Inspection on 29/11/05 for Overstone

This inspection was carried out on 29th November 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

Overstone 03/08/09

Overstone 17/08/07

Overstone 12/10/06

Overstone 02/09/05

Overstone 25/01/05

Overstone 08/06/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Overstone Elvaston Road Hexham Northumberland NE46 2HH Lead Inspector Mary Blake Announced Inspection 29th November 2005 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 Overstone DS0000000621.V256599.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. Overstone DS0000000621.V256599.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Overstone Address Elvaston Road Hexham Northumberland NE46 2HH 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) 01434-606597 Mrs F C Robson Mrs Noreen Campbell Care Home 15 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (14) of places Overstone DS0000000621.V256599.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Should the service user in the DE(E) category leave the home, the CSCI must be notified immediately, at which time the category will revert back to OP. 2nd September 2005 Date of last inspection Brief Description of the Service: Overstone cares for 15 people in a two storey detached property. It is set in a quiet residential area in Hexham. The home is on two floors with a passenger lift to all levels. There are a variety of aids and adaptations to allow service users to move freely around their part of the home. The majority of bedrooms are single or occupied by couples and the communal bathing and toilet facilities are situated around the home. There is sufficient communal lounge and dining space. There are extensive gardens and parking within the grounds. The home is close to local amenities and transport networks. Overstone is registered to provide residential care for frail older people and has one place for an older person with dementia. Overstone DS0000000621.V256599.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced, the second of the year and took place over one day. A general tour of the ground floor of the premises was carried out. Residents care records; staff files, pre-admission documentation, monetary and medication systems were examined. The Manager, proprietor, chef and care staff and four residents were spoken to. Twelve questionnaires were received from residents and one from a relative, all of who wrote positively about the service provided, with the exception of activities, where five residents commented that there were sometimes insufficient activities. During inspection the residents gave comments “this is a lovely place to live” “all of the staff are very kind” “it is always spotless” “I’ve put on weight, the food is so good” “the manager and proprietor always have time to listen”. What the service does well: What has improved since the last inspection? Individual care plans have continued to improve and it was apparent that the Registered Manager is encouraging staff involvement in planning and evaluating care. Manager and staff are attending more training opportunities. Overstone DS0000000621.V256599.R01.S.doc Version 5.0 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. Overstone DS0000000621.V256599.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 Overstone DS0000000621.V256599.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 Overstone does not provide intermediate care. Residents have their needs assessed prior to admission and assured that these will be met. EVIDENCE: Examination of pre-admission assessments and discussion with residents, staff and the manager confirmed that residents’ care needs had been assessed prior to admission. Overstone DS0000000621.V256599.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): Resident’s personal needs are set out in their individual plan of care; social needs and nutritional assessments were not always documented. Resident’s health care needs are fully met. Residents are protected by the homes policies and procedures for dealing with medicines. EVIDENCE: Individual residents plans of care were examined and have continued to improve. These had been appropriately reviewed and updated. Individual social care needs were not always identified (see standard 12). Residents are weighed regularly however nutritional risk assessments are not always carried out or actions detailed within the care plans. Overstone DS0000000621.V256599.R01.S.doc Version 5.0 Page 10 Examination of care plans, discussions with residents and staff indicated that individual health needs are met, with residents having access to community health professionals such as GP, domiciliary dentist and optician, chiropodist, speech therapist, district nurses, community psychiatric nurses and consultants. A satisfactory audit of storage, administration, recording and disposal of medication was undertaken. Staff undertake the safe handling of medication training with Newcastle College and spoke knowledgably about the administration of medication and safeguarding residents. It was agreed that the practice of secondary dispensing would cease from 1st December 2005. Overstone DS0000000621.V256599.