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Inspection on 28/06/05 for Shipbourne House Hotel

Also see our care home review for Shipbourne House Hotel for more information

This inspection was carried out on 28th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The Providers/Manager work very hard in providing a homely atmosphere and those residents spoken to felt that the staff make every effort to provide a good quality of life for them. The home is always very keen to ensure all requirements and recommendations made by the commission are met. The home has a very good track record of caring for the dying and have a number of letters from very grateful relatives expressing their gratitude.

What has improved since the last inspection?

Decoration and furnishings are gradually being improved, the front room has been re decorated and a new carpet laid. A carpet cleaner has been purchased. A shower room has been put in downstairs; the outside has been decorated and windows replaced where required. Various bedrooms have been re decorated. The home is very good at providing care and resources for the prevention of pressure sores.

What the care home could do better:

Staff need more training and records kept of this. Activities could be better managed and more effort made to motivate the residents. The residents would benefit from being taken out more. Care plans could be improved and clear records kept.

CARE HOMES FOR OLDER PEOPLE Shipbourne House Hotel 6 Vicarage Road Cromer Norfolk NR27 9QD Lead Inspector Marilyn Fellingham Unannounced 28 June 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Shipbourne House Hotel I55 S27375 Shipbourne House V236695 280605 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Shipbourne House Hotel Address 6 Vicarage Road Cromer Norfolk NR27 9DQ 01263 514370 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Alison McCrory Miss Carole McCrory Mrs Alison McCrory Care Home 20 Category(ies) of Learning disabilities - over 65 (1) registration, with number Old age (19) of places Shipbourne House Hotel I55 S27375 Shipbourne House V236695 280605 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to nineteen (19) older people may be accommodated. 2. One (1) person with a learning disability who is over the age of 65 years may be accommodated. 3. Maximum number accommodated not to exceed twenty (20). Date of last inspection 8 February 2005 Brief Description of the Service: Shipbourne House Hotel is a three storey late Victorian building that has retained many of it’s 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 I55 S27375 Shipbourne House V236695 280605 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over five hours. A tour of the home took place and care and staff records were inspected. The Manager/Providers were present for the inspection; the Inspector spoke with seven service users and three members of staff. Those service users that were spoken to all expressed their satisfaction with the care that they were receiving and said that they were very happy living in the home. The Inspector gained the impression that the staff were very kind and caring. What the service does well: What has improved since the last inspection? Decoration and furnishings are gradually being improved, the front room has been re decorated and a new carpet laid. A carpet cleaner has been purchased. A shower room has been put in downstairs; the outside has been decorated and windows replaced where required. Various bedrooms have been re decorated. The home is very good at providing care and resources for the prevention of pressure sores. Shipbourne House Hotel I55 S27375 Shipbourne House V236695 280605 Stage 4.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Shipbourne House Hotel I55 S27375 Shipbourne House V236695 280605 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Shipbourne House Hotel I55 S27375 Shipbourne House V236695 280605 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2,5 The admission procedure is good and no one is admitted unless the home is sure it can meet the needs of the prospective service users. Each service user is given a contract/statement of terms and conditions. EVIDENCE: The framework for admission of service users is adequate and is formulated to allow a thorough assessment process. The newly admitted resident whom the inspector spoke with confirmed that she was given sufficient information before her admission that enabled her to make an informed decision. All service users are given and sign copies of statement of terms and conditions, the Inspector saw samples of these. Shipbourne House Hotel I55 S27375 Shipbourne House V236695 280605 Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,10 The health needs of the residents are identified and met, however the process for this needs improving and is undergoing enormous change to improve the system. EVIDENCE: Individual plans of care were available but need to be addressed to ensure all care is clearly recorded. The home is in the process of changing the system for care planning and the Inspector was able to see evidence of this and viewed some examples. There was evidence of monthly reviews. The care plans contain risk assessments with special attention to falls; the Inspector was able to confirm this after examination of the incident record documents. Discussion with staff and the Manager suggested that needs were being met and there was the beginning of evidence to show that there was also service user involvement with care planning process. Shipbourne House Hotel I55 S27375 Shipbourne House V236695 280605 Stage 4.doc Version 1.40 Page 10 The Inspector also noted that appropriate action was taken to reduce the incidence of pressure sores and skin integrity assessments were done and interventions recorded on the care plans. The Inspector also noted that specialist help was obtained if needed and that resources were obtained if thought necessary by other health care professionals. Those residents that the Inspector was able to speak with were adamant that they were treated with dignity and respect: whilst the Inspector was in the home she noted that all members of staff treated the residents with great respect and that they had a very caring manner. The Manager feels that they are very good at handling death and dying and provide emotional support not only to the relatives, residents but also to each other. The Inspector gained the impression from numerous letters the home had received that all the staff treated those residents at the time of their death with dignity, sensitivity and great respect. Shipbourne House Hotel I55 S27375 Shipbourne House V236695 280605 Stage 4.doc Version 1.40 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 standard(s) 12,13,14 Social activities could be managed better and time set aside for taking residents out. Those residents that are able are encouraged to exercise control over their own lives. EVIDENCE: A number of residents were spoken to and they all agreed that their lifestyle experienced whilst living in the home matched that of their expectations and suited them in their present time of life: some felt however that they would like to be given the opportunity to be taken out more, especially those who are less mobile. One resident who used to visit the local agricultural show was given the opportunity to go, but she refused as she felt she was too old. Past resident’s relatives still maintain contact with the home and visit quite often, this the residents enjoy and the visits also maintains links with those who have known Cromer well in the past. Shipbourne House Hotel I55 S27375 Shipbourne House V236695 280605 Stage 4.doc Version 1.40 Page 12 There is no recorded evidence of any service user involvement with activities, and it is recommended that it be made part of the care planning process. The staff that were spoken to suggested that the residents were hard to motivate to take part in planned activities; some of the residents spoken to said that they did not want to join in the activities and preferred “their own company”. The Inspector did note that the staff who were on duty during the inspection process chatted with the service users who seemed to enjoy this activity and there was also some laughter and the residents seemed to enjoying this. Shipbourne House Hotel I55 S27375 Shipbourne House V236695 280605 Stage 4.