Inspection on 02/02/06 for Falstone Court Nursing Home

This inspection was carried out on 2nd February 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

Falstone Court Nursing Home 20/07/09

Falstone Court Nursing Home 24/08/07

Falstone Court Nursing Home 21/07/06

Falstone Court Nursing Home 01/09/05

Falstone Court Nursing Home 10/02/05

Falstone Court Nursing Home 07/07/04

Falstone Court Nursing Home 13/02/04

Similar services:

Eastwood

Farmborough Court

Connolly House

Craghall Residential Home

Elaine House

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

CARE HOMES FOR OLDER PEOPLE Falstone Court Nursing Home Rocklodge Road Roker Sunderland SR6 9NQ Lead Inspector Mrs P A Worley Announced Inspection 2nd February 2006 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 Falstone Court Nursing Home DS0000018192.V267834.R01.S.doc Version 5.1 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. Falstone Court Nursing Home DS0000018192.V267834.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Falstone Court Nursing Home Address Rocklodge Road Roker Sunderland SR6 9NQ 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) 0191 549 6699 0191 549 7799 Ashbourne Healthcare Care Home 41 Category(ies) of Dementia - over 65 years of age (41) registration, with number of places Falstone Court Nursing Home DS0000018192.V267834.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st September 2005 Brief Description of the Service: Falstone Court Nursing Home provides accommodation and nursing care for 41 older people with a dementia type illness. Falstone Court opened as a purpose built home in 1995 and is next door to a sister home Falstone Manor. A General Manager oversees both homes and is based at Falstone Manor, as are personnel records and financial information. The Home has two floors with communal rooms available on both floors. All areas within the Home are accessible to people with mobility difficulties. Ensuite toilet facilities are available in the bedrooms and toilets and bathrooms are available throughout the Home. The home is on the sea front and can easily be seen when driving along the sea front main road towards the city centre. A car park is provided and the home is accessible to wheelchair users. Falstone Court Nursing Home DS0000018192.V267834.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and was carried out by one Inspector over one day. Before the inspection a questionnaire had been completed by the General Manager, which gave up to date information about the Home to allow more time to be spent with residents on the day. A tour around the home to check the cleanliness, health and safety matters, and maintenance and decoration was carried out and found it to be clean, tidy and well decorated. Fifteen residents, seven visiting relatives, and a number of staff including the General Manager, Unit Manager, Activities Co-ordinator, care staff and nurses were spoken with. Lunch was taken with some residents in one of the two dining rooms. A number of records and documents were examined including residents’ care plans, personal allowance records and medication records. An action plan had been received from the Provider following the last inspection and all the requirements have been dealt with. Not all standards were looked at this inspection and from those that were; no requirements, but some recommendations, were made. What the service does well: The Home is well managed with constant support from the General Manager and Unit Manager and relatives spoken to said, the residents receive a good standard of care, and support by the Activities Co-coordinator with their social and leisure activities. Relatives spoke of better communications between staff and themselves in recent months. The Home has welcoming surroundings and a friendly atmosphere. All visitors to the home are made welcome and treated with courtesy and respect by the staff. Residents who were able to express their views, and visiting relatives spoke well of the staff. Some made such comments as “I’m very happy with the home, and the staff are lovely”, “” living here’s as good as you could get”, “I like the activities here, they’re enough for me” and “ They have a hard job but do it well”. Falstone Court Nursing Home DS0000018192.V267834.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? 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. Falstone Court Nursing Home DS0000018192.V267834.R01.S.doc Version 5.1 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 Falstone Court Nursing Home DS0000018192.V267834.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. The Home is in the process of ensuring that all service users are issued with a copy of the terms and conditions of the Home. EVIDENCE: The action plan received from the last inspection indicated that the Home endeavours to ensure that all service users are issued with a statement of the Home’s terms and conditions prior to admission. In discussions with the General Manger she confirmed that where service users did not have this statement all are being issued with them now. Falstone Court Nursing Home DS0000018192.V267834.