. (These missing documents were of staff who had transferred from another Home and although the certificates were only a few months old a new employment means a new certificate). The training of the staff has been slow. Looking through the personnel files it was evident that some staff are not up to date with current training and a system to ensure all staff receive training is not apparent. The Home is to purchase some training DVDs but these are only current at the time of making and to ensure staff are up to date a trainer within the home needs to obtain the current information to cascade to the staff team. This is not in place and staff are not all sufficiently trained. (Requirement x 2). Driftwood House DS0000027358.V332768.R01.S.doc Version 5.2 Page 18 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, 36 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The Home has a Manager who, once the building works are completed will be able to carry out the duties fully. The comprehensive quality assurance system to identify that the Home is run within the best interests of the residents is yet to be achieved. Staff are yet to have formal supervision to record and develop good practise. The health safety and welfare of residents is not evident with little recording or training fully completed. Driftwood House DS0000027358.V332768.R01.S.doc Version 5.2 Page 19 EVIDENCE: Although the person who is aiming to Manage the Home at present is not registered with the Commission she has now completed her RMA and is waiting for the certificate. The knowledge gained from the course is apparent when talking about the plans for the Home and the systems she wishes to see in place. At present the paperwork is not given priority so evidencing some Management tasks is difficult. The quality assurance for the Home has still not been carried out recently. There is no evidence of an annual development plan created from a quality monitoring system with no planning, action and review of the service, reflecting aims and outcomes for residents. (Requirement x 2). The Home does hope to have in place a new system shortly using a known company to assist them, which should improve the way quality is measured. Supervision of staff is still not taking place in a formal way. Day to day practise is observed and staff are assisted with issues as they arise but no recorded sessions of one to one is in place as yet. The Home does have plans to send the Senior team on a course to understand the supervision role and then plan the formal supervision sessions. (Requirement x 2). As mentioned in both the environmental standards section and in staff training section of this report, risk assessments and health and safety training is not all up to date to ensure all tasks are carried out safely. (Requirements listed in environment and staffing). The Home does have health and safety procedures but there is no way of knowing how informed or how read these documents are. No signatures of when read by whom and no supervision notes to say policies have been discussed. The proprietor states in the returned action plan that the Commission is notified of all death’s incidents and injuries yet nothing has been received by the Inspector. On discussion the notification is being sent to the County Council and not CSCI. (Requirement x 2). There are plans for the proprietor to hand over the Management side of Driftwood House to the newly qualified Manager once the building works are completed. This should ensure that there is a continuous improvement in the quality of care provided at Driftwood. Driftwood House DS0000027358.V332768.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x 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 2 1 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 1 x x 1 x 1 Driftwood House DS0000027358.V332768.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP19 Regulation 17(2) Requirement It is required that the home has a programme of routine maintenance, renewal of the fabric, and decoration of the premises with records kept. Extended time scale due to building work. (Outstanding Requirement) 2. OP25 13.4 (c) It is required that radiators throughout the building are guarded to eliminate as far as possible the risk of injury to residents. Extended time scale due to building work. (Outstanding Requirement) 3. OP33 24 It is required that the Home establish a method of measuring quality that is reviewed and aims to improve the quality of the service. (Outstanding Requirement). It is required that staff are DS0000027358.V332768.R01.S.doc Timescale for action 01/10/07 01/10/07 01/06/07 4. OP36 18.2 01/06/07 Version 5.2 Page 22 Driftwood House appropriately supervised. (Outstanding Requirement) 5. OP38 18.1 (a) It is required that all staff are offered all training/knowledge listed within this standard to ensure qualified staff can promote health, safety and welfare throughout their work. (Outstanding Requirement) It is required that risk assessments should be in place for all parts of the Home to ensure residents have access to all areas that are practicably free from hazards. (Outstanding Requirement) It is required that the manager informs the Commission without delay the occurrences of any deaths, accidents, injuries or events as listed within this regulation. (Outstanding Requirement) It is required that all fire extinguishers are serviced as soon as possible and the annual service pattern is established and not allowed to expire. 01/06/07 6. OP38 13.4 (a) 01/06/07 7. OP38 37 01/04/07 8 OP19 23.2(c) 23.4(c) iv 01/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP12 Good Practice Recommendations It is recommended that all interests and life stories are gathered from residents and families to encourage and maintain lifestyles that are personal and individual. Driftwood House DS0000027358.V332768.R01.S.doc Version 5.2 Page 23 2 OP36 It is recommended that some formal training on supervision is undertaken by senior staff as recommended previously to enable the full value of supervision sessions to be established within the Home. It is recommended that a system with the GP surgery is in place to ensure residents do not go without medication. It is recommended that all MAR sheet front covers have a photo of the resident and at the front of the charts is a list of all staff who administer medication with a copy of their initials to assist with auditing the medication records. It is recommended that the home continues to ensure all staff have the relevant training in the Protection Of Vulnerable Adults. 3 4 OP9 OP9 5 OP18 Driftwood House DS0000027358.V332768.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Driftwood House DS0000027358.V332768.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!