Inspection on 09/01/07 for Scarborough House

This inspection was carried out on 9th January 2007.

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

Scarborough House 22/11/07

Scarborough House 13/02/06

Scarborough House 09/05/05

Scarborough House 07/02/05

Scarborough House 17/08/04

Scarborough House 26/01/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Scarborough House Clubbs Lane Wells Next The Sea Norfolk NR23 1DP Lead Inspector Ann Catterick Unannounced Inspection 9th January 2007 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 Scarborough House DS0000027502.V327417.R01.S.doc Version 5.2 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. Scarborough House DS0000027502.V327417.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Scarborough House Address Clubbs Lane Wells Next The Sea Norfolk NR23 1DP 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) 01328 710309 NO FAX # Imperial Care Homes Limited Position Vacant Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Scarborough House DS0000027502.V327417.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th February 2006 Brief Description of the Service: Scarborough House is a care home providing personal care and accommodation for 17 older people. There were 17 service users accommodated on the day of inspection. The home is owned by Imperial Care Homes and at present there is no registered manager. The acting manager is Christine Hodnett. The home is located in the coastal town of Wells and is located close to shops, public transport and other local amenities. The home is a two storey detached property with a single extension attached to the side of the original building. The home offers bedroom accommodation on the ground and first floor. The home has a variety of communal areas throughout the home. A new kitchen has recently been installed. There are patio and garden areas that are accessible to service users and these are well tended with attractive potting and planting. The weekly cost of a placement at Scarborough House at the time of inspection was from £338 to £400 Scarborough House DS0000027502.V327417.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was a key inspection that took place on the 9th January 2007. The inspection lasted six hours and was unannounced. There was opportunity to speak with service users, staff, visitors and management as well inspect files and documents and have a tour of the building. Prior to the inspection a pre inspection questionnaire was received from the manager. Nine comment cards were received from service users and nine from relatives. All comments were positive other than one comment about the smoke from the staff room and two comments relating to staff numbers. All service users and relatives were satisfied with the care being provided in the home. The outcome of the inspection concluded that the home provides good quality care in a comfortable and well maintained environment. Service users comments are recorded throughout the report and these are a sample of them. “Lovely here, it’s a good place.” “Manager very good.” “Excellent food.” “Very nice room with lots of light.” “Its nice to have more activities.” “I enjoy staying in my room” “Girls are good and male carers are very good.” What the service does well: The home is well managed and the proprietors take an active and positive role within the home. The environment is comfortable and offers good quality accommodation. All service users spoke very positively about the care they received and good care practice was observed on the day of inspection. The dining area has been refurbished and all service users spoke very positively about the food provided in the home with food being nutritious, varied and well presented. Scarborough House DS0000027502.V327417.R01.S.doc Version 5.2 Page 6 Staff receive the appropriate training to fulfil their role and staff were observed to work in a caring a competent way 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. The summary of this inspection report can be made available in other formats on request. Scarborough House DS0000027502.V327417.R01.S.doc Version 5.2 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 Scarborough House DS0000027502.V327417.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessments were seen on file and all service users in the home are having their needs met. EVIDENCE: Care plans were seen and evidence of assessment being made prior to admission was seen on file. If social service or health are involved in the placement documentation from these organisations is sought. Each service users has a record of their daily living needs on file. Those service users seen and spoken to within the home were having their needs met on the day of inspection. Intermediate care is not offered in the home. Scarborough House DS0000027502.V327417.R01.S.doc Version 5.2 Page 9 Service users comments “Could not wish for better” “It’s like being at home, here.” Scarborough House DS0000027502.V327417.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of service users were being met on the day of inspection. Service users needs are met in a way that promotes dignity and protects privacy. EVIDENCE: Following assessment a full care plan is completed for each service users identifying their individual needs. No detailed social history was seen in the care plans and it is felt this would be helpful and enable staff to know what preferences and interests service users have. A recommendation has been made in this area. Several service users were spoken to on the day of inspection and all said that their personal, social and health needs were being met. Scarborough House DS0000027502.V327417.R01.S.doc Version 5.2 Page 11 Medication practice was observed and safe practice was seen. The home needs to devise a way of ensuring that at any time they could audit the amount of medication in the home. This relates particularly to medication that is packaged in boxes or bottles and is administered PRN. A recommendation has been made in this area. Service users spoken to said that there privacy and dignity is promoted and protected in the home and this was observed on the day of inspection. Service users comments “Staff are here as soon as you ring your bell” “Have my own phone and my door can be locked.” “Could not wish for better.” “Go to bed and get up whenever you want.” Scarborough House DS0000027502.V327417.