Inspection on 10/10/06 for Shipbourne House Hotel

This inspection was carried out on 10th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Shipbourne House Hotel 03/11/05

Shipbourne House Hotel 28/06/05

Shipbourne House Hotel 08/02/05

Shipbourne House Hotel 30/11/04

Shipbourne House Hotel 04/02/04

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 Shipbourne House Hotel 6 Vicarage Road Cromer Norfolk NR27 9DQ Lead Inspector Mrs Marilyn Fellingham Unannounced Inspection 10th October 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 Shipbourne House Hotel DS0000027375.V315350.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. Shipbourne House Hotel DS0000027375.V315350.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shipbourne House Hotel Address 6 Vicarage Road Cromer Norfolk NR27 9DQ 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) 01263 514370 NO FAX # Position Vacant Position Vacant Care Home 20 Category(ies) of Learning disability over 65 years of age (1), Old registration, with number age, not falling within any other category (19) of places Shipbourne House Hotel DS0000027375.V315350.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Up to nineteen (19) Older People may be accommodated. One (1) person with a learning disability who is over the age of 65 years may be accommodated. Maximum number accommodated not to exceed twenty (20). Date of last inspection 3rd November 2005 Brief Description of the Service: Shipbourne House Hotel is a three storey late Victorian building that has retained many of its original features and is registered as a residential care home offering care and accommodation for up to nineteen older service users and one service user with a learning disability. It benefits from the use of a shaft lift to all floors and service users have the choice of seventeen single or three shared bedrooms that all contain a washbasin, one has an en-suite toilet and all are sited near to adapted bathrooms containing bath, sink and toilet. There is a newly fitted shower room on the ground floor and service users have the communal use of two lounges and a dining room. The home stands in its own grounds in a quiet residential area in the seaside town of Cromer and benefits from having the town centre and the sea front just a few minutes away. There is a small amount of parking to the side and rear of the building and small gardens to the front and rear of the building that are maintained in good order and offer wheelchair access and seating for those service users who wish to sit outside. A hairdressing facility is available and an independent chiropodist also visits. Shipbourne House Hotel DS0000027375.V315350.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspector arrived unannounced and spent five hours at the Home. The views of the management, staff, a selection of service users and one visitor were obtained; a tour of the Home was made and records were examined and have helped inform the judgements made. Three service user comment cards were received and nine from relatives. The Home has undergone a number of changes since the last key inspection, one being the death of one of the providers. However the Home has continued to ensure that the service users needs are met. What the service does well: What has improved since the last inspection? The Home has employed more staff. There has been much improvement in the care planning system, risk assessments and daily notes; this has further enabled staff to fully meet the health care needs of the service users. Many areas have been refurbished and there is new dining room furniture. The garden has been tidied up and a gazebo erected for service users use during the summer months. Training records have improved. Shipbourne House Hotel DS0000027375.V315350.R01.S.doc Version 5.2 Page 6 A system is being introduced to monitor quality. 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. Shipbourne House Hotel DS0000027375.V315350.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 Shipbourne House Hotel DS0000027375.V315350.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5. The quality outcome for this group is good. This judgement is made using available evidence during the inspection process. Persons who use the service have adequate information to make an informed decision about admission to the Home. Prospective service users and other interested parties need written confirmation that needs can be met. EVIDENCE: Case tracking confirmed good practice. The manager had visited prospective service users and a thorough assessment carried out; in some cases a second visit is made with a senior carer to confirm that the persons needs can be met. One resident stated that she had, had sufficient information to make a decision about admission to the home. Although it appears that the assessment to ascertain prospective service users needs is very thorough, it is recommended that the process is made more formal and a ‘set format’ used for this process. It is also recommended that a letter be sent to interested parties to confirm that needs can be met. The care notes for four most recent admissions to the Home indicated that physical, social and emotional needs were addressed. Contracts were seen for these service users. Prospective service users are always given the opportunity to visit the Shipbourne House Hotel DS0000027375.V315350.R01.S.doc Version 5.2 Page 9 Home prior to admission to the Home, one service user said she had been given the option but did not wish to. Shipbourne House Hotel DS0000027375.V315350.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality outcome in this group is excellent. This judgement is made using available evidence and speaking with service users. Although there was found to be too much Panadol held in stock it does not affect this judgement made. The content of the assessments and care plans meant that all needs were fully met. The care given is good and dignified. EVIDENCE: The Inspector examined four care plans; the assessment made on admission to the Home was excellent and this information was used to formulate very detailed care plans. It was noted that the care plans covered all the assessed needs and were amended according to events and changing needs that were also indicated in the daily notes: these daily notes were very informative. There was evidence of review of care. It was noted that skin integrity and nutritional assessments had been carried out and weights monitored and recorded. Risk assessments were in place for that covered such risks as the potential for developing urine infections, pressure sores and also indicated the risks involved with falls, manual handling and use of kettles. The care plans showed evidence of service user and relative’s involvement in the care planning and this was confirmed by one new admission. Shipbourne House Hotel DS0000027375.V315350.R01.S.doc Version 5.2 Page 11 Those service users spoken to felt that their privacy was respected and that staff were exceptionally kind and caring; the Inspector observed interaction between the service users and staff, she noted that it was respectful and dignified and that doors were being knocked on before entry. The Home has policies in place for the handling and administration of medication. One service user self medicates and there was a risk form in place for this, it is recommended that a continued assessment is carried over time to ensure that the service user continues to be able to perform this task. A random check was made of the NOMAD system and all medication tallied with the medication record charts. The storage of medication was adequate but too much Panadol was held in stock and is considered not a safe practice. Shipbourne House Hotel DS0000027375.V315350.