Inspection on 30/10/06 for East Riding

This inspection was carried out on 30th October 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

East Riding 22/09/09

East Riding 05/12/08

East Riding 05/12/07

East Riding 11/05/06

East Riding 24/11/05

East Riding 23/05/05

East Riding 05/11/04

East Riding 06/05/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE East Riding Whoral Bank Ashington Road Morpeth Northumberland NE61 3AA Lead Inspector Ian Armstrong Key Unannounced Inspection 30th October 2006 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 East Riding DS0000000506.V316598.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. East Riding DS0000000506.V316598.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service East Riding Address Whoral Bank Ashington Road Morpeth Northumberland NE61 3AA 01670 - 505444 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) East.Riding@fshc.co.uk Four Seasons Health Care (England) Ltd Mr William George Guy Care Home 67 Category(ies) of Dementia - over 65 years of age (34), Old age, registration, with number not falling within any other category (33) of places East Riding DS0000000506.V316598.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Two named service users are known to be under pensionable age, receiving EMI nursing care. No further admissions are to take place without the prior agreement of CSCI. Two named service users are known to be under pensionable age receiving general nursing care. No further admissions are to take place without the prior agreement of CSCI. 11th May 2006 2. Date of last inspection Brief Description of the Service: The home is a two-storey purpose built facility situated on the outskirts of Morpeth. It is within walking distance of local shops and the town centre. The approach to the home is via a steep driveway, which leads to generous car parking from which there is level access to the home. The home comprises of two units. Millview Unit is situated on the ground floor and caters for thirty older persons with nursing care needs and there are three beds for residents who require social and personal care only. The Wansbeck Unit is situated on the first floor and has thirty-four beds for mentally ill service users requiring nursing care. Bedroom facilities are mainly single en-suite with a total of six double rooms throughout the home. Each unit has lounges and dining rooms and there are specialist bathrooms and shower rooms located on each floor. The kitchen and laundry is located on the ground floor, stairs and a passenger lift access the first floor. Information about the homes services and facilities are displayed in the entrance area. Fees in the home are £383 to £613. East Riding DS0000000506.V316598.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection of the home which took place over one day. On the day of the inspection there was 52 residents in occupation, 13 males and 39 females. Time was spent with residents, relatives and staff. A number of records were inspected. These were assessments and care plans, medication records, policies and procedures, residents financial records, staff training and recruitment files. A tour of the premises was carried out. What the service does well: What has improved since the last inspection? What they could do better: Outstanding building maintenance work needs to be completed. Social care plan recording needs to be improved so that staff can meet individual needs of the residents. East Riding DS0000000506.V316598.R01.S.doc Version 5.2 Page 6 In-house fire instructions for staff must be in line with those specified by the Fire Brigade. Glasses to be purchased to replace plastic beakers. Menus need to be improved. These need to be displayed in dining areas. Wall mounted heaters must have adequate safety guards fitted so that residents are protected from the risk of harm. Clinical waste bins must be kept locked when not in use to reduce the risk of the spread of infection. 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. East Riding DS0000000506.V316598.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 East Riding DS0000000506.V316598.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 & 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The system of assessments prior to admission means that residents know that the service will meet their needs. The home does not provide intermediate care. EVIDENCE: Four residents pre-admission assessment records were read. All of these records were completed to a good standard. Relatives said they had visited the home prior to the admission and had been given good information about the homes services and facilities. East Riding DS0000000506.V316598.R01.S.doc Version 5.2 Page 9 East Riding DS0000000506.V316598.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 & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents individual plans of care include most of the information about their needs so that staff can give the care that they need. Health care needs are recorded and met. Medication policies are safe and detail the arrangements in the home. Residents are treated with respect. EVIDENCE: East Riding DS0000000506.V316598.R01.S.doc Version 5.2 Page 11 Four residents care plan records were inspected. All of these showed a good range of care plans written, with regular evaluations being carried out. However social care plans are not very individualised or detailed. Records by visiting professionals are well completed. The systems for the management of medications were checked and were satisfactory. A residents controlled medication stock balance was checked and was correct. Residents preference of staff undertaking their personal care is recorded and actioned. Residents food likes and dislikes are recorded and some of these are met. A resident said the cook provided her with baked potatoes with various fillings at lunchtimes which she liked instead of a larger meal. Records seen showed that for a number of residents individual food likes and dislikes were not being particularly well met. Visiting professionals see residents in their bedrooms so that the residents privacy and dignity is respected. Staff were observed to knock before entering residents bedrooms. Records seen show that staff address residents by their preferred title. East Riding DS0000000506.V316598.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 & 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents individual needs in respect of equality, diversity and recreation are in the main met through a range of activities, opportunities to attend religious services and adaptations made for residents with disabilities. Residents maintain contact with family and friends as they wish. Residents have some choice and control over their lives so promoting independence. Residents generally receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. EVIDENCE: East Riding DS0000000506.V316598.R01.S.doc Version 5.2 Page 13 The homes weekly activities programme shows a good range of activities for the residents. Two residents said they liked the chairobic sessions and singalongs. Three relatives were met during the inspection they said they could visit at any time and that staff were very friendly and helpful. A resident said the homes cook provided her with food that was not on the menu but was of her own choosing for lunchtime meals. Menus need to be improved. Vegetables need to be stated for main meals each day. Sandwich ingredients need to be specified. Alternative sweets need to be specified for the main meals each day. Menus should be displayed in the dining rooms. Crockery and glasses need to be purchased for use by residents. Plastic beakers are used for cold drinks. Improvements in these areas will enhance mealtimes for the residents. East Riding DS0000000506.V316598.