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 & 9. Service users health, personal and social care needs are set out in an individual plan of care, to guide staff as to the care needs of the individuals’ to ensure that they are met. The systems and procedures for the administration of medicines are satisfactory with clear and comprehensive arrangements in place to ensure residents’ medication needs are met. EVIDENCE: A sample of residents care plans was examined. They gave good assessment information and identified residents’ health, personal and social care needs, and were up to date. Appropriate health and other risk assessments were in place for such areas as self-harm, falls and maintaining a safe environment for self and others. The format of the care plan documentation requires ‘normal day care needs’ to be recorded but do not always generate a plan of action for that care. Where specific needs are identified a care plan was available to indicate how those needs should be met. Daily evaluations are written but the statements made only indicate that the care is monitored and not the effectiveness or value of the care given, and do not cover all plans of care or measures of intervention. In conversations with staff they demonstrated Falstone Court Nursing Home DS0000018192.V267834.R01.S.doc Version 5.1 Page 10 awareness of residents’ needs and of how they were met, and relatives spoken with said they felt their relatives’ needs were being met satisfactorily. Inspection of the arrangements for the storage, ordering, receipt, administration and disposal of medicines was carried out and were satisfactory. A twenty-eight day blister pack Monitored Dosage System (MDS) is used. The Home has sight of the original prescriptions and photocopies are kept in the Home. Copies of all medicines ordered are kept and on receipt, all medicines are checked and signed in by a designated person. The medicine administration records (MAR) were generally well kept with clear records made. A contract is in place for the appropriate disposal of medicines including controlled drugs and two nurses sign to confirm which drugs are disposed of. The Company policy needs to be amended to reflect the change of arrangements and new procedure for the disposal of medicines. Falstone Court Nursing Home DS0000018192.V267834.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15. Residents receive varied and nutritious meals but the arrangements at mealtimes did not provide adequate supervision and support for those who needed it. EVIDENCE: The residents in the dining room on one floor were joined for lunch to observe the practices carried out by staff in serving meals, as required at the last inspection. Whilst actions have been taken since the last inspection to provide more suitable support and attention to residents, on this occasion only one member of staff was available to attend to residents’ needs in the dining room. This proved inadequate in that a number of residents needed assistance or support at the same time. The staff member was not able to observe all the activities of residents, particularly those who were mobile and were walking around the dining room, whilst serving meals at various stages of the mealtime. Another member of staff served the meals from the small kitchen area and a third member of staff attended to residents who were in their rooms. These issues were discussed at length with the General Manager, Unit Manager and the staff concerned. As the staff were aware of individuals’ behaviour patterns at mealtimes it was agreed that it would be more beneficial if all Falstone Court Nursing Home DS0000018192.V267834.R01.S.doc Version 5.1 Page 12 residents were attended to at the same time in the dining room, by all the staff to enable sufficient support and supervision to be given so that the activities of some residents that were disruptive could be diffused or dealt with before they escalated. The Manager indicated that a further review of the procedures at mealtimes would be made to improve the arrangements. Falstone Court Nursing Home DS0000018192.V267834.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed on this occasion. They were all assessed at the last inspection and were met, and discussions with management indicated that the procedures were unchanged. EVIDENCE: Falstone Court Nursing Home DS0000018192.V267834.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 & 26 The Home provides a safe, comfortable, clean and well maintained environment for residents to live in. Recent decoration of the corridors and communal areas has enhanced the homely appearance and image of the home. EVIDENCE: A tour of the Home was carried out with the General Manager. The corridors have been decorated since the last inspection. The appearance, when walking along corridors, now simulates ‘streets’ with external type lamps, doorknockers on resident’s bedroom doors, also stained glass coverings to the windows in the doors, and brickwork wallpaper in certain parts. Specific rooms such as the dining rooms depict cafes and the walls behind the sitting areas in the corridors on both floors have murals and seating that represent garden areas. Coat stands with jackets and hats are strategically placed in appropriate places and various wall mounted visual and sensory objects, for example, carpet, coloured pebbles, metals etc., provide an effective stimulus for residents as they walk by. The grab rails along the corridors have been painted in a bright Falstone Court Nursing Home DS0000018192.V267834.R01.S.doc Version 5.1 Page 15 and effective contrasting colour to enable residents to easily identify and use them. Residents were observed to respond with interest to all of these things, which offer interest and familiar memories to them. The provision of these facilities is a positive step in providing appropriate stimulus for residents with dementia and is commendable. A new carpet has been provided in the lounge on the ground floor and the stained carpet in the dining room carpet has been cleaned as required from the last inspection. A number of other rooms in the Home such as the small kitchens on each floor and some toilets are in need of decoration and the general Manager said these would be dealt with as part of the planned programme of decoration of the Home. Specialist equipment and facilities are provided for those residents who require assistance to enable them to maintain their independence for example, grab rails, bathing facilities, and easy access around the Home. The Home was clean to a good standard although one bedroom emitted a sight odour despite regular carpet cleaning. The General Manager said new flooring had been ordered for that room to assist with the management of the odour control. Falstone Court Nursing Home DS0000018192.V267834.