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 Social care needs are not always met; recreation and stimulation are not always adequate. Residents’ are able to maintain contact with family, friends and the local community. Residents are helped to have choice and control over their lives. EVIDENCE: A number of residents said that the social and stimulating activities on offer was insufficient. Activities are organised on an adhoc basis with no individual plan or home programme. Community links such as visits from local schools and choirs was evident. Residents spoke of making decisions about visitors, of going into town and visitors were observed to see residents in private. Residents spoke of having choice in personalising their bedrooms. The majority of residents are able to manage their own financial affairs with the Manager ensuring that relatives or care management provide support to residents. Overstone DS0000000621.V256599.R01.S.doc Version 5.0 Page 12 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): 18 Residents are protected from abuse by robust policies and procedures. EVIDENCE: The Manager and senior staff spoke knowledgeably about the policies and procedures in place to protect residents. The Manager reported that staff are to undertake training in protection of vulnerable adults. Overstone DS0000000621.V256599.R01.S.doc Version 5.0 Page 13 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 & 26 Residents’ live in safe, well-maintained and comfortable surroundings. The home is clean and pleasant but does not have satisfactory laundry systems. EVIDENCE: A general tour of the ground floor indicated that the homes is well maintained was clean and free from offensive odours. The laundry facilities need to be reviewed to ensure that floors and walls can be washed. Clarification is also needed as to whether washing machines have a sluicing facility and are able to wash foul laundry at appropriate temperatures to prevent spread of infections. Liquid soap and paper hand towel dispensers must be accessible in the laundry area. Overstone DS0000000621.V256599.R01.S.doc Version 5.0 Page 14 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 & 30 Residents are in safe hands and are supported and protected by the homes recruitment policies and practices. Staff are trained and competent to do their jobs. EVIDENCE: Discussion with the Manager and examination of two staff files indicated that the procedures for the recruitment of staff were satisfactory. Two staff training files indicated that staff have undertaken mandatory, NVQ and other relevant training in meeting the care needs of older people. A training programme was in place for the forth-coming year Overstone DS0000000621.V256599.R01.S.doc Version 5.0 Page 15 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): 33,35 & 38 There are some quality assurances and monitoring system in place, this need to be developed in order to enable the home to be run in the best interests of the residents. Residents’ financial interests are safeguarded The health, safety and welfare of residents and staff are not always promoted or protected. Overstone DS0000000621.V256599.R01.S.doc Version 5.0 Page 16 EVIDENCE: The Manager has introduced some good quality assurance tools to enable residents and families to comment on the service provided. This involves the use of questionnaires Health and safety issues identified related to • • • • The need for a satisfactory electrical wiring certificate Actions to prevent Legionella Risk assessments and the fitting of restrictors to first floor windows. Update of laundry facilities to meet standard 26. Overstone DS0000000621.V256599.R01.S.doc Version 5.0 Page 17 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X 3 2 Overstone DS0000000621.V256599.R01.S.doc Version 5.0 Page 18 Yes 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 OP1 Regulation 6 Requirement Support arrangements for the bungalows must be clarified and submitted to CSCI, this will be addressed outside of this inspection The care plans must be updated and include risk assessments and address nutritional needs of residents A review of the laundry facilities must be undertaken to meet standard 26 Quality assurance systems must be in place to meet standard 33 The following must be provided • Electrical Wiring Certificate • Prevention measures in relation to Legionnaires • Risk assessments and/or fitment of window restrictors to first floor windows. Timescale for action 01/01/06 2 OP7 15 01/01/06 3 4 5 OP26 OP33 OP38 13 (3), 6 (j) 24 23 (2) 13 (3) 01/03/06 01/04/06 01/03/05 Overstone DS0000000621.V256599.R01.S.doc Version 5.0 Page 19 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP19 OP12 OP27 Good Practice Recommendations To resurface the drive and/or provide safe walkways for residents To provide individual social activities assessment and programme and provide a social activities co-ordinator To review staffing hours in relation to laundry provision, to include support provided to the adjacent bungalows Overstone DS0000000621.V256599.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Overstone DS0000000621.V256599.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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