Inspection on 16/01/06 for Falstone Manor Nursing Home

This inspection was carried out on 16th January 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 Manor Nursing Home 12/11/09

Falstone Manor Nursing Home 08/10/08

Falstone Manor Nursing Home 10/10/06

Falstone Manor Nursing Home 15/08/05

Falstone Manor Nursing Home 17/03/05

Falstone Manor Nursing Home 08/10/04

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

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

CARE HOMES FOR OLDER PEOPLE Falstone Manor Nursing Home Cliffe Park Whitburn Road Roker Sunderland SR6 9NQ Lead Inspector Sheila Head Unannounced Inspection 16th January 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 Falstone Manor Nursing Home DS0000018215.V282738.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 Manor Nursing Home DS0000018215.V282738.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Falstone Manor Nursing Home Address Cliffe Park Whitburn Road Roker Sunderland SR6 9NQ 0191 5496699 0191 5497799 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) Ashbourne Healthcare Care Home 53 Category(ies) of Old age, not falling within any other category registration, with number (36), Physical disability (17) of places Falstone Manor Nursing Home DS0000018215.V282738.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Manager is allocated supernumerary hours as registered manager. Date of last inspection 15th August 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. The 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 a complex, which also includes Falstone Court, another care home that 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 DS0000018215.V282738.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over seven hours with two inspectors carrying out the inspection. One inspector spent time in the older persons unit and the other in the younger adults unit. Time was spent talking to residents, staff and visitors. The inspectors shared lunch with the residents, one with the younger adults and one with older people who live on the first floor. A selection of records were examined including staff files, care plans, training records, financial records and maintenance records. All communal areas of the Home were inspected plus some bedrooms. Discussions were held with the manager about progression of the service. What the service does well: The people who live in the home had lots of good things to say about their home. They described the staff as ‘great’ and ‘ they can’t do enough for you’ One person said ‘Its really clean and always looks nice.’ Most residents said they felt very lucky to have such a wonderful view over the sea. There was a good atmosphere in the home with plenty of chatting between residents, staff and visitors. Residents knew what was going on and were taking part in various activities around the home. Some visitors said they had a lot of confidence in the manager and the home was changing ‘for the better’. The manager listens to the residents and takes notice of their comments. Falstone Manor Nursing Home DS0000018215.V282738.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 Manor Nursing Home DS0000018215.V282738.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 Manor Nursing Home DS0000018215.V282738.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): None of these standards were assessed during this inspection EVIDENCE: Falstone Manor Nursing Home DS0000018215.V282738.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, 10 Individual care plans are in place that show the health, social and personal care needs of each resident. There is a clear care planning system in place that gives staff adequate information to effectively meet residents needs. Medication practices ensure that the needs of residents are safely met. Clear systems are in place. Residents are treated with respect and the staff make sure that each resident has their privacy protected EVIDENCE: The care plans relating to residents in the Young Disabled Unit were clear, up to date and had been developed with the involvement of residents and relatives. There is a full and detailed holistic assessment for each resident. Staff have worked very hard to produce such improved, meaningful care plans that show in depth assessment to make sure the residents are cared for in the manner they expect and have agreed. Falstone Manor Nursing Home DS0000018215.V282738.R01.S.doc Version 5.1 Page 10 On the nursing unit care plans are individual to each resident outlining the care they need and receive from the nurses and carers. Residents said ‘the nurses are lovely, so are the carers’. One resident commented ‘They know how to look after me’. The care plans include assessments for pressure damage prevention, moving and handling, nutrition and weight monitoring and dependency levels. Pressure relieving mattresses are provided along with other aids to assist in care. The care plans are sparse in some areas such as identifying the social needs of the residents. The residents have a wide social activities programme The home has a safe and effective policy in place for administration of medicines. The recording and storage of medicines in both units was satisfactory and audit trails showed no discrepancies. Everything was correct. The storage area in the nursing unit was very clean and tidy. Handover sheets between staff are used when there are shift changes and sheets sampled were complete and helpful. There were no extra stocks and the medicine trolley was clean and tidy. The fridge was clean, locked and temperatures were recorded. In the Younger Disabled Unit the standard was high reflecting good practice. Each resident had a photo and allergy details were recorded. Audits are carried out daily by staff to check that amounts and quantities are correct and that each medicine given out is recorded. Care is given in a discreet manner with staff knowledgeable about residents preferences. Staff were observed on the nursing unit knocking on doors before entering residents rooms. Residents were observed in the nursing unit being helped by use of hoists to move to the dining room. The staff were kind, polite and unhurried. They spoke to the residents and reassured them about what they were about to do and what was going to happen before using equipment, which they did so in a safe manner. All residents have individual rooms that give relatives and visitors a space to go to discuss things privately if they wish. Falstone Manor Nursing Home DS0000018215.V282738.