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. More staff have been appointed and this has enabled more activities to take place in the home. Visitors are always made welcome. Service users are encouraged to be as independent as possible and the quality and presentation of at meal times is good. EVIDENCE: All of those service users spoken to were satisfied with the activities that took place during the home and several said that staff now have more opportunity to sit and chat to them. Activities were identified on the notice board and marbles was very popular on the day of inspection. During the afternoon staff were seen sitting talking to service users in a relaxed and meaningful way. A service user said that she also enjoyed the activities and quizzes whilst another mentioned skittles. All said they had a good Christmas with some service users spending time with relatives and other staying in the home. Scarborough House DS0000027502.V327417.R01.S.doc Version 5.2 Page 13 The home has a mini bus and service users are offered trips and outings. Comment cards suggested visitors are made welcome and this was the case on the day of inspection and confirmed by visitors spoken with. Service users and families are encouraged to take responsibility for any money and service users are encouraged to be as independent as possible and make choices in their day-to-day lives. One comment card suggested that a service user was not always asked what they would like to wear and would prefer a little more choice. All other comments were positive. All comments about the meals at the home were good with all service users saying they enjoyed the food. The ceiling in the dining area has been lowered and the room redecorated, giving a much more positive ambience. Tables were well dressed with flowers, napkins, and condiments. The dining room is now a welcoming comfortable place to eat. Since the last inspection service users have been encouraged to have tea in the dining area and this gives a further opportunity for socialising. Of course, service users can have tea in their room if this is what they prefer. The food on the day of inspection was well presented and looked appetising and nutritious. Service users said that they have choice and variety at meal times. Service users comments “It is nice now to have more activities.” “Food is usually good.” “Food good, well presented and they don’t just pile your plate up.” “Only grumble about the food is that it is too good!!” “Good Christmas.” “Have activities, marbles, skittles and exercise.” “My relatives are always made welcome.” Scarborough House DS0000027502.V327417.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an accessible complaints procedure and has procedures in place to support the protection of service users. EVIDENCE: The home has a complaints policy that is available to service users and their families. Any complaints that the home has followed up have been dealt with appropriately. Service users all said that if they had any concerns they would be more than happy to speak with Laura, the proprietor or Christine the manager. The home has a policy and procedures with regard the protection of adults and are aware of the local adult protection procedures. Service users comments “Can always speak to Laura, she is lovely.” Staff comments “Christine is approachable and would always share any concerns with her.” “ Would always report poor practice.” Scarborough House DS0000027502.V327417.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are offered a comfortable good quality environment to live in. This quality outcome should move to excellent when the smoking area is addressed. EVIDENCE: The accommodation at Scarborough House is comfortable and of good quality. The proprietor continues to develop and improve the property as well as keep up with the general replacement and refurbishment of fixtures and fittings. A programme of routine maintenance is followed. The communal areas are comfortable and well furnished. The home has a large lounge at the front of the home that is tastefully decorated and furnished including a chandelier and large fish tank. Scarborough House DS0000027502.V327417.R01.S.doc Version 5.2 Page 16 Since the last inspection the hallways, corridor, stair areas and all communal areas have been carpeted. There is now a key code to the front door to promote safety and security. The ceiling in the dining area has been lowered and the whole area has been redecorated, offering a comfortable place for service users to eat their meals. All bedrooms seen were very comfortable and well furnished. Bedrooms vary in size with some being very large. All service users spoken to were very happy with their accommodation. All bedrooms have en suite facilities. Service users had made their bedrooms their own with many personal belongings and furnishings. One comment has been received concerning the smell of cigarette smoke near the staff room on the ground floor. None of the present service users smoke, however staff are able to smoke in the staff room. The smoke wafted out of this area and had a negative impact on the areas of the home nearby. It was also an unpleasant environment for non-smoking staff. As the home has no service users that smokes at the present time the proprietors may wish to take this opportunity to designate the home as non smoking home. A recommendation has been made in this area. Other than the smoking area the home was clean and tidy throughout, being free from any offensive odours. Service user comments “I have a large room and the bathroom is close.” “Very homely.” “Very nice room, lots of light.” “Large room lovely view.” “You have a smell of cigarettes from the staff room.” Scarborough House DS0000027502.V327417.