Inspection on 03/01/06 for Saltmarsh House

This inspection was carried out on 3rd 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

Saltmarsh House 29/01/09

Saltmarsh House 01/03/07

Saltmarsh House 07/09/05

Saltmarsh House 18/01/05

Saltmarsh House 05/07/04

Saltmarsh House 09/02/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Saltmarsh House 12 Saltmarsh Lane Hayling Island Hampshire PO11 OJT Lead Inspector Ms Sue Kinch Unannounced Inspection 3rd 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 Saltmarsh House DS0000011784.V273193.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. Saltmarsh House DS0000011784.V273193.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Saltmarsh House Address 12 Saltmarsh Lane Hayling Island Hampshire PO11 OJT 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) 023 9246 2183 karen.morriss-dixon@virgin.net Mrs Karen Dixon Mrs Karen Dixon Care Home 12 Category(ies) of Dementia - over 65 years of age (12), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (12), Old age, not falling within any other category (12) Saltmarsh House DS0000011784.V273193.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th September 2005 Brief Description of the Service: Saltmarsh House is a large detached property situated in a quiet, residential area of Hayling Island. The accommodation comprises of twelve single rooms, of which eight have en-suite facilities. The shared space within the home includes a large lounge, a conservatory and a dining room. Outside is an attractive well maintained garden to the rear of the house with tables, chairs and umbrellas. To the front of the house is a swimming pool not currently used by residents. Saltmarsh House DS0000011784.V273193.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second, unannounced inspection for the year 2005-2006. The inspection was carried out on 3 January 2006 from 14.30-18.30. The inspector spent four hours talking with residents, staff and the manager, examining records and viewing parts of the home. Other information obtained through questionnaires and a pre-inspection form completed by the manager, was also considered. What the service does well: What has improved since the last inspection? What they could do better: Records of recruitment need some improvement. They must include, in all instances, evidence of Pova (Protection of Vulnerable Adults) and CRB (Criminal Records Bureau) checks for all staff employed after July 2004. Saltmarsh House DS0000011784.V273193.R01.S.doc Version 5.1 Page 6 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. Saltmarsh House DS0000011784.V273193.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 Saltmarsh House DS0000011784.V273193.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): Standard 6 does not apply. Standard 3 was assessed at the last inspection. EVIDENCE: Saltmarsh House DS0000011784.V273193.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 Residents benefit from care provision based on details recorded in care plans. An effective medication system ensures that service users receive their prescribed medication. EVIDENCE: Two files were viewed to consider the information to guide staff in care provision. These held care plans with details of support needed, risk assessments and evidence that these had been recently reviewed. Short-term care plans were also held to underline the support needed when people are ill. Staff members are advised of changes through the diary and communication book. Residents spoke positively about the care that they received at the home. Staff said that they were aware of, and used, the care plans. The manager reported to be reviewing the care planning process in the weeks following the inspection. The purpose of this is to expand information to give more details of the history of residents. It would also to give more details of some of the support needed. The manager has noted the changing needs of some of the residents who increasingly need more stimulation and activity. This will be reviewed at the next inspection. Saltmarsh House DS0000011784.V273193.R01.S.doc Version 5.1 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 the following standard(s): Not assessed. EVIDENCE: Saltmarsh House DS0000011784.V273193.R01.S.doc Version 5.1 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 the following standard(s): 16,17 Residents are confident that any issue or concern raised will be addressed promptly. Systems are in place to protect residents from abuse. EVIDENCE: Adequate attention is given to complaints. The complaints procedure is in the Service User Guide. All feedback from residents and relatives indicated that they were aware of it. During the inspection residents said that they had no complaints to make. Those spoken to said that staff or the manager addressed any issue they raised as soon as possible. One resident mentioned a problem with a curtain and was aware that repairs were being organised. No formal complaints were reported to have been received by the home in the twelve months prior to the inspection. The staff on duty said they had received adult protection training and would be able to recognize where abuse may have occurred. They were aware that there was a written procedure for their use and said they would consult management if a situation occurred where they had suspicions. All service users who contributed to the inspection spoke very highly of the care provided at the home. They spoke of good relationships with the staff. On comment cards all respondents said that they