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): 13, 14 and 15 Visitors are welcomed into the home and therefore residents are able to keep in touch with their families and friends. Care practices in the home support residents making their own choices and residents are encouraged to take control over their own lives. Residents are provided with meals that are plentiful and that they enjoy. EVIDENCE: Visitors were seen coming and going throughout the day. They can visit whenever they want and staff were seen chatting and welcoming them into the home with offers of refreshment. Two visitors had travelled quite a distance to see a relative. They said ‘We are always made to feel welcome’ and ‘ Mums bedroom is very comfortable to spend time in with her, the staff offer drinks throughout our visit, we feel we know everyone well’ Residents still talked about their hot dog stall they ran outside the Home on the day of the Air Show. This was organised by the staff and residents and raised substantial amounts of money for the homes’ fund which is used to help Falstone Manor Nursing Home DS0000018215.V282738.R01.S.doc Version 5.1 Page 12 pay for social events. Residents choose to get involved in local events and are say they are proud of where they live. In the nursing unit there are residents meetings held but these are not well attended as residents said ‘we know what’s going on’ and ‘the staff talk to us all the time and if we want to do something they see that we do it.’ Residents were chatty and told the inspector that they can get up when they like and go to bed when they want. In the Younger Persons unit three residents commented that they did not have a residents’ forum to discuss the running of the home and to talk about changes. They said they felt a few people made decisions. However the nurse in charge explained that meetings were held to discuss decorating and other issues but could not produce documentation to substantiate this. Consultation was often between staff and residents on a one to one basis and noted in the care plans. Some residents remarked that ‘nothing ever gets done and nothing changes.’ Residents are however fully involved in writing and agreeing their care plans. One resident said ‘I’m chuffed with the place, the staff are great and I love the freedom I have’. Lunch was shared with the residents with one inspector in each of the units. The dining room in the nursing unit is pleasantly decorated with well-presented tables that have tablecloths, napkins and condiments. Lunch is served via a hatch from a small kitchen area. The residents were chatty and there was a good atmosphere between residents and staff. Residents had a choice of two main meals, toad in the hole or lamb stew. They are given the menu the day before and they choose which dish they want to have. One resident said ‘ the foods not too bad’ another said ‘we get plenty’ Omelettes and jacket potatoes are offered as an alternative. Desert offered was tinned fruit salad with ice cream or yoghurt. The meal was hot and plentiful however the quality was mediocre. Although the meat was tender, there was not much of it in comparison to vegetables in the gravy. The chef works with a company system that dictates menus and quantities of ingredients. The residents are only allowed bacon on Thursdays as part of the set menu process, controlled outside the home. The chef is restricted by a rigid ordering regime. In the Younger Persons Unit the menu was the same, with a choice of cold or hot drink. Meals were served from the kitchenette and assistance was given to residents in a respectful, discreet manner. The dining room was homely with music playing in the background. Tables were well presented with adapted cutlery available for those who needed it. One resident asked for soup and a cup of tea and that was immediately provided. The portions were large and served reasonably hot. Falstone Manor Nursing Home DS0000018215.V282738.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): 16 Complaints are taken seriously and action is taken quickly and sympathetically to resolve concerns. EVIDENCE: The complaints procedure is available to all residents and their visitors explaining to them how to make a complaint and who to. The procedure is given to residents as part of their welcome pack when they come to live in the home. There have been no complaints recorded by the manager since August 2004. Talking to the manager during the inspection she said operated an open door policy for residents, their families and the staff. The manager was very positive about people talking to her about concerns as this then leads to improvement in service. The manager also encourages daily communication between the units and herself through daily meetings and she walks around the units every day talking to residents and relatives. Visitors spoken with during the inspection said ‘Yes we know we can go to the manager at anytime. We know who she is and where her office is’ Falstone Manor Nursing Home DS0000018215.V282738.