Inspection on 27/07/05 for Heversham House

This inspection was carried out on 27th July 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 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

Heversham House 20/11/06

Heversham House 15/02/06

Heversham House 02/11/04

Heversham House 10/05/04

Heversham House 11/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Heversham House Heversham Milnthorpe Cumbria LA7 7ER Lead Inspector Margaret Drury Unannounced 27 July 2005 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. Heversham House F58 F10 s22651 heversham house v234437 270705 ui stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Heversham House Address Heversham Milnthorpe Cumbria LA7 7ER 015395 63769 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Isobel Hellena Wales Care Home 13 Category(ies) of OP - Old Age registration, with number DE(E) - Dementia, over 65 of places Heversham House F58 F10 s22651 heversham house v234437 270705 ui stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Old Age not falling within any other category (12). 2. To include one named service user in the category of Dementia over 65 years of age (1) Date of last inspection 02 November 2004 Brief Description of the Service: Heversham House is a care home registered to accommodate 13 older people. It is situated in a small village close to Milnthorpe, a market town on the edge of the Lake District. The premises comprise a detached Georgian residence with a very attractive walled garden. There is a small car park at the rear of the home. The house has many original features including attractive bay windows, Delft tiled fireplaces and corniced ceilings. There is a large lounge / dining room and a small quiet sitting room on the first floor where service users can meet visitors in private. The gardens are pleasant and private.The home is owned and managed by Mrs Wales with her daughter working as the deputy manager. Heversham House F58 F10 s22651 heversham house v234437 270705 ui stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of the home, and took place over one morning. During the inspection time was spent talking with the manager and care staff on duty, looking at records to do with the day-to-day running of the home and the care of residents. Time was also spent with some of the residents and their visitors. What the service does well: What has improved since the last inspection? There has been some internal redecoration in the home and one bedroom has had new carpet fitted. The exterior of the building was being painted on the day of the inspection. Heversham House F58 F10 s22651 heversham house v234437 270705 ui 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. Heversham House F58 F10 s22651 heversham house v234437 270705 ui 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 Heversham House F58 F10 s22651 heversham house v234437 270705 ui 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) 2, 3, 4 & 5 The residents benefit from an admission procedure that includes a full assessment of need. Residents and their families benefit from the opportunity of visiting the home prior to admission. EVIDENCE: There is a clear admission procedure to the home, which includes a full assessment of need being carried out to ensure the home can adequately meet the person’s needs. Residents and their families are invited to visit prior to admission, to assess the quality, facilities and suitability of the home before a decision is made about the resident moving in. Heversham House F58 F10 s22651 heversham house v234437 270705 ui 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 & 10 The home has a clear and consistent care planning system, which ensures residents health, and social care needs are met in a way that promotes their privacy and dignity. EVIDENCE: The care plans contain information about residents care needs, including moving and handling. They are regularly reviewed and updated with the resident and/ or their family. Visitors who spoke with the inspector said how pleased they were to be invited to take part in the care plan review. The plans provide the care staff with the information they need to deliver the care required to meet resident’s needs. Records are kept about GP appointments and when district nurses visit, and people said that an appointment is made for them if they ask to see the doctor or nurse. The care staff spoke to residents in a courteous and polite way, knocking before entering bedrooms, and closing the doors when assisting people with personal care tasks. Heversham House F58 F10 s22651 heversham house v234437 270705 ui stage 4.doc Version 1.40 Page 10 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 & 15 Social activities and meals are varied and provided residents with a range of choices and opportunities on a daily basis. EVIDENCE: There is a programme of activities available for those residents wishing to take part in although the manager did say that many of the residents like to spend much of their time in their rooms. Residents who spoke to the inspector confirmed this and said that the choice whether or not to join in the activities was theirs although the one activity they all enjoyed was music and movement. Local ministers visit the home and there is a communion service each month to which staff and visitors are also invited. Visitors are welcome at any time providing it does not interfere with the life of the residents. Visitors who spoke with the inspector said they always received a warm welcome and now considered the manager and deputy to be their friends. Discussions with the cook evidenced she works hard to provide wholesome appealing meals for the residents to enjoy. Heversham House F58 F10 s22651 heversham house v234437 270705 ui stage 4.doc Version 1.40 Page 11 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) 16, 17 & 18 The home has a satisfactory complaints system with evidence that residents feel that their views are listened to and acted upon. Staff understand adult protection issues, which safeguard residents from abuse. EVIDENCE: Residents are given information about how to complain when moving into the home, and said that if they have anything to raise it is dealt with promptly. Information about making a complaint is displayed in the entrance area of the home. All residents take part in the national and local elections, through the postal voting system, and do enjoy the discussion with the staff before they cast their own vote. Heversham House F58 F10 s22651 heversham house v234437 270705 ui stage 4.doc Version 1.40 Page 12 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) 19, 20, 23, 24, 25, & 26 Residents benefit from warm, safe and comfortable surrounding in which to live. EVIDENCE: Some recent internal redecoration and the refurbishment of one of the bedrooms have improved the already well decorated and maintained home. Access to the pleasant, well-kept walled garden is suitable for all and there is a stair lift servicing the first floor. All except one of the bedrooms are for single occupation and the one room registered as a double, currently has one resident only. The rooms are well furnished and all have a washbasin. They are all personal to the residents who have brought in possessions from their own homes. Domestic arrangements in the home mean it is clean pleasant and hygienic. Heversham House F58 F10 s22651 heversham house v234437 270705 ui stage 4.doc Version 1.40 Page 13 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, 28, 29 & 30 Residents benefit from being cared for by an experienced and qualified staff team who are appointed following a thorough staff recruitment process. EVIDENCE: There is a minimum of three care staff plus the owner and/or the deputy in the morning and two care staff plus management in the afternoon. The home has one member of waking night staff plus the manager or deputy on call. There are also two cooks to cover the seven-day week. This number of staff is adequate to care for the resident, keep them safe and prepare meals and snacks throughout the day. Staff training is up to date with 75 of the staff qualifies to NVQ level 2 or above. The manager and deputy access as much training as possible, which is appreciated by the staff team. One member of staff told the inspector she was enjoying her NVQ level 3 as she was learning something new with each unit completed. Heversham House F58 F10 s22651 heversham house v234437 270705 ui stage 4.doc Version 1.40 Page 14 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, 36 & 37 There is clear leadership, guidance and direction to staff to ensure residents receive consistent good quality care. Residents benefit from an easy style of management and approach. EVIDENCE: Discussions with the registered manager confirmed her commitment to giving the highest level of care to the residents. She works closely with the staff team to ensure all the assessed needs are met. She is a qualified nurse, has completed the Registered Manager’s Award and has considerable experience in the care of older people. During the inspection she demonstrated clear lines of responsibility and delegation to the deputy manager but also provided a “hands on approach” when necessary. Staff are supervised every two months and health and safety policies and procedures ensure the residents and staff have a safe place to live and work in. Heversham House F58 F10 s22651 heversham house v234437 270705 ui stage 4.doc Version 1.40 Page 15 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 3 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 x x 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 3 3 3 3 3 x x 3 3 x Heversham House F58 F10 s22651 heversham house v234437 270705 ui stage 4.doc Version 1.40 Page 16 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 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. Refer to Standard Good Practice Recommendations Heversham House F58 F10 s22651 heversham house v234437 270705 ui stage 4.doc Version 1.40 Page 17 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith, Cumbria CA11 9BP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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