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 Those residents that were spoken to seemed happy that any concerns they have are taken seriously. Strategies are in place to protect the service users from abuse. EVIDENCE: The home has a detailed complaints procedure and no complaints have been made to the Commission. The residents that were spoken to by the Inspector were knowledgeable about the homes procedure for complaints and it is also detailed in the Service User’s guide. These residents stated also that they felt that they could easily approach the management if they had any concerns and felt that they would be listened to. A whistle blowing policy is in place and the Inspector was able to examine this; those staff that she spoke to were familiar with this policy and stated that they would not hesitate to ‘blow the whistle’ if the need arose and respected that it was there to protect the vulnerable adults in their care. Training sessions in all issues related to abuse have taken place, records were seen for this and the staff also confirmed that they had attended these sessions. Shipbourne House Hotel I55 S27375 Shipbourne House V236695 280605 Stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,26 A number of improvements have been made to the internal and external environment. Service users have safe access to the external environment. There was one area of the home that was not odour free. Shipbourne House Hotel I55 S27375 Shipbourne House V236695 280605 Stage 4.doc Version 1.40 Page 15 EVIDENCE: A tour of the home took place and it was evident that a lot of refurbishment had taken place both inside and outside. All the outside windows had been treated and some had been replaced. Although a specialised carpet cleaner had been purchased the Manager shared with the Inspector that she was concerned about the slight smell of urine in one area of the home. The Inspector had not detected this on past inspections; the Manager said that all the time they managed continence they never had a problem, but now pads for continence care is managed by the PCT there seems to be a big problem. The Manager felt it had something to do with the quality of the pads and the restriction of use of them, as they have to use them as dictated by the continence care team. The Manager said she would discuss the problems with the continence acre team. Shipbourne House Hotel I55 S27375 Shipbourne House V236695 280605 Stage 4.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 The procedures for recruitment are robust. Training of care staff needs to be extended to ensure all care needs are met. EVIDENCE: Examination of the staff duty rotas indicated that there were sufficient staff deployed to meet the needs of the service users; however inspection of training records and discussion with staff led the Inspector to believe that more training is needed to ensure that all service users needs are met and that the home is functioning according to its statement of purpose. Designated domestic staff are kept and there is a housekeeper who ensures the home is kept clean and furnishings replaced. Induction of new staff is thorough and TOPPs training records were seen, a new member of staff confirmed that she had an induction and records for this were seen; she also confirmed that she had received the obligatory mandatory training when she commenced work at the home. The Manager confirmed that two references for new staff were always obtained and the Inspector was able to see records for this for all new members of staff. The Inspector also noted all CRB checks were up to date and records for this were inspected. Shipbourne House Hotel I55 S27375 Shipbourne House V236695 280605 Stage 4.doc Version 1.40 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,35,36 It is apparent that there is clear leadership within the home that is constant and on going; this results in practices that promote the safety and welfare of the residents. Some areas could be improved to ensure that the home is totally run in the best interests of the service users. Procedures for staff supervision need to be formalised. EVIDENCE: The Manager is quite clear about her role and was seen to give clear direction to the staff; those members of the care team that the Inspector spoke with also confirmed this. The Manager has enrolled to commence the Manager’s Award in September. Inspection of records showed that regular checks for fire safety have been carried out. Shipbourne House Hotel I55 S27375 Shipbourne House V236695 280605 Stage 4.doc Version 1.40 Page 18 The Manager discussed with the Inspector what actions had so far taken place for the supervision for staff; although the ‘paper work’ was in place little had been done to formalise the process and a requirement is made. After discussion with staff, the Manager and the service users it was evident that the home had commenced a small survey to monitor quality, however more work needs to be done to formalise this procedure to ensure that the home is run in the best interests of the service users. Shipbourne House Hotel I55 S27375 Shipbourne House V236695 280605 Stage 4.doc Version 1.40 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 x x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 2 x x x x x 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x 3 2 x 3 2 x x Shipbourne House Hotel I55 S27375 Shipbourne House V236695 280605 Stage 4.doc Version 1.40 Page 20 No 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 33 Regulation 24 Requirement The registered person shall establish and maintain a system for reviewing and improving care. The registered person shall ensure that persons working witihin the home are appropriately supervised. Timescale for action 31 October 2005 31 October 2005 2. 36 18 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 7 Good Practice Recommendations The registered person shall encourage the staff to keep detailed care plans that can be used as working documents. Shipbourne House Hotel I55 S27375 Shipbourne House V236695 280605 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection 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 I55 S27375 Shipbourne House V236695 280605 Stage 4.doc Version 1.40 Page 22 - 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. 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