Inspection on 22/06/05 for Falmouth House Residential Care Home

This inspection was carried out on 22nd 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

Falmouth House Residential Care... 20/08/07

Falmouth House Residential Care... 02/10/06

Falmouth House Residential Care... 05/12/05

Falmouth House Residential Care... 07/02/05

Falmouth House Residential Care... 28/06/04

Similar services:

Ashlea Mews Residential Home

Eastwood

West Lodge

Arran House

Avenue Community Nursing Home

Cosin Lodge

Farmborough Court

Cragston Court

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

CARE HOME ADULTS 18-65 Falmouth House Residential Care Home 24 Edwards Road Whitley Bay Tyne & Wear NE26 2BJ Lead Inspector Jim Lamb Unannounced 22 June 2005 09:30 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Falmouth House Residential Care Home B53-B03 S312 Falmouth House V226693 220605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Falmouth House Residential Care Home Address 24 Edwards Road Whitley Bay Tyne & Wear NE26 2BJ 0191 251 3729 n/a n/a Mrs Anne Elkin 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) Mrs Anne Elkin CRH 10 Category(ies) of MD Mental Disorder (10) registration, with number of places Falmouth House Residential Care Home B53-B03 S312 Falmouth House V226693 220605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Three named service users are known to be category LD and four named service users are over pensionable age, category MD(E) Should any of these named service users leave the home, the CSCI should be informed immediately, at which time places will revert to category MD. Date of last inspection 7 2 05 Brief Description of the Service: The home is located close to the town centre and sea front of Whitley Bay. The home provides personal care and accommodation for up to 10 younger adults with a mental disorder or a learning disability. The home is a large converted terraced house. The accommodation is on three floors with changes of level within this space, there is no passenger lift. The laundry and office are located in the basement of the home, service users do not have access to these areas. The home has a large lounge and a seperate dining area and there is a small additional lounge where service users can see visitors in private. The service users have access to a back yard with a seating area. Falmouth House Residential Care Home B53-B03 S312 Falmouth House V226693 220605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the homes first annual unannounced visit, which took place over half a day. This inspection focused mainly on key standards. Time was spent talking to the manager and examining records, policies and procedures. Considerable time was spent talking to the service users and staff on duty. What the service does well: What has improved since the last inspection? The homes menus now include a choice/alternative. The service users said that the food was good and confirmed that a choice is available. Falmouth House Residential Care Home B53-B03 S312 Falmouth House V226693 220605 Stage 4.doc Version 1.30 Page 6 A new format has been introduced to record and monitor service users personal allowances. 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. Falmouth House Residential Care Home B53-B03 S312 Falmouth House V226693 220605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Falmouth House Residential Care Home B53-B03 S312 Falmouth House V226693 220605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 4 5 Service users had an appropriately detailed pre-admission assessment completed. Service uses were invited to visit the home prior to admission. Each service user is provided with a written contract/statement of terms and conditions. EVIDENCE: Details of the extra charges and what these are for, are in the contract given to service users and are agreed prior to their admission. A copy of the standard contract contained the range of information required by the standards and the service users sign these. Two service users interviewed confirmed they had a copy of their individual contract. Three service users’ files were checked and on each were a copy of a full needs assessment. These were carried out by the referring social worker they did contain a range of appropriate information and service users interviewed confirmed they were involved in drawing up both these initial assessments and the home’s subsequent service user plans. Falmouth House Residential Care Home B53-B03 S312 Falmouth House V226693 220605 Stage 4.doc Version 1.30 Page 9 The 3 service user plans checked by the inspector were comprehensive, and listed details of service user’s needs and actions taken by the staff to meet these needs. Five service users interviewed said their needs were met and they were happy with the care offered to them, all were aware of risk strategies implemented and understood the need for them. Three care plans were checked these provided evidence that a range of specialist health care services was provided to service users. Staff interviewed had had a range of relevant training and experience. All service users are invited to visit the home prior to admission to meet other service users and staff. Overnight stays can also be arranged. Two service users confirmed that they were invited to visit the home and had the opportunity to stay over night prior to moving into the home. Unplanned admissions are avoided. Falmouth House Residential Care Home B53-B03 S312 Falmouth House V226693 220605 Stage 4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 7 9 Arrangements for planning care in this home are good ensuring that the health, personal and social care needs of the service users are met. Detailed risk profiles were in place and service users rights are limited only through the assessment process. Self-advocacy is promoted. EVIDENCE: There is evidence of a comprehensive assessment in the service users’ care plans. There is also a comprehensive risk assessment of service users; two service users confirmed that they were involved in drawing up these plans/risks. There was evidence of advocacy arrangements, as well as family input. Care plans are drawn up with service users. There is evidence that plans are amended and reviewed on a regular basis. Falmouth House Residential Care Home B53-B03 S312 Falmouth House V226693 220605 Stage 4.doc Version 1.30 Page 11 All aspects of standard 7 have been met; self-advocacy is promoted, service users can access a range of external agencies that promote independence, any rights that are restricted are linked to risk assessments. Service users’ confirmed that they are able to make decisions for themselves. Falmouth House Residential Care Home B53-B03 S312 Falmouth House V226693 220605 Stage 4.