Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 15/08/05 for Falstone Manor Nursing Home

Also see our care home review for Falstone Manor Nursing Home for more information

This inspection was carried out on 15th August 2005.

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

There has been a lot of effort made to improve the living environment for the residents with a good deal of thought put into involving them in making choices particularly on the young adult unit. The Home offers a very pleasant, well-maintained Home with tremendous views across the sea front, which many residents appreciated and said this was a main reason for wanting to live in this Home. Whilst there is some concern about the ability of the Home to help the younger people to have more one to one help with social events the activity person tries very hard to organise a varied range of social events for the residents to enjoy. The Registered Provider has made sure there is good support now in place for the manager and her staff. This is a large and complex home caring for people with many different care needs. The benefits of this support are now being seen as ways of ensuring care and practices in the Home are monitored.

What has improved since the last inspection?

What the care home could do better:

Increased staffing levels on the young adult unit would help people to be involved in activities they would like to do on an individual basis rather than as a group. Further work is needed with the care plans to make sure the social needs of the residents are identified and action put in place to help meet those needs.

CARE HOMES FOR OLDER PEOPLE Falstone Manor Nursing Home Cliffe Park Whitburn Road Roker Sunderland SR6 9NQ Lead Inspector Sharon McDowell Announced Monday 15 August 2005 9.30 am 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 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 Manor Nursing Home B52-B02 S18215 Falstone Manor Nursing Home V219497 150805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Faslstone Manor Nursing Home Address Cliffe Park Whitburn Road Roker Sunderland SR6 9NQ 0191 5496699 0191 5497799 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) Ashbourne Healthcare Care Home with nursing 53 Category(ies) of PD Physical Disability (17) registration, with number OP Old Age (36) of places Falstone Manor Nursing Home B52-B02 S18215 Falstone Manor Nursing Home V219497 150805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17 March 2005 Brief Description of the Service: Falstone Manor provides nursing care for up to thirty-six older persons on the first and second floor of the building and a unit on the ground floor for up to seventeen younger adults with a physical disability. Falstone Manor Care Home is a purpose built three-storey building situated near to the sea front at Roker, enjoying panoramic views across the coastline. It is part of a complex, which also includes Falstone Court, another care home, which is separately registered for personal care for people with dementia, with the Commission for Social Care Inspection. The two services share car parking space to the front and rear of the building, kitchen and laundry facilities. The home is within short walking distance of the sea front, local seaside amusements and shops. It is accessible by local transport services and is within easy reach of Sunderland City centre. Falstone Manor Nursing Home B52-B02 S18215 Falstone Manor Nursing Home V219497 150805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over seven and a half hours with two inspectors carrying out the inspection. One inspector spent time in the older persons unit and the other on the younger adults unit. A pre-inspection questionnaire was submitted to the Commission for Social Care Inspection prior to the inspection containing information about staffing, training, company policies, maintenance and servicing of building A number of residents, staff and visitors were spoke with during the inspection and one inspector shared lunch with the residents on the young adult unit. A range of documents were reviewed including care plans, staff duty rotas, training records and activity plans. What the service does well: What has improved since the last inspection? The décor of the Home has improved in the young adult unit therefore making the Home look more like a younger persons home. Staff are working hard to improve the care plans. They have more detail in them about the residents care needs and there are plans to improve them further particularly in the area of social care. Falstone Manor Nursing Home B52-B02 S18215 Falstone Manor Nursing Home V219497 150805 Stage 4.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Falstone Manor Nursing Home B52-B02 S18215 Falstone Manor Nursing Home V219497 150805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Falstone Manor Nursing Home B52-B02 S18215 Falstone Manor Nursing Home V219497 150805 Stage 4.doc Version 1.40 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 standard(s) 3 Information about residents assessed needs is supplied to the Home to enable staff to develop a plan of care that will meet their needs. EVIDENCE: Care management or nursing assessments are available in the residents care plan from the funding authorities therefore the Home has sufficient information to be able to develop a plan of care when the resident moves into the Home. The manager advised a letter is given to residents to confirm the Home can meet their assessed needs. Falstone Manor Nursing Home B52-B02 S18215 Falstone Manor Nursing Home V219497 150805 Stage 4.doc Version 1.40 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 standard(s) 7 & 8 Staff have made a good effort to improve the care plans however they not yet completed sufficiently to ensure the needs of the residents are fully met particularly in relation to social care. EVIDENCE: A review system is in place where the named nurse reviews residents care plans. This is audited by the Registered Manager to ensure care plans are reviewed and evaluated. Care plans contained relevant risk assessments for problems such