Inspection on 03/01/06 for Somerset House

This inspection was carried out on 3rd January 2006.

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

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

Other inspections for this house

Somerset House 14/05/09

Somerset House 29/08/07

Somerset House 17/11/06

Somerset House 30/06/05

Somerset House 21/12/04

Somerset House 03/08/04

Somerset House 26/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Somerset House 157 High Street Yatton North Somerset BS49 4DB Lead Inspector Paul Grey Announced Inspection 3rd January 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Somerset House DS0000008057.V266575.R01.S.doc Version 5.0 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. Somerset House DS0000008057.V266575.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Somerset House Address 157 High Street Yatton North Somerset BS49 4DB 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) 01934 832114 NONE Mrs Wendy Rita Hiles Mrs Julie Denise Jones Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Somerset House DS0000008057.V266575.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 26 persons aged 65 years and over requiring personal care. 30th June 2005 Date of last inspection Brief Description of the Service: Somerset House is a pleasant period property situated off the main road through Yatton. The property has been extensively modified and extended to meet the needs of up to 26 people over 65 years of age. The premises also have a small satellite home suitable for service users who wish to use the support offered by the home but desire a more private form of accommodation. Somerset House DS0000008057.V266575.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Somerset house is a long-running service providing care to older persons. Historically, there have been a range of issues with the homes standard of administration and documentation, but the standard of care within the home appears constant and reasonable. The Inspector spoke with 4 service users who were generally satisfied with the service they received. The Inspector noted on inspection that the staff team related well to service users and the home generally had a relaxed and homely feel. The Inspector audited care files and documentation and noted some areas of improvement generally. The Inspector noted evidence to indicate the home has capacity to meet the service users assessed needs however, the Inspector would have concerns should the home start to admit service users with any complex needs. What the service does well: 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. Somerset House DS0000008057.V266575.R01.S.doc Version 5.0 Page 6 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 Somerset House DS0000008057.V266575.R01.S.doc Version 5.0 Page 7 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, 3, Prospective service users are supplied with the information they need to make an informed choice about the home. Prospective service users know that the home can meet their needs and aspirations. EVIDENCE: The Inspector noted the home has a statement of purpose outlining the service offered. The statement of purpose meets the requirements of National Minimum Standards. Service user spoken with could not recall having been given a service user guide. Whilst auditing care records the Inspector noted evidence of an assessment procedure for new service users. The assessment procedure covered aspects of the service users day-to-day life, and general needs such as dietary preferences, mobility and dexterity, incontinence etc. The Inspector noted the assessment procedure covered the service users basic needs. The Inspector noted little information relating to service users emotional, psychological or social needs. Somerset House DS0000008057.V266575.R01.S.doc Version 5.0 Page 8 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, 10 The service users health needs are set out in a plan of care. However this did not include sufficient personal and social care information to meet national minimum standards. Service users can make decisions about their lives with assistance from the home. Service users feel they are treated with respect and their right to privacy is upheld. EVIDENCE: The Inspector audited 3 service user care plans. Service user care plans addressed a range of physical and environmental needs. The Inspector noted care plans were generally not holistic and often lacking in detail. The Inspector discussed the need for holistic care planning. The Inspector would have concerns at the homes ability to organise and deliver care to service users with any degree of complex needs. Currently, the home would not be able to demonstrate how they would meet those needs. Somerset House DS0000008057.V266575.R01.S.doc Version 5.0 Page 9 The Inspector noted evidence that the care staff support service users to maintain personal and oral hygiene. During observations the care staff appeared caring, committed and interested in the service users well-being. At the time of inspection the home had no pressure sores. Service users were registered with the GP who had regular contact with the service. The service will support service users to obtain specialist medical support when necessary. The Inspector noted from manager statement and service user statement that service users are treated with dignity and respect at all times. The Inspectors noted that staff are taught how to treat and communicate with service users appropriately and how to be aware of issues such as privacy and dignity when delivering personal care. Somerset House DS0000008057.V266575.