Inspection on 20/05/05 for Slate House

This inspection was carried out on 20th May 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Slate House 11/07/07

Slate House 07/06/06

Slate House 10/11/05

Slate House 28/10/04

Slate House 21/04/04

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 SLATE HOUSE 26 Wellington Road Sandhurst Berks GU47 9AN Lead Inspector Robert Dawes Unannounced 20th May 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. SLATE HOUSE H51-H01-S42970-Slate House-V217747-170505Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Slate House Address 26 Wellington Road, Sandhurst, Berks, GU47 9AN 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) 01344 773358 Mr Ahmad Issac Beeharry, Mr Nasar Khan, Mrs Anne-Marie Antoinette Beeharry Miss Liza Sabrina Beeharry Care Home 13 Category(ies) of Dementia (DE), Old age, not falling within any registration, with number other category (OP) of places SLATE HOUSE H51-H01-S42970-Slate House-V217747-170505Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 28 October 2004 Brief Description of the Service: Slate House is a privately owed care home providing personal care and accommodation for thirteen service users aged 65 years and over. The home can admit up to four service users who suffer from dementia. The three storey home is situated close to the centre of Sandhurst. Seven of the home’s bedrooms are single and three are shared rooms. There is a passenger lift. The home has an easily accessible garden. SLATE HOUSE H51-H01-S42970-Slate House-V217747-170505Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection, which was carried out over the course of 3.75 hours. The Inspector spoke with the manager, two members of staff and six service users. The Inspector also toured the premises and saw relevant records. Eighteen standards were assessed, of which one was exceeded, fifteen were met and two were nearly met. Three requirements and three recommendations were made. What the service does well: What has improved since the last inspection? What they could do better: More formal supervision should take place and be recorded. An assessment of the home must be undertaken by an Occupational Therapist. A record must be made of when the individual plans are reviewed. SLATE HOUSE H51-H01-S42970-Slate House-V217747-170505Stage 4.doc Version 1.30 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. SLATE HOUSE H51-H01-S42970-Slate House-V217747-170505Stage 4.doc Version 1.30 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 SLATE HOUSE H51-H01-S42970-Slate House-V217747-170505Stage 4.doc Version 1.30 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) 3. Standard 6 does not apply to this home. New service users are admitted only on the basis of a full assessment undertaken by the proprietor. EVIDENCE: Pre-admission assessments were seen on service users files. SLATE HOUSE H51-H01-S42970-Slate House-V217747-170505Stage 4.doc Version 1.30 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, 9 and 10. All service users have an individual care plan. Service users are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and dignity. EVIDENCE: All the service user files seen had detailed care plans. The Inspector recommended the monthly reviews of the individual plans be recorded. The medication records were in order. Policies and procedures are in place. There were no controlled drugs on the premises. The Inspector recommended arrangements are made for the pharmacist to visit the home at regular intervals to inspect the storage, dispensing, recording and disposal of the medication. Service users informed the Inspector that the staff are kind, respectful, friendly and care for them very well. They have choice in their daily lives. The Inspector observed the service users looked clean and presentable and staff engaged with them in a pleasant manner. The home had a very relaxed and SLATE HOUSE H51-H01-S42970-Slate House-V217747-170505Stage 4.doc Version 1.30 Page 10 friendly atmosphere. A member of staff said ‘she would be happy for her mother to be a resident in the home’. SLATE HOUSE H51-H01-S42970-Slate House-V217747-170505Stage 4.doc Version 1.30 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 and 15. Service users’ social, cultural, religious and recreational interests and needs are met. Service users are able to have visitors at any reasonable time. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome and balanced diet. EVIDENCE: Service users have the opportunity to exercise their choice in relation to activities, food and routines of daily living. Service users have the opportunity to take part in activities such as scrabble, bingo and reminiscent sessions. The daily activities were displayed on the main notice board. Social events take place during the year. Service users’ birthdays are celebrated. Staff take service users out for a walk and to the shops. Their religious observance is maintained through a lay minister visiting the home every fortnight. Relatives and friends are made welcome and can visit at any reasonable time. SLATE HOUSE H51-H01-S42970-Slate House-V217747-170505Stage 4.doc Version 1.30 Page 12 Service users are encouraged to bring in their own personal items. Bedrooms reflected this. Service users are encouraged to make choices and live in their bedroom as they wish. Service users in double rooms have use of a privacy screen Service users informed the Inspector that they enjoy the food and there is always a choice of menu. They contribute to the planning of the menu that showed a good range and