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 The home is safe, well looked after and comfortable for residents to live in. EVIDENCE: Both units are decorated to a high standard and reflect the needs and age groups of the residents so that they feel at home, especially as they are consulted about colours and fabrics. A bar area has been introduced into the younger persons unit that has a jukebox and an arcade style games machine. It is properly equipped and cosily decorated. Drinks are reasonably priced and the area is very popular with the residents. In this unit, though it has been recently decorated, it is showing signs of wear and tear, mainly from wheelchair damage. The nursing unit is decorated in a more traditional style but is well kept. There are specialist chairs available for those residents that need them and lounges are comfortable and restful making the most of the spectacular views of the sea. Falstone Manor Nursing Home DS0000018215.V282738.R01.S.doc Version 5.1 Page 15 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): 29 The staff recruitment procedure is operated in a robust manner therefore safeguarding the residents from potential harm. EVIDENCE: Personnel files of three members of staff were examined. All contained evidence such as application form, references, Criminal Record Bureau clearance and records of interview. These records were all up to date so that residents are safe in the knowledge that the right people have been employed to look after them. There is a clear recruitment policy from the company for the manager to follow. Informal interviews are held which is good practice; to give prospective employees an insight into the work and to give them chance to chat about what is expected from them before they formerly apply for a position. Falstone Manor Nursing Home DS0000018215.V282738.R01.S.doc Version 5.1 Page 16 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): 35 and 38 There are systems in place to make sure service users finances are dealt with efficiently and that they are safely kept, however these systems were not up to date on the day of the inspection. Rigorous monitoring and checks of health and safety matters protect the service users and the staff. EVIDENCE: The home encourages friends and family to be responsible for financial matters of residents if the resident is unable to manage for them. Residents have the choice of having social services look after their interests if they so wish. The home does look after pocket monies for the residents. Each resident has an individual wallet with an individual balance sheet plus the balance of the money in cash in the wallet. There is also a computerised record. Falstone Manor Nursing Home DS0000018215.V282738.R01.S.doc Version 5.1 Page 17 Three resident wallets were checked to see if the balance sheet corresponded with the total of money in the wallet. All three were found to be short. After discussion with the admin staff it was found that entries onto the balance sheet had not been made at the same time as money had been taken out to pay the hairdresser two weeks previously. Although there were receipts available from the hairdresser the balances had not been reconciled. There is also a system of wallet checks that are carried out fortnightly but there was no record that these had been done or that total balances tallied. The last audit was carried out in November but there was no documentation to prove this had taken place. By the end of the inspection the balances were correct. However more thorough checks are needed and audits should be made by senior admin staff to make sure that all transactions are recorded. There must be evidence of audits taking place and the outcomes must be recorded. The systems are in place but the staff failed to follow procedure. The home has clear and concise files that are up to date and correctly filled in showing that maintenance checks are regularly carried out and all the relevant servicing of equipment certificates are in place. These checks include fire alarm testing, testing fire extinguishers, fire drills, nurse call bells, hot and cold water temperatures, ambient air temperatures and lift checks. Any repairs that are needed are recorded clearly by staff in a repair book that is checked every day by the maintenance person. Once a repair is made the book is signed and dated. The manager checks the book, checks the standard of repair and also actions any repairs needed that have to have specialist people do them. Accidents are reported and documented on each of the units. The manager carries out an audit every month and looks at the reasons behind any accidents and looks to see if any further accidents can be prevented. She also sees that risk assessments are in place and up to date. The company also has a policy that the regional manager carries out an audit on their visits to the home. Falstone Manor Nursing Home DS0000018215.V282738.R01.S.doc Version 5.1 Page 18 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 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 3 x x x x x x x STAFFING Standard No Score 27 x 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x 3 x x 3 Falstone Manor Nursing Home DS0000018215.V282738.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? STTUTORY 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 OP35 Regulation 17(2) Requirement Written records of all financial transactions are maintained and balances reconciled immediately. Timescale for action 01/03/06 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 OP34 Good Practice Recommendations As part of the monthly visit by the registered provider a check of all financial transactions carried out on behalf of residents should take place and be records kept. Falstone Manor Nursing Home DS0000018215.V282738.R01.S.doc Version 5.1 Page 20 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 Manor Nursing Home DS0000018215.V282738.R01.S.doc Version 5.1 Page 21 - 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. 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