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27. These standards were assessed at the last inspection and were all met. The staffing provided has increased in numbers to meet the needs of service users. EVIDENCE: Discussion with the Managers and some staff showed that care staff numbers have increased in order to better enable residents’ needs to be met. This was not however apparent at the lunchtime meal as the Unit Manager who would normally assist in this was occupied elsewhere at that time. Also, during the inspection one resident who constantly walks around and can be disruptive, clearly needed more direct supervision than was provided. This was also discussed with the Managers who agreed that this would be addressed. Staff training files were seen and confirmed that staff receive the appropriate training in all required areas and training programmes indicated that training was planned and ongoing. 95 of all staff has received up to date and the required statutory training and evidence was seen of other relevant training provided. Falstone Court Nursing Home DS0000018192.V267834.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 35, 36 & 38. The General Manager is appropriately qualified and experienced in care and related management, to competently run the home and service. Appropriate systems are in place and function well, to safeguard service user’s personal allowances. Records are clear and well documented. Appropriate supervision is given to staff but records need to be are kept of this. Staff follow appropriate safe working practices to promote and protect service users’ health, welfare and safety. Falstone Court Nursing Home DS0000018192.V267834.R01.S.doc Version 5.1 Page 18 EVIDENCE: The General Manager oversees the management of Falstone Court and its sister home, Falstone Manor. Since the last inspection she has been successful in gaining Registered Manager status with the Commission. Since the last inspection a Unit Manager has been appointed for this Home and is responsible to the General Manager for the day to day running of the Home. Although this person was employed at the Home previously as a Registered Mental Nurse (RMN), both staff and visiting relatives spoke positively of the support and improvements made since he took up this appointment as Unit Manager. In discussions with the Unit Manager it was evident that staff receive both group and one-to-one supervision but no records are kept of this. Staff spoken with confirmed that supervision takes place but without records made. The Unit Manager was advised that records of staff supervision must be kept as evidence that it takes place and also to assist in referring back, and identifying strengths and weaknesses, for the training and development of individual members of staff. Inspection of the arrangements for the personal allowances of residents was carried out. No residents at the Home are able to handle their own finances. The records and monies held for residents at this Home are dealt with by the Administrator and are kept at the office at Falstone Manor. Residents’ personal monies are received into the Home from their families or by cheque from Social Services. Individual records are kept of cheques received, and where relatives bring in cash, a receipt is given to them, copies of which were seen. Receipts and two signatures are available to back up transactions. The hairdresser and the chiropodist submit communal receipts to the Administrator and she agreed to speak with them to request individual receipts for each resident. The security arrangements and records of service users’, whose monies are held in the home, are well organised and well maintained. A random check of some residents’ monies held and their records showed them to be accurately accounted for. Two-weekly in-house audits are carried out and monthly reconciliation checks and a report are sent to head office. The health and safety policies and procedures and documentary evidence of the servicing and maintenance of equipment and services were inspected at the last inspection and were satisfactory. During this visit staff were observed to carry out appropriate health and safety procedures and no breaches of health and safety or fire safety were observed. Falstone Court Nursing Home DS0000018192.V267834.R01.S.doc Version 5.1 Page 19 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X 3 X X X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 3 X 3 Falstone Court Nursing Home DS0000018192.V267834.R01.S.doc Version 5.1 Page 20 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. Standard Regulation Requirement Timescale for action 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. 2. Refer to Standard OP7 OP15 Good Practice Recommendations The evaluations of care documented in residents’ care plans records should more clearly reflect how effective the care interventions are. The level of supervision and assistance by staff for residents at mealtimes should be further reviewed to ensure that all residents are appropriately supported, and allow a more relaxing environment for all residents in the dining room. A record should be kept of all staff supervision sessions as evidence that they take place. 3. OP36 Falstone Court Nursing Home DS0000018192.V267834.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Falstone Court Nursing Home DS0000018192.V267834.R01.S.doc Version 5.1 Page 22 - 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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