Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 30/06/05 for Somerset House

Also see our care home review for Somerset House for more information

This inspection was carried out on 30th June 2005.

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

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 home is well established and offers a pleasant environment for service users. Service users were relaxed and supported by staff with personal care needs. Service users were generally satisfied with their care.

What has improved since the last inspection?

The inspector is unable to comment as this was his first inspection.

What the care home could do better:

On the whole the home offers a reasonable service. The inspector noted a number of fundamental procedural and administrative short falls. The inspector also notes that the same short falls have been repeatedly highlighted by the Commission and made subject to repeated legal requirement. In particular formal supervision for care staff has been required from 9/12/2002 and sufficient staff ID for the protection of service users as outlined in schedule 2. (Regulation 7,8,19) were required in reports dated 9/12/2002, 27/8/2003, 26/3/2004, 3/8/2004, 21/12/2004. The inspector would urge the manager to look at issues highlighted in this report. They are easily remedied, are indicators of good practice in care and are legally required by the commission. The inspector would emphasise the value to service users of a regular reviews of care delivered.

CARE HOMES FOR OLDER PEOPLE Somerset House 157 High Street Yatton North Somerset BS49 4DB Lead Inspector Paul Grey Announced 30 June 2005 th 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. Somerset House D53-D02 S8057 Somerset House V226829 140605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Somerset House Address 157 High Street, Yatton, North Somerset, BS49 4DB 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) 01934 832114 Mrs Wendy Rita Hiles Mrs Julie Denise Jones PC Care Home only 26 Category(ies) of Old age (26) registration, with number of places Somerset House D53-D02 S8057 Somerset House V226829 140605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: May accommodate up to 26 persons aged 65 years and over requiring personal care. Date of last inspection 21st December 2004 Brief Description of the Service: Somerset House is a pleasant period property situated off the main road through Yatton. The property has been extensivley modified and extended to meet the needs of up to 26 people over 65 years of age. The premises also have a small satelite home suitable for service users who wish to use the support offered by the home but desire a more private form of accomidation. Somerset House D53-D02 S8057 Somerset House V226829 140605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection found a pleasant, well run home. Service users appeared comfortable and well cared for. General feedback to the inspector was positive about overall care. Three service users complained to the inspector about the manner in which they were addressed by a staff member. This was discussed with the manager who supported the member of staff and service users and addressed the complaint. The inspector does not feel this was common place in the home and is satisfied at the manager’s course of action. NO complaints had been made prior to inspection. 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 D53-D02 S8057 Somerset House V226829 140605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Somerset House D53-D02 S8057 Somerset House V226829 140605 Stage 4.doc Version 1.30 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 standard(s) 1,2,3 The Home provides potential service users with a statement of purpose and service user guide meeting National Minimum Standards. Service users are provided with a statement of terms and conditions concerning their stay at the home. The inspector noted service users had been assessed prior to admission. EVIDENCE: The inspector notes the statement of purpose and service user guide met the national minimum standards. All service user records sampled during inspection had an appropriate agreement outlining cost, rooms to be occupied and any additional costs that may be incurred by the service user. Somerset House D53-D02 S8057 Somerset House V226829 140605 Stage 4.doc Version 1.30 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 standard(s) 7,8 10 The inspector observed a plan of care was drawn up for residents from the assessment process. The Home supports service users obtain external health care support where necessary and promotes service users health needs. On the whole service users dignity is respected. The inspector received complaints concerning the way in which service users had been addressed by one member of staff. The3 manager has addressed this issue. EVIDENCE: The inspector sampled 4 care plans. All were adequate for the needs of the service users and were generated from the assessment process. The inspector has made a recommendation regarding care plans in final section of the report. The inspector also noted that out of 4 files sampled, no care plans were signed and 3 were reviewed at 3 to 6 monthly intervals. The inspector sampled files and noted evidence that service users health needs have been assessed and met by the home. Where necessary appropriate professional input has been sought in the form of district nurses, chiropodists and G.P’s Somerset House D53-D02 S8057 Somerset House V226829 140605 Stage 4.doc Version 1.30 Page 9 The inspector spent time with a number of service users within the home. One issue that arose was that a number of service users felt their privacy and dignity was not respected on occasion. On further investigation it appeared that this issue involved one member of staff and could be easily resolved. Generally feedback regarding standard 10 was positive with service users expressing satisfaction with the service. The inspector noted a service user questionnaire conducted by the home gave very positive feedback from those who participated. Somerset House D53-D02 S8057 Somerset House V226829 140605 Stage 4.doc Version 1.30 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 standard(s) 12, 13 The atmosphere of the home and routines of daily living are suited to meet service users needs. Service users are encouraged, and supported to have visitors at reasonable hours within the home. EVIDENCE: Service users spoken with during inspection felt the general routine of the home was suitable to their needs and that day to day living met their general expectations. Staff indicated that guests are welcome at reasonable hours and service users are welcome to have guests in their rooms or communal areas if they chose. Somerset House D53-D02 S8057 Somerset House V226829 140605 Stage 4.doc Version 1.30 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 standard(s) 16, The inspector noted a complaints procedure was in place but service users spoken with were unaware of it, or its contents. EVIDENCE: Service users who spoke to the inspector were unsure how they should complain and felt unable to complain directly to the manager. Service users did not know they were able to approach CSCI if they were unsatisfied with the managers findings or the general procedure for making a complaint. Somerset House D53-D02 S8057 Somerset House V226829 140605 Stage 4.doc Version 1.30 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 standard(s) 19,23,24, 26 The location and layout of Somerset House was suitable for its purposes as a residential home. Somerset House provides accommodation to service users of sufficient size to meet National Minimum Standards. Service users are provided with suitably furnished and equipped accommodation. The premises are clean and hygienic throughout. EVIDENCE: The home was well maintained with a programme of routine maintenance. The inspector requires the downstairs (Apollo) Bathroom have a new floor covering or carpet. Service users bedrooms were appropriately furnished by the home, or with service users wanting to personalise their rooms. All rooms were carpeted or had an appropriate floor covering. The inspector required the carpets in rooms 11 and 12 be replaced. Somerset House D53-D02 S8057 Somerset House V226829 140605 Stage 4.doc Version 1.30 Page 13 The premises were clean and hygienic throughout. The inspector noted no offensive odours throughout the home. The inspector noted appropriate sluicing facilities in the home. Somerset House D53-D02 S8057 Somerset House V226829 140605 Stage 4.doc Version 1.30 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 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) 29 The home doe not meet national minimum standards. Most staff records were complete but not all had sufficient ID or photographs to protect service users. EVIDENCE: The inspector audited staff records. The inspector noted that not all records contained proof of ID for all employees. The manager must ensure all employees have sufficient forms of ID as outlined in schedule 2.The inspector notes that this has been identified in previous inspection reports and is subject to requirement. This remains an outstanding requirement. Somerset House D53-D02 S8057 Somerset House V226829 140605 Stage 4.doc Version 1.30 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 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) 31,33,36, The home has a manager who is experienced, competent and able to meet the homes and objectives. The home has an effective quality assurance system to monitor the standard of care delivered. Staff receive supervision in the home. EVIDENCE: The manager has extensive experience within the home having worked as a cook, cleaner and carer in the home. This gives her a unique insight into all aspects of care delivery in Somerset House. The manager has conducted service user questionnaires and acted on evidence gained from these. This was good practice. Somerset House D53-