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11 12 13 15 16 17 The service users are supported to use community-based activities and maintain contact with their relatives and friends. The menus are varied and nutritional and a choice is available. Nutritional assessments will need to be introduced for service users over 65. EVIDENCE: Each service user has a practical life skills assessment carried out and this is reviewed and updated every six months, all service users participate in this process. Validated intervention treatment programmes are accessed if a need does arise. The service users said that they have access to a range of community-based services and agencies, some of which promote and provide opportunities to learn and use life skills, including supported work programmes, education and training. Falmouth House Residential Care Home B53-B03 S312 Falmouth House V226693 220605 Stage 4.doc Version 1.30 Page 13 Nutritional assessments are required for service users over the age of 65. The staff team liaise closely with external agencies in order to monitor each service user progress. The service users informed me that they are supported to maintain close links with their families. All are able to choose who they want to see and when. There was evidence that daily routines promote independence, choice and freedom of movement. The service users said that they are involved in housekeeping tasks. Staff interacted in a sensitive and respectful manner with service users. The Home’s menus are based on the known likes and dislikes of the service users. At least two hot meals are provided on a daily basis. Service users have access to the kitchen day and night and are able to prepare drinks and snacks for themselves if they wish. The service users that I spoke with said that the food was good. The use of nutritional assessments was discussed with the homes manager and these will be introduced, routinely for service users over 65. A range of special diets can be catered for. Falmouth House Residential Care Home B53-B03 S312 Falmouth House V226693 220605 Stage 4.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 20 The systems for the administration of medication are good. Service users following assessment have the opportunity to manage their own medications. The health needs of the service users are well met, they have access to a wide range of health care professionals. Falls assessments are required for service users over the age of 65. EVIDENCE: No service users currently have any moving and handling needs. The inspector was informed that service users mainly need supervision and minimum help with their personal care tasks. Service users over the age of 65 require detailed falls assessments implemented. The service users said that privacy and dignity are respected at all times. No service users currently have or require any technical aids or equipment. There was evidence within the service users care records that they have access to a range of external health care services. Falmouth House Residential Care Home B53-B03 S312 Falmouth House V226693 220605 Stage 4.doc Version 1.30 Page 15 G.P.’s visit when necessary, and service users are referred for specialist health care if appropriate. All service users receive regular health care checks. Two visiting health care professionals visiting the home informed the inspector that they were very satisfied with the care provided. The records and the procedures for the administration of medication appeared to be appropriately detailed. The medication systems were examined for ordering, receiving and administering and disposal. All were found to be well maintained. One-service user self medicates and this appears to be well managed. The dispensing pharmacist offers good support and advice. Staff had undertaken accredited medication training. Falmouth House Residential Care Home B53-B03 S312 Falmouth House V226693 220605 Stage 4.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 23 The service users were confident that their concerns would be listened to, taken seriously and acted upon. The staff had good knowledge and understanding of Adult Protection issues. Adult Protection training is on going for staff employed. EVIDENCE: The home does have a complaints procedure, which the inspector saw. It contains details of how to contact the CSCI to make a complaint, that complaints would be responded to within 28 days and that complainants would be supported. Two service users interviewed confirmed that they had been given copies of the procedure and that staff listened to their complaints and dealt with them fairly. One service user spoken to who had made a complaint said it had been dealt with fairly. The home does keep a record of complaints. The home has a Whistle Blowing policy procedure as well as, the Local Authorities Vulnerable Adults procedures. The home also has a copy of the D.H. “NO SECRETS” for further information. The Home maintains detailed financial records on behalf of the service users Falmouth House Residential Care Home B53-B03 S312 Falmouth House V226693 220605 Stage 4.doc Version 1.30 Page 17 And have recently introduced a new format to record service users personal allowances. Staff has recently attended POVA training. Recent notifications submitted to the CSCI report incidents of both physical and verbal aggression between service users, there is evidence that staff has dealt with these incidents appropriately and strategy meetings arranged involving external professionals. Falmouth House Residential Care Home B53-B03 S312 Falmouth House V226693 220605 Stage 4.doc Version 1.30 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 25 26 27 28 29 30 The home has an infection control policy. The home is comfortable and suits the needs and lifestyles of the service users. The standard of cleanliness throughout the home was good. All bedrooms are single there are no en-suite facilities. EVIDENCE: On the day of the inspection the home was clean, well decorated and well maintained. The home is in a residential location. The service users interviewed said the accommodation was very good, homely and comfortable. The grounds were tidy, safe and accessible. It is recognised by the providers that the home would not be suitable for service users with a physical disability. Falmouth House Residential Care Home B53-B03 