Inspection on 06/12/05 for Fell House

This inspection was carried out on 6th December 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

Fell House 04/01/10

Fell House 21/11/08

Fell House 24/11/06

Fell House 20/03/06

Fell House 06/10/04

Fell House 27/04/04

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 Fell House Albion Terrace Springwell Village Gateshead Tyne & Wear NE9 7RJ Lead Inspector Mr Tom Moody Unannounced Inspection 6 December 2005 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 Fell House DS0000039416.V250502.R01.S.doc Version 5.0 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. Fell House DS0000039416.V250502.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Fell House Address Albion Terrace Springwell Village Gateshead Tyne & Wear NE9 7RJ 0191 417 4520 0191 417 7977 fellhouse@highfield-care.com 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) Southern Cross Home Properties Limited Mrs Gillian Batey Care Home 52 Category(ies) of Old age, not falling within any other category registration, with number (52), Physical disability (41), Physical disability of places over 65 years of age (41) Fell House DS0000039416.V250502.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th October 2004 Brief Description of the Service: This purpose built home is in a suburban setting away from the main road. It is in a quiet location with no through traffic. There are shops and other amenities nearby. The home has two floors and is of traditional brick and tile construction. Fell house provides care, including nursing care, to older people over the age of 65 years; some of whom may have physical disability. There is level entry to the ground floor and the upper floor has passenger lift access. There are lounge/dining areas on each floor and a South-facing conservatory. The corridors are wide and the communal areas and bathrooms are of generous proportions. The grounds are well kept, and although the majority of this space is devoted to car parking, service users enjoy the use of a small south facing terrace in fine weather. Fell House DS0000039416.V250502.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day on 6 December 2005. One inspector carried out the inspection. The manager was present at the time of inspection. The views of people living at the home were gathered during the day of inspection, by talking to them, their visitors and by reading documents. Positive feedback was received from all of those whom the inspector spoke to. The manager was interviewed and documents were examined, including care plans. A tour of the home took place. A mealtime was observed but the inspector did not sample the food at this inspection What the service does well: What has improved since the last inspection? The home has been redecorated and presents a pleasant aspect. The ventilation system in the kitchen has been repaired. Fell House DS0000039416.V250502.R01.S.doc Version 5.0 Page 6 A quality monitoring system is now in place. There is a robust system of recording financial transactions, including service user’s personal allowance, that is easily understood and demonstrates accountability. The home now has a loop inductions system in each lounge to help those with hearing aids. 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. Fell House DS0000039416.V250502.R01.S.doc Version 5.0 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 Fell House DS0000039416.V250502.R01.S.doc Version 5.0 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): 3 Service users needs are assessed by the home and professionals, from Local Authorities, or Primary Care Trusts. This ensures that they are placed in a home that can meet their needs. EVIDENCE: The home manager told the inspector that she carries out her own assessment of the needs of service users before they are admitted. An assessment is also done by the placing authorities. This was confirmed by care plan documentation. Fell House DS0000039416.V250502.R01.S.doc Version 5.0 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): 8, 9, 10, Service users health care needs are met and the home has the equipment and facilities it needs. The home has appropriate policies, storage and practice to ensure service users receive their medication in an appropriate way although some storage is limited. Service users are treated with respect by staff and, practice and procedures in the home ensure their privacy. EVIDENCE: The home has most of the equipment and facilities it needs, and a loop system has been installed for service users with a hearing problem. The manager is aware of service users needs to have access to primary care services and told inspectors that she will not admit service users unless they are able to receive this. Service users confirm they are able to see their GP and some told the inspector Of hospital appointments or equipment that was being arranged for them. Fell House DS0000039416.V250502.R01.S.doc Version 5.0 Page 10 The homes medication storage and administration systems are largely good although there is limited storage for controlled drugs. A drug round was seen and the recording of drug administration is good. Stock balances of controlled drugs are kept accurately. Service users were addressed respectfully by the staff and the privacy of their rooms was observed by staff knocking before entering. Fell House DS0000039416.V250502.R01.S.doc Version 5.0 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): 12, 13, 14, 15 Residents are offered the opportunity of participating in a wide range of leisure and social activities, within and outside of the home, enabling them to lead active and fulfilled lives. Service users make choices and are generally encouraged to take a degree of control over their surroundings. Service users are offered and receive a varied, wholesome, nutritious and wellpresented menu. This contributes to their health and wellbeing and offers opportunities to make choices. EVIDENCE: The manager states that the home does not have an activity organiser at this time but all of the staff take responsibility for helping service users with social and recreational activities. Service users confirm these take place and several spoke enthusiastically about recent entertainments such as a wine and cheese party and singers who had entertained them. There were a number of photographs of event that had taken place in the home during the summer including a medieval “joust” and visit from a professional storyteller. Fell House DS0000039416.V250502.R01.S.doc Version 5.0 Page 12 Service users also spoke of being able to go out of the home in good weather The home’s Christmas tree was decorated with “memorial” decorations bearing a tag remembering lost loved ones. The manager said that a local minister held a memorial service that was enjoyed by participants. A number of visitors were present during the time of inspection