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 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are handled well and where necessary action is taken. Residents are protected from abuse. EVIDENCE: The homes complaints policy is good. There have been no new complaints since the last inspection. The Protection of Vulnerable Adults policy is well written as is the Whistle blowing policy. Records seen show that good levels of training is being carried out and staff when questioned were aware of the procedures to follow. Relatives said that they were aware of how to complain and had been given a copy of the complaints procedure. Relative meeting minutes showed concerns in the past had been aired and appropriate actions taken by the home to resolve the issues.. East Riding DS0000000506.V316598.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, 24 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The systems in place to ensure that the environment is safe and well maintained to protect residents are adequate. Residents bedrooms are nicely personalised. This helps them feel at home. The home is generally clean and hygienic. EVIDENCE: East Riding DS0000000506.V316598.R01.S.doc Version 5.2 Page 16 Since the last inspection new corridor carpets have been fitted and new furniture and chairs have been purchased. Decoration of these areas is good. Bathrooms and toilet areas are not homely. Work still needs to be completed to replace a number of condensation damaged windows to the building. Window limiters open beyond the specified standard. Safety guards still need to be purchased for a number of wall mounted heaters. The heating to the lounge areas in the two wings of the home is not adequate. New dining tables and chairs have been purchased and are of a good standard. Work is ongoing to clean and replace some bathroom and toilet floors. The kitchen was visited this was very clean and tidy. Cleaning schedules for the kitchen were checked and were satisfactory. The homes laundry was satisfactory. Clinical waste bins to the rear of the home were checked and were not locked. East Riding DS0000000506.V316598.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 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are well supported by staff who have skills to meet the needs detailed in their care plans. There are systems in place to ensure that adequate competent staff are available for the safety of the residents. The recruitment policy is good and helps ensure the safety of the residents. Staff training is satisfactory in most areas. EVIDENCE: The following levels of staff are rostered in the home each day; Am, - 2 Qualified staff and 8 care staff. Pm, - 2 Qualified staff and 8 care staff, Nights, - 2 Qualified staff and 4 care staff. Rosters showed this level of staffing is being maintained. East Riding DS0000000506.V316598.R01.S.doc Version 5.2 Page 18 Two staff recruitment files were seen all appropriate checks had been carried out. Staff training records were seen these were generally satisfactory. Client centred training was not being carried out for all staff. Residents said the staff were very kind caring and supportive. Staff said that their training and support was good. East Riding DS0000000506.V316598.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 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home is generally good and focuses on the needs of the residents. The systems for the management of residents finances are satisfactory. The health, safety and welfare of residents and staff is generally protected through the policies and practises used in the home. EVIDENCE: East Riding DS0000000506.V316598.R01.S.doc Version 5.2 Page 20 The manager of the home is an experienced Registered Mental Nurse who has worked with older people with enduring mental health needs for many years. He has recently completed the Regional Managers Award. Minutes of staff and relatives meetings were seen, agendas for these were appropriate action is taken on issues raised. A Relative questionnaire survey carried out in June 2006 showed very positive responses to the services provided. Four residents financial records were checked. These showed regular expenditures, with two staff signatures for all transactions. Utility certificates were checked and were satisfactory. Accident book records were satisfactory. The Fire log book, all checks were correct, however in house fire instructions for staff are not being carried out at levels specified by the Fire Brigade East Riding DS0000000506.V316598.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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 2 X X 3 2 2 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 2 East Riding DS0000000506.V316598.R01.S.doc Version 5.2 Page 22 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 OP7 Regulation 15.1. Requirement Each resident in the home must have a written social care plan to meet their individual needs. The registered persons must review the menus to ensure they offer choice. Sandwiches, ingredients must be specified. Menus must be displayed in dining areas. Crockery and glasses to be purchased to replace plastic items. The registered persons must ensure that faults in the doubleglazing are repaired. Timescale of 08/05/06 not met. The registered persons must ensure that all bathrooms and toilet floors are deep cleaned. Where stains and ingrained debris cannot be removed the flooring must be replaced. Timescale of 08/05/06 not met. The registered persons must ensure that the problems with the under floor heating are DS0000000506.V316598.R01.S.doc Timescale for action 31/01/07 2. OP15 12,14 31/12/06 3. OP20 16,23 30/11/06 4. OP21 23 30/11/06 5. OP25 23 30/11/06 East Riding Version 5.2 Page 23 identified and resolved. Ambient temperatures must be maintained throughout the home. Timescale of 08/05/06 not met. 6. 7. 8. OP26 OP38 OP38 23.2(o) 23.2(p) 23.4(d&e) Clinical waste bins must be kept locked when not in use. 01/11/06 Wall mounted heaters must have 30/11/06 adequate safety guards fitted. Staff in the home must receive in 30/11/06 house fire instruction at levels specified by the Fire Brigade. 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 OP19 Good Practice Recommendations More needs to be done to make bathrooms and toilets more homely. East Riding DS0000000506.V316598.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 East Riding DS0000000506.V316598.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. 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