S312 Falmouth House V226693 220605 Stage 4.doc Version 1.30 Page 19 The fire service department had made a recent visit to the home. Requirements made must be actioned; the use of door chocks must cease. The proprietor informed the inspector that she would purchase mechanical devices to hold doors open. The manager was asked to check all fire doors to ensure that the intumescent strips have not been painted over. At least one of the strips to one of the service users bedroom doors had been coated with gloss paint. The home does have an appropriate amount of sitting, recreational and dining space. There are sufficient rooms for a variety of activities to take place. Service users can see visitors in private in their own rooms. The dining area is large enough to cater for all service users. Furnishings and fittings were domestic in design and in satisfactory condition. Lighting was sufficiently bright and also domestic in design. The home does have a sufficient number of baths, showers and toilets. These are close to bedrooms, lounges and dining areas. Doors had privacy locks. Room sizes varied and appeared to meet the minimum required. The home has one double bedroom. The service users are a couple that had made a positive choice to share with each other. Service users’ bedrooms checked all had opening windows. The rooms were centrally heated and the heating level could be controlled within each bedroom. Lighting levels were sufficient and there was emergency lighting throughout the home. The home was clean and free from offensive odours. The laundry facilities appeared to be well organised and the washing machines have the specified programme to meet disinfection standards. Falmouth House Residential Care Home B53-B03 S312 Falmouth House V226693 220605 Stage 4.doc Version 1.30 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32 33 36 The staff work positively with the service users in order to promote their independence, freedom of movement and their overall quality of life. Currently previously agreed staffing levels are being maintained, however if the dependency levels of the service users change, staffing levels will need to be reviewed. Staff have the opportunity to develop their skills and knowledge by attending relevant training courses. EVIDENCE: Staff levels on the day of the inspection did meet the agreed level. Staffing; 7.30am – 11.00pm 1 staff, with 1 sleep-in staff during the night. The manager/proprietor said that the home operates an effective on-call system and that back-up would be available within minutes. Staff spoken to and service users interviewed said that currently staffing levels were appropriate. All the staff were over 18 years of age and those left in charge were at least 21. Training needs of staff are identified via supervision and appraisal sessions. Falmouth House Residential Care Home B53-B03 S312 Falmouth House V226693 220605 Stage 4.doc Version 1.30 Page 21 Staff receive supervision six times per year. The staff interviewed had a wide range of knowledge, experience and training relevant to this client group, including an NVQ level 2. Training has included; POVA, challenging behaviours, abnormal psychology, understanding schizophrenia, learning disabilities workshop, the theory of ageing and all statutory training. Falmouth House Residential Care Home B53-B03 S312 Falmouth House V226693 220605 Stage 4.doc Version 1.30 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 38 40 41 43 The proprietor/manager manages both Falmouth and Albany house, which is located within walking distance; deputy managers are employed in both homes. The staff and service users said that she effectively communicates a clear development plan and vision for the home. The manager is aware that she needs to complete NVQ level 4 in management and care by 31.12.05. Policies and procedures are audited annually. EVIDENCE: The registered manager has many years experience in senior management and care, she is aware that she will need to commence a level 4 National Vocational Qualification in management and care. Falmouth House Residential Care Home B53-B03 S312 Falmouth House V226693 220605 Stage 4.doc Version 1.30 Page 23 Staff interviewed were clear about the their responsibilities. Staff and service users interviewed spoke positively about the manager saying she had actively encouraged them to contribute to the development of the service. Service users are informed when inspections take place and have access to inspection reports. The manager has developed a range of policies and procedures that are reveiwed on a regular basis. The records inspected were found to be appropriately completed, these included the fire log book, accident book, personal allowance records, Health and Safey manual, and there was information which verified that appropriate maintenance contracts for the home are in place. Finance records have previously been forwarded to the CSCI to verify that the home is viable. Falmouth House Residential Care Home B53-B03 S312 Falmouth House V226693 220605 Stage 4.doc Version 1.30 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 x 3 3 2 Standard No 31 32 33 34 35 36 Score x 3 3 x x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Falmouth House Residential Care Home Score x 2 3 x Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 3 x 3 B53-B03 S312 Falmouth House V226693 220605 Stage 4.doc Version 1.30 Page 25 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 YA 24 Regulation 23 (4) Requirement Following the recentt visit by the Fire Service the home must stop the practice of chocking doors open, the manager has agreed to purchase dorguards as recommended by the Fire Officer. Outstanding Nutritional assessments to be introduced for service users over the age of 65. Outstanding Detailed falls assessments to be inroduced for service users over the age of 65 Outstanding. The homes registered manager must achieve an NVQ level 4 in management and care. Ensure that the intumescent strips on all fire doors are free from gloss paint Timescale for action 1.9.05 2. 3. 4. 5. YA 17 YA 19 YA 37 YA 24 12 12 9 (i) 23 (4) 1.9.05 1.9.05 31.12.05 1.8.05 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 No recommendations were identified. B53-B03 S312 Falmouth House V226693 220605 Stage 4.doc Version 1.30 Page 26 Falmouth House Residential Care Home Commission for Social Care Inspection Northumbria House Manor Walks, Cramlington Northumberland NE23 6UR 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. 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