as, pressure areas, moving and handling, nutrition and falls. However there was little or no social care plans available, which means the health needs of the residents are given attention but little attention is paid to their social needs. There is a variation on the completion of life histories with some being completed in detail and others being very scant although it is recognised the resident might not want to or be able to give information about themselves. Generally, the care plans concentrate in healthcare issues and detail the care required. However some do not contain enough information in relation to specific needs of the residents. One care plans contained information on the Falstone Manor Nursing Home B52-B02 S18215 Falstone Manor Nursing Home V219497 150805 Stage 4.doc Version 1.40 Page 10 pre-admission assessment about the person suffering from anxiety but there was no care plan in place about this. Therefore staff had no information about what might make the person anxious and how they could help alleviate their anxiety. There is evidence in the care plans of visits from healthcare professionals to the Home, for example, doctors, chiropodists and opticians and also of residents attending appointments at clinics at local hospitals. One residents was most impressed that the optician visited the Home and that they could choose their own glasses. Falstone Manor Nursing Home B52-B02 S18215 Falstone Manor Nursing Home V219497 150805 Stage 4.doc Version 1.40 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 standard(s) 12 &13 Activities are well organised by a very motivated staff member therefore residents can expect opportunities to participate in a social events. However, younger adults not have the levels of support to enable them to pursue preferred social events on an individual basis. Visitors are welcomed to the Home therefore residents are able to keep in touch with their family and friends. EVIDENCE: The Home employs an activity person who residents greatly appreciate as comments were made, such as, ‘he is great’. Social events are advertised on the notice boards in the Home so that residents can see what is happening. A variety of outings have been organised and some residents particularly enjoyed the trips to feed horses with apples and carrots and many enjoy the bingo sessions. The activity person has a sweet trolley that he takes around, which is useful for those residents that do not have visitors and cannot get out of the Home. Any profit made goes towards the residents activity fund. Some residents would like to get out on a more personal level, for example, being pushed out for a walk in their wheelchair along the seafront, an outing to the hairdressers. However, staffing levels cannot meet this level of activity on a regular basis. Falstone Manor Nursing Home B52-B02 S18215 Falstone Manor Nursing Home V219497 150805 Stage 4.doc Version 1.40 Page 12 The younger adults said they preferred outings to places like Durham City rather than a planned holiday away from the Home. They had enjoyed a range of activities, which included shopping trips, pub visits, ten-pin bowling and the theatre. Relatives and friends are encouraged to participate and this helps with the supervision and assistance required by some residents. One resident commented they liked to play pool but there were not enough balls on the table, therefore the game is not realistic. Church services are held in the Home with Holy Communion held every Friday and additional visits from the church to individual residents. The residents enjoyed the International Air Show, which occurs on the sea front outside the Home. The Home organised hotdog and drinks stall in the grounds of the Home, which successfully raised funds for the residents activity fund. Visitors were seen coming into the Home throughout the day and were welcomed to the Home by staff. One couple visiting expressed their total satisfaction with the care provided at the Home and commented how their relative was very poorly when they were admitted and now was a different person. They felt peace of mind that their relative was being well cared for. Falstone Manor Nursing Home B52-B02 S18215 Falstone Manor Nursing Home V219497 150805 Stage 4.doc Version 1.40 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 standard(s) 18 Staff have are aware of Protection of Vulnerable Adults procedures therefore residents and relatives can be assured correct action will be taken in the event of harm occurring to a resident in the Home. EVIDENCE: All staff are booked to attend Protection of Vulnerable Adults training from September 2005 through to March 2006. A copy of the local Protection of Vulnerable Adults policy and procedure file is available on each of the units in the Home ensuring staff have up to date information about what to do in the event of suspected or actual harm occurring to a resident and the Registered Provider has policies available in the Home for staff reference regarding action to be taken in the event of any form of abuse. Staff receive in house training in relation to Protection of Vulnerable Adults during their initial induction to working in the Home, which gives them a basic level of knowledge prior to them attending a course. Registered nursing staff are available at all times for support and advice to care staff and the manager is available out of hours. The Registered Manager has carried out appropriate alerts to the Protection of Vulnerable Adults team therefore demonstrating correct action is taken to allow investigations of alleged abuse to be carried out by the right people. Some residents on the young adult unit were concerned about laundry going missing. They thought this was more to do with it not being put back in the right rooms rather that during the laundry process. Some also said they had Falstone Manor Nursing Home B52-B02 S18215 Falstone Manor Nursing Home V219497 150805 Stage 4.doc Version 1.40 Page 14 not had toast recently as the toaster had gone on fire and was therefore removed from the kitchen. The manager explained a new industrial toaster was to be purchased, as a domestic