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Competent staff, in sufficient numbers were in the home on the day of inspection. Staff have the appropriate training and opportunities for further development. EVIDENCE: Since the last inspection the proprietor has appointed more staff during the day. An extra member of staff is on duty at the busy time in the morning and the busy time in the afternoon. This had given opportunity for staff to spend more social time with service users. The home had 15 service users accommodated on the day of inspection. The home has one member of waking night staff with another on call. This meets needs at the present time as many service users have minimal needs during the night. If this situation changed the proprietor will need to re assess the situation. The home was clean and tidy on the day of inspection indicating that the home employs enough domestic staff. The food was good, the kitchen clean and cakes cooked for tea, indicating sufficient staff in the kitchen. Fifty per cent of staff have NVQ level II Scarborough House DS0000027502.V327417.R01.S.doc Version 5.2 Page 18 Four staff files were inspected and all included all of the relevant information needed by the home prior to appointment. Staff were spoken to and all received induction training when they first came to the home and said that the manager supported them in developing their skill and accessing relevant training. Staff training and supervision files were seen and included certificates from training programmes attended. Service user comments “Staff from Poland are very, very good and speak good English.” “Staff first class.” “Staff very kind.” Staff comments “Always have time to talk to residents.” “Training is good.” “Additional staff in the morning gives more time to residents.” “You could always do with more staff, but staffing levels OK.” “Good atmosphere and happy staff group.” Scarborough House DS0000027502.V327417.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration in the home provides good quality care to service users. EVIDENCE: The home is well managed and the service users and staff spoke very positively about the home. The manager is planning to complete her Registered Manager Award but has not yet applied to become the Registered Manager. Some quality assurance has been completed but this is an area that needs to be further developed. A recommendation has been made in this area. Scarborough House DS0000027502.V327417.R01.S.doc Version 5.2 Page 20 Small amounts of service user’s money are looked after by the home. The safe keeping and documentation in this area was looked at and was in good order. Staff have individual and group supervision that is recorded. The manager needs to ensure that this happens on a regular basis. New staff have induction training and NVQ training is supported. The manager ensures that all staff receive appropriate training relating to the health and safety of service users. All staff have received medication training. Staff have received training with regard food hygiene, first aid, fire training, COSHH and infection control. The home has a new security lock since the last inspection. All accidents and incidents are recorded, however the manager needs to ensure that she completes regulation 37 documentation, and sends it to the commission when appropriate. A requirement has been made in this area. Risk assessments are completed and acted upon. It is understood that the home complies with the legislation identified in standard 38.4 of the National Minimum Standards. Service user comments “Manager Chris very Good.” Staff comments “Manager is approachable.” “Staff are supported.” “Training is good.” Scarborough House DS0000027502.V327417.R01.S.doc Version 5.2 Page 21 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 3 8 3 9 3 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 3 3 3 x x x 3 x 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 3 3 3 x 3 3 x 3 Scarborough House DS0000027502.V327417.R01.S.doc Version 5.2 Page 22 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 OP38 Regulation 37 Requirement The registered person must ensure that they report to the CSCI all information as described within this Regulation. Timescale for action 01/02/07 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 OP7 Good Practice Recommendations It would be good practice to develop the care plans to include more detailed information with regard the social history and hobbies of service users. It would be good practice to devise a system to enable clear auditing of brought forward medications. This relates particularly to the medication that is provided in boxes or bottles. It would be good practice to have a new smoking policy that enables all parts of the home to be smoke free. This is particularly relevant as no service users in the home are smokers. 2. OP9 3. OP19 Scarborough House DS0000027502.V327417.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Scarborough House DS0000027502.V327417.R01.S.doc Version 5.2 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!