felt safe. Saltmarsh House DS0000011784.V273193.R01.S.doc Version 5.1 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 the following standard(s): 19,26 Residents benefit from a clean, well-maintained, homely and hygienic environment. EVIDENCE: The lounge, dining room, conservatory and two bedrooms seen were clean and pleasantly decorated. The manager has organised an effective system to ensure that maintenance takes place. The manager uses lists when checking areas of the home and records action required and completed. These were viewed. They demonstrated that household maintenance is dealt with. Staff record breakages and maintenance issues as they arise showing that they also take some responsibility for the upkeep of the home. Residents were confident that things would be fixed as necessary. Those asked about the chairlift confirmed that it was working and were not aware of it ever going wrong. Staff were dealing with a leaking washing machine during the inspection. The plumber arrived to rectify the problem during the inspection. After Christmas the conservatory had been out of use for a week while new flooring was laid. The manager reported that this had been dried out and was Saltmarsh House DS0000011784.V273193.R01.S.doc Version 5.1 Page 13 shortly to be returned to use. No resident raised a concern about it being temporarily unavailable. Hygiene and infection control is given attention in the home. Aspects were discussed with the manager and the staff. Staff confirmed that a cleaner works at the home regularly and that they did other urgent cleaning. Infection control procedures are held in the home and staff confirmed that they had received training. There is written evidence of training, which included MRSA, skin care, general health matters, wound care and infection, and scabies. One or more staff members had attended each course. The information is then shared with other staff. Further training was reported by the manager to be planned for the staff in 2006. Saltmarsh House DS0000011784.V273193.R01.S.doc Version 5.1 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): 27,28,29 Residents benefit by receiving care from a stable and committed staff group, which is regularly receiving training and new guidance. More records are needed to fully demonstrate that the recruitment procedure is robust. EVIDENCE: The home is adequately staffed to meet the needs of the current residents. There are two care staff for each shift. Each day a cook works in the morning for five hours. A cleaner works for seventeen hours a week. Two staff sleep in at night. The manager is additional to the staff on the rota and assists at times with some of the care and domestic tasks. In the evening before the inspection a member of staff, additional to the shift, took some residents out to see Christmas lights. Other residents were also expecting to be taken. Most of the staff have worked at the home for some time. Only three new staff members were recruited late in 2005. Staff are encouraged to attend a range of training courses throughout the year. And they attend in-house training. Of the fourteen care staff working at the home, eight have achieved National Vocational Qualifications (NVQ) level 2 or to be assessed. This demonstrates that just over fifty percent above and others are registering of care staff are trained to an adequate NVQ level as required. A sample of recruitment records was viewed. There was insufficient evidence that CRB and POVA checks are completed within appropriate timescales. Saltmarsh House DS0000011784.V273193.R01.S.doc Version 5.1 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): 31,38 Residents benefit from and strong and clear management of the home, which includes adequate attention to their health, safety and welfare. EVIDENCE: The manager is well respected and approachable. Residents and staff comments about her were positive. Staff said that she visits each resident daily. The manager has the registered managers award and NVQ level four in care. She is as committed to her own training as she is to that of her staff group. Certificates to demonstrate that she is keeping herself updated with training were viewed by the inspector. The manager confirmed that checks and servicing of systems and equipment is regular. Information was given in the pre-inspection questionnaire. Some of the records were sampled during the inspection. Risk assessments, an environmental health officer report, a gas landlord’s certificate, and records of fire checks by specialists, were all viewed. These provided further evidence Saltmarsh House DS0000011784.V273193.R01.S.doc Version 5.1 Page 16 that checks were regular. Action that had been taken and to be completed was discussed with the manager. Adequate attention was being given to these issues. Saltmarsh House DS0000011784.V273193.R01.S.doc Version 5.1 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 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X 3 Saltmarsh House DS0000011784.V273193.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? no 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 OP29 Regulation 19 Schedule 2 Requirement The manager must ensure that the records of recruitment are held for each person including evidence of CRB and POVA checks. Timescale for action 03/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Saltmarsh House DS0000011784.V273193.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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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