choice of meals. Drinks are provided during the day. Snacks are available at night. SLATE HOUSE H51-H01-S42970-Slate House-V217747-170505Stage 4.doc Version 1.30 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) This section will be assessed at the next inspection. EVIDENCE: SLATE HOUSE H51-H01-S42970-Slate House-V217747-170505Stage 4.doc Version 1.30 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, 22 and 26. Service users live in a safe, well-maintained and comfortable environment. Specialist equipment and adaptations to the home are in place but an assessment of the premises by a competent person needs to take place. The home is very clean, pleasant and hygienic. EVIDENCE: On purchasing the home, the proprietors made a plan of refurbishment that has resulted in the communal areas of the home and a number of service users’ bedrooms being decorated, carpets replaced and new beds and furniture purchased. There is still work to be done including several service users’ bedrooms and the first and second floor landing and stairs. The home is comfortable, homely and suitable for the service users’ needs. An assessment of the premises by a suitably qualified person has still to be completed. SLATE HOUSE H51-H01-S42970-Slate House-V217747-170505Stage 4.doc Version 1.30 Page 15 The home is kept very clean and hygienic. SLATE HOUSE H51-H01-S42970-Slate House-V217747-170505Stage 4.doc Version 1.30 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 and 28. The numbers and skill mix of the staff meets service users needs. Service users are in safe hands at all times but the proprietor must ensure 50 of the care staff achieve NVQ2 or above in care as soon as possible. EVIDENCE: Staffing levels are a minimum of 2 care staff on duty plus a domestic during the day. There is one waking night care staff. To reduce the number of care hours that the manager and co-proprietor undertake a full time carer and a part time carer are to be recruited. Three care staff have a NVQ2 or above in care. Two members of staff are currently studying for a NVQ in care. The cleaner is also studying for a NVQ. SLATE HOUSE H51-H01-S42970-Slate House-V217747-170505Stage 4.doc Version 1.30 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) 31, 33, 35, 36 and 38. The manager is qualified, competent and experienced to run the home. A quality assurance and quality monitoring system is being developed. Service users’ financial interests are safeguarded. Staff are appropriately supervised but it needs to be more formalised. The health, safety and welfare of service users and staff are promoted and protected. EVIDENCE: The manager has completed NVQ 4 in care and management plus short relevant courses. Mr Nasar Khan, a co-proprietor, supports the manager with her duties. Both impressed as having a good understanding of the conditions and ailments associated with old age and being committed to providing the best possible care for the service users. SLATE HOUSE H51-H01-S42970-Slate House-V217747-170505Stage 4.doc Version 1.30 Page 18 A quality assurance questionnaire will be sent to relatives and visiting professionals next month. Regular service users meetings take place. An annual development plan will be produced when the questionnaires are returned. The home does not hold any service users personal money. Relatives or appointed representatives manage the finances of those service users who do handle their own affairs. Appraisals take place for staff three months after starting and then every six months. Supervision takes place informally during the working day if the need arises. More formal supervision should take place and be recorded. The health and safety records seen by the Inspector showed the proprietor/manager ensures so far is reasonably practicable that service users are protected. SLATE HOUSE H51-H01-S42970-Slate House-V217747-170505Stage 4.doc Version 1.30 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 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 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 3 x x 2 x x x 4 STAFFING Standard No Score 27 3 28 3 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 3 x 2 x 3 3 x 3 SLATE HOUSE H51-H01-S42970-Slate House-V217747-170505Stage 4.doc Version 1.30 Page 20 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 22 Regulation 16 Requirement An assessment of the premises by a competent qualified person must take place. (The timescale of 31/12/2004 was not met). All staff must be CRB and POVA checked before starting work. (This requirement was made at the previous inspection but not assessed this time). A quality assurance questionnaire must be sent to relatives and visiting professionals to inform the annual development plan. (The timescale of 31/12/2004 was not met). Timescale for action 31/8/2005 2. 29 19 31/7/2005 3. 33 35 31/8/2005 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 7 9 Good Practice Recommendations The monthly reviews of the individual plans should be recorded. Arrangements should be made for the pharmacist to visit the home at regular intervals to inspect the storage, dispensing, recording and disposal of the medication. H51-H01-S42970-Slate House-V217747-170505Stage 4.doc Version 1.30 Page 21 SLATE HOUSE 3. 36 More formal supervision should take place and be recorded. SLATE HOUSE H51-H01-S42970-Slate House-V217747-170505Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 2nd Floor, 1015 Arlington Business Park Theale Berks RG7 4SA 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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