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality outcome for this group is good. The judgement has been made using available evidence, the inspection process and discussion with service users and staff and also observation. Activities suit the service users who are well supported and encouraged to be in control over their lives. Mealtimes are well managed. EVIDENCE: A friend, who stated, that, she was always made welcome by the staff and that they were very friendly, was visiting one service user. The Home does provide activities for the service users and on the afternoon of the inspection some entertainers were providing music and songs for the service users; many of them were seen to be enjoying it and participating in the action. The manager/provider stated that she really would like to provide some simple exercises for the residents but could not find anyone in the area to do this. A record is kept of all service user involvement in activities and this confirmed visits out to various locations and to the shops. Two of the service users have their own mobility cars and these enable them to get out and be independent. One carer is responsible for organising the various activities and those residents spoken to state that they felt that they were sufficient to meet their needs. A number of the residents enjoy being taken out on a one to one basis. Shipbourne House Hotel DS0000027375.V315350.R01.S.doc Version 5.2 Page 13 Menus were examined and were found to be nutritious and well balanced. The Inspector observed lunch being served, it was unhurried and relaxed; the Inspector noted that three different meals were given to one service user who stated that she did not like what she was eating, this was done with respect and in a dignified manner. Those service users spoken to state that they felt that the food was good and they could always have an alternative if they disliked something. One service user said she felt that the food was adequate. Shipbourne House Hotel DS0000027375.V315350.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality outcome for this group is good. This judgement has been made after discussion with management, staff and service users. Service users feel safe. The service users money needs to be recorded more efficiently. EVIDENCE: A complaints procedure is available to all service users and their relatives; it is given to all residents with the service user’s guide and can also be found on the notice board in the front hall. Those service users and staff spoken to were all aware of the procedure and how to air their concerns; they also stated that they felt that they could approach the manager/provider any time and also felt that they would be listened to. The management only holds money for one service user, the record for transactions were found to be correct but needs to be more formal and a recommendation is made to encourage the use of two signatories. Shipbourne House Hotel DS0000027375.V315350.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,22,23,24,25,26. Quality outcome for this group is good. This judgement has been made on observations made during a tour of the Home, available evidence and discussion with staff, service users and management. The overall appearance of the Home has been greatly enhanced. EVIDENCE: The Inspector found the Home to be clean and tidy. The duty rosters reveal that an adequate number of domestic staff are employed to maintain the cleanliness of the Home. Cleaning agents are about to be stored in an appropriate cupboard. It was noted that one lavatory had a communal bar of soap and towel; this is considered bad practice as there is a risk of infection and a requirement is made to install liquid soap and paper towels. Many rooms have been re decorated with the addition of new carpets. The corridor downstairs has been painted which makes it look much brighter and lighter. The dining room has new dining furniture and looked most pleasing. The garden at the back of the premises has been attended to, making parking much easier. A gazebo has been used throughout the summer and two of the residents stated how much they had enjoyed sitting in it. Shipbourne House Hotel DS0000027375.V315350.R01.S.doc Version 5.2 Page 16 The manager stated that the kitchen was the next area to be re furbished and that there was an on going plan for refurbishment. A new stand aid has been purchased. It was noted that all the communal rooms were being utilised by the residents. Records were seen for all the specialist equipment. Shipbourne House Hotel DS0000027375.V315350.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality outcome for this group is good. This judgement is made by, examining staff records, training plans and discussion with staff and management. EVIDENCE: Those residents spoken with felt that they were adequately supported by the staff and that they were well cared for; one service user stated that the staff cannot do enough for them and that they were very well looked after. The manager stated that staffing had improved of late and that she had a very good team in place. Those staff spoken with felt that staffing had improved and the duty rosters reflected this. Records for newly appointed staff were examined and confirmed that a robust system was in place to ensure all relative checks had been made before staff were employed; it was noted that two references were also obtained. Discussion with staff members revealed that they considered that they were well supported in their roles. Training is on going and some mandatory training is being re visited for all staff to ensure competency; the manager/provider is very much aware of the training needs for her staff. Shipbourne House Hotel DS0000027375.V315350.R01.S.doc Version 5.2 Page 18 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): 31,32,33,36,37,38. Quality outcome for this group is good. This judgement is made using information gained from service users, staff and the manager/provider. Records were also checked to provide further information. It is felt that the Home is managed well and meeting the needs of the service users. EVIDENCE: Although one of the providers has died this does not seem to have interfered with the overall running of the Home; some areas related to the position of providers is still in probate but the manager/provider hopes that this will be settled soon. Considering that the provider/manager has suffered a personal bereavement the Home continues to be well run and she is very keen to work within the parameters of the National Minimum Standards. Staff members commented that they felt they could approach the manager/provider any time and discuss any concerns. Records were seen to evidence that there is a system in place for formal supervision. Shipbourne House Hotel DS0000027375.V315350.R01.S.doc Version 5.2 Page 19 The management have just started to introduce a system for monitoring quality and documents were seen to substantiate this. Shipbourne House Hotel DS0000027375.V315350.R01.S.doc Version 5.2 Page 20 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 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 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 2 3 x 3 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 3 3 3 x 3 3 3 3 Shipbourne House Hotel DS0000027375.V315350.R01.S.doc Version 5.2 Page 21 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 OP19 Regulation 13 (4) (a) (c) Requirement The registered person shall ensure that all parts of the Home to which service users have access are so far as reasonably practicable free from hazards to their safety and that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. Timescale for action 10/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP3 OP9 Good Practice Recommendations It is recommended that a letter be sent to all prospective service users to confirm that their needs can be met. It is recommended that a continual review be carried out for all service users who self medicate. Shipbourne House Hotel DS0000027375.V315350.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Shipbourne House Hotel DS0000027375.V315350.R01.S.doc Version 5.2 Page 23 - 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. 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