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 Service users find that life in the home matches their expectations and preferences. Service users are able to maintain contact with family and friends as they wish. Service users are supported to exercise choice and control in their lives. EVIDENCE: The day-to-day routine in the home support service users to live, as they prefer. Service users can choose to have their breakfast in their rooms, when to get up and generally control their lives as they wish. The home will support service users with routines of daily living without undue control or interference. The home encourages service users to maintain contact with family and external friends. Service users are able to choose who they do and do not see and there are no unreasonable rules regarding visiting hours. The home is run generally to maximise the service users choice and control over their own lives. Service users handle their own financial affairs with their able to. Service users are entitled, and encouraged to bring personal items with them, subject to health and safety. Somerset House DS0000008057.V266575.R01.S.doc Version 5.0 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Service users are confident that their complaints will be listened to, taken seriously and acted upon. The home protects service users from abuse. EVIDENCE: The home has a clear, simple and accessible complaints procedure. The Inspector noted documentary evidence of this and that the home has had no complaints since the previous inspection. At the time of inspection, service users were generally satisfied with the service. One service user did wish to make a request to the Inspector that a toilet door and toilet flush were fixed as they had requested this be done by staff and manager to no avail. The service user did not wish to make this a complaint. The home has robust procedures for the reporting of abuse or neglect. The manager was aware of the whistleblowing procedure and could give examples of the homes interventions should abuse or neglect be suspected. Somerset House DS0000008057.V266575.R01.S.doc Version 5.0 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24, 26 Service users live in a safe and well maintained environment. Service users have access to safe comfortable indoor and outdoor communal areas. Service users are provided with safe comfortable bedrooms in which they can have their own possessions. Service users are provided with safe comfortable bedrooms. The home is clean, pleasant and hygienic. EVIDENCE: The home is a pleasant older building, which has been considerably extended. The location and layout of the home are suitable for its purpose as a residential home. The home and grounds are kept tidy and attractive the service users. The building complies with fire service regulations. Somerset House DS0000008057.V266575.R01.S.doc Version 5.0 Page 13 The home has a range of large pleasant communal spaces. It also has a pleasant outdoor area the service users can use in the summer. Furnishings in the communal areas are homely and of good quality. The home provides service users with well-equipped pleasant bedrooms. The rooms have pleasant fixtures and furnishings, although the service users can bring their own. Service users are provided with the Kiefer their own bedroom. The premises were clean and hygienic throughout. Somerset House DS0000008057.V266575.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 The home has a sufficient staff to meet the needs of service users. Service users are supported and protected by the homes recruitment policy. EVIDENCE: The home has sufficient care staff on duty to meet the needs of the service users. The Inspector noted the staff rota showed sufficient staff throughout the day and evening. Sufficient staff are available on nights to meet service users needs. The Inspector noted a great improvement in the homes recruitment processes and procedures. All files audited had 2 references, POVA and CRB checks. The Inspector commends the manager on the improvements shown. Somerset House DS0000008057.V266575.R01.S.doc Version 5.0 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36 The home is managed and run up by a person who is fit to be in charge and of good character. The home is clearly run for the benefit of the service users, the ethos and general management of the home of very positive. The home is running the best interests of the service users. The staff are not appropriately supervised, the home does not meet national minimum standards. EVIDENCE: The registered manager has in excess of 2 years experience running the care home. The manager has undertaken training to improve her knowledge and skills to manage the home. The manager is familiar with conditions associated with old age. Somerset House DS0000008057.V266575.R01.S.doc Version 5.0 Page 16 Staff feedback, service user feedback and manager statement indicate that the home has an open, positive and inclusive atmosphere for the service users. The registered manager is approachable by the service users. Service user spoken with felt the manager was approachable and could be spoken to about concerns or complaints. The Inspector noted the efforts of the home to assess and improve its quality assurance. This was good practice. The Inspector noted extensive evidence of questionnaires and effort on the part of the manager to review the quality of care. The Inspector commends the effort of the manager and notes the home exceeds national minimum standards for this area. The Inspector audited staff supervision. The Inspector noted no documentary evidence of staff supervision to be available. The Inspector also noted this issue has been highlighted in reports since 2002. The manager outlined to the Inspector that she approached employees individually and informally, and offered an open door to employees. However, it is apparent that the home still does not offer for formal supervision, it appears to have no supervision strategy and has consistently failed to meet national minimum standards regardless of requirements made by the commission. The Inspector would highlight that this practice places the service in an exceptionally vulnerable position should complaints of abuse arise, or the home become challenged about any aspect of employee conduct. Somerset House DS0000008057.V266575.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x 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 X 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 4 x x 1 x x Somerset House DS0000008057.V266575.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP24 Regulation 23(2) b,c Requirement The inspector requires the toilet door lock, and flush, be maintained and repaired on the first floor small toilet near the managers office stairway. Care plans must address service users holistic needs. The registered manager will ensure the employees receive appropriate supervision Timescale for action 30/03/06 2. 3. OP7 OP36 15 18 (2) 30/03/06 30/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Somerset House DS0000008057.V266575.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Somerset House DS0000008057.V266575.R01.S.doc Version 5.0 Page 20 - 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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