and they confirmed that the home encouraged visiting. Relatives expressed satisfaction with he care he home provides. One visitor said, “My mother has been in 4 homes and this is the best by far.” Another said, of the staff, “They are very caring folk.” One service user’s relatives, who live abroad, are able to have email messages conveyed to the service user in question. The lunchtime meal was well presented and looked appetising. Service users were supported appropriately by staff if they needed help to eat. The comments that were received from service users, confirmed the good quality of the food in the home. One service user remarked that, “the food is very good and there is a good variety.” The kitchen was well stocked and tidy. The manager told the inspector that service users had meetings where they decided on seasonal variations in the menu. Fell House DS0000039416.V250502.R01.S.doc Version 5.0 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, 18 Service users and relatives are able to raise issues with staff and the manager and they are sure that these will be acted upon. Although the staff are aware of issues surrounding abuse the homes policy does not support adequate action if such a situation arose, and could not guarantee proper protection. EVIDENCE: Relatives and service user confirm that they would be happy to raise issues with staff or the manager if they had concerns. It is evident that the manager has an “open door” policy and relatives repeatedly came to the office to talk with her. During one conversation between the inspector and two service users, one advised the other to, “See Gillian (the manager) she will get you sorted.” Complaints are well recorded and staff have a good awareness of issues surrounding complaints and representations. The home manager is aware of local adult protection issues and has participated in these. Unfortunately the company policy is out of date and does not reflect the current best practice in adult protection or the guidance given in No Secrets. Fell House DS0000039416.V250502.R01.S.doc Version 5.0 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, 20, 21, 22, 23, 24, 25, 26. The environment is well maintained to ensure service user’s safety. Communal facilities are easily accessible inside and outside of the home. Service users have most of the equipment they need to meet their needs. Bedrooms are safe, comfortable, well-furnished and meet service users needs. The home is clean hygienic and pleasant to be in. EVIDENCE: The home was warm, well ventilated and well decorated. Heating is provided from a safe, low surface-temperature source. No extremes of temperatures were experienced during the inspection. The home has good levels of natural and artificial light. The home has ramped access and appropriate lifts. Bedrooms are well furnished and contain personal items belonging to the occupants. The soft furnishings match the décor and the overall effect is homely. There is ample space in communal areas and service users have a variety of lounge, dining and sitting space to choose from. Fell House DS0000039416.V250502.R01.S.doc Version 5.0 Page 15 There are sufficient bathrooms and washing facilities and they provide generous space. Unfortunately there is no hair dressing facility and service users who were having their hair dried were placed in corridors. The home has a small patio area at the front of the conservatory, which was being used on the day of inspection. Service users confirm that they used this regularly in good weather. The home is kept clean and there were no unpleasant odours in the home at any time. Fell House DS0000039416.V250502.R01.S.doc Version 5.0 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, 30 The home has an appropriate number of staff, with the right skills, to meet service users needs Staff receive appropriate training and they are able to carry out their work in an appropriate manner. EVIDENCE: The number of staff in the home of the day of the inspection was appropriate and the care needs of service users were being met. Call buzzers were responded to promptly by staff. The manager stated that staff were updated and relieved in service training. Records support this and staff who were spoken to, confirmed they received good training and support from he company. Fell House DS0000039416.V250502.R01.S.doc Version 5.0 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, 32, 33, 34, 35, 38 The home is run by an experienced and competent manager who’s leadership and approach benefits service users. Service users financial affairs are safeguarded by the homes policies and practice. The health and welfare of service users is being protected by efficient management. EVIDENCE: The manager is an experienced registered nurse who has managed this care home for some time. She states she receives support from her senior management team. The home is regularly audited by the company and she receives feedback on the homes performance. Copies of audit documents were seen. Fell House DS0000039416.V250502.R01.S.doc Version 5.0 Page 18 There is good morale in the staff team. The manager states that the homes are works as a cohesive team and she adopts a practical approach involving a high level of contact with service users, relatives and staff. Relatives were seen to “pop in” to the office regularly and the manager has a good and open relationship with relatives. There is a robust accounting system for service users personal allowances. This is subject to monthly reconciliation and safeguards service users finances. The manager states that the company carries out quarterly service user satisfaction surveys. The response to these goes directly to “head Office”, anonymously if the respondent wishes, and the results are fed back to the home. Fell House DS0000039416.V250502.R01.S.doc Version 5.0 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 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 3 3 2 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 x x 3 Fell House DS0000039416.V250502.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP9 OP18 Regulation 13 13 Timescale for action There must be sufficient space to 01/02/06 store the amount of controlled drugs stocked in the home. The policies and procedures on 01/02/06 adult abuse must be updated to reflect current guidance and link in with the local authority’s procedures. Requirement 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 OP22 Good Practice Recommendations Suitable provision should be made for hairdressing or other therapeutic techniques. Fell House DS0000039416.V250502.R01.S.doc Version 5.0 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 Fell House DS0000039416.V250502.R01.S.doc Version 5.0 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. 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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