toaster was not substantial enough for the number of people wanting toast. Falstone Manor Nursing Home B52-B02 S18215 Falstone Manor Nursing Home V219497 150805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) nil None of the environmental standards were assessed in full at this inspection therefore will be reviewed at the next inspection. EVIDENCE: It was pleasing to note the young adults unit has been redecorated. The process involved the residents choosing colour schemes for the painting and carpets. This part of the Home now reflects the younger age group of the people accommodated. Falstone Manor Nursing Home B52-B02 S18215 Falstone Manor Nursing Home V219497 150805 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 Staffing levels are maintained to a level that meets the health and personal care needs of the residents. However the staffing levels are not sufficient to offer the residents on the young adults unit support to achieve their social interests and wishes. EVIDENCE: On the day of inspection there were seventeen residents accommodated on the young adult unit. Three care staff and one registered nurse were on duty from 8am until 8pm. Overnight there is one carer and one registered nurse. These staffing levels support basic care needs being attended to but do not allow a great deal of support for social care needs being met. The residents were very complimentary of the unit manager and a staff member described the unit as ‘happy and contented’. At a residents meeting comments were made praising the Home manager for the improvements to the young adult unit. Staff stated there is little use of external agency staff and that they tend to cover shifts themselves, which promotes continuity for the residents having familiar staff caring for them. The older persons unit covers two floors with seventeen people accommodated on each floor. During the day each floor has two care staff and one registered nurse with one carer available to help over the two floors. Over night there three carers and one registered nurse to cover the two floors. Staff and residents did not express any concerns about staffing levels. However the manager has addressed some issues raised by residents about there care Falstone Manor Nursing Home B52-B02 S18215 Falstone Manor Nursing Home V219497 150805 Stage 4.doc Version 1.40 Page 17 needs not being met overnight by changing some of the staff around between day duty and night duty. A visitor comment card stated they did not think there were sufficient staff on duty particularly experienced staff but did say that staff were generally helpful. Falstone Manor Nursing Home B52-B02 S18215 Falstone Manor Nursing Home V219497 150805 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32 & 33 The Registered Manager has implemented a strong leadership style promoting positive outcomes of care for the residents, relationships with relatives and support to staff working at the Home. EVIDENCE: The manager is not registered with the Commission for Social Care Inspection as the Registered Manager. This means she is not yet legally accountable under The Care Home Regulations 2000 as the Registered Manager. Her application has been submitted to the Commission for Social Care Inspection and is currently being processed. She has just started the Registered Manager Award, which is a requirement for managers of care homes. The manager has implemented a number of processes to audit practices in the Home, particularly in response to complaints and issues raised in the inspections, for example, her audit schedule for the remainder of this year Falstone Manor Nursing Home B52-B02 S18215 Falstone Manor Nursing Home V219497 150805 Stage 4.doc Version 1.40 Page 19 covers, health and safety, documentation, medication, food safety, training and hotel services. Residents on the young adult unit said they had residents meetings about every three months however the last one was cancelled at short notice. They felt they would like the meetings to happen more often to enable them share their views about the Home. Several visitors and staff made comment about the improvements in the management of the Home since she took over as manager. This has been a difficult task due to previous issues around staffing and care practices at the Home. She stated she was well supported by her line manager, which has been evident during complaints and Protection of Vulnerable Adults meetings and investigations. Satisfaction surveys are conducted to seek the views of the residents and their relatives. The survey covers topics, such as, health and personal care, social activities, daily life, complaints, environment and staffing. Falstone Manor Nursing Home B52-B02 S18215 Falstone Manor Nursing Home V219497 150805 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION x x x x x x x x 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 Standard No 16 17 18 Score x x 3 3 3 3 x x x x x Falstone Manor Nursing Home B52-B02 S18215 Falstone Manor Nursing Home V219497 150805 Stage 4.doc Version 1.40 Page 21 No 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 OP7 & YA6 Regulation 12 Requirement All health, personal and social care needs of the residents must be fully assessed and documented with care plans available adressing how those needs will be met. Timescale for action 31/12/05 2. 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 12 Good Practice Recommendations Consideration should be given as to how to increase staffing levels to provide greater opportunity for residents on the young adult unit achieve their social and recreational aspirations. The system for laundry management should be reviewed in relation to clothing being placed with the correct owner. 2. 16 Falstone Manor Nursing Home B52-B02 S18215 Falstone Manor Nursing Home V219497 150805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Baltic House Port of Tyne South Shields Tyne Wear 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 Manor Nursing Home B52-B02 S18215 Falstone Manor Nursing Home V219497 150805 Stage 4.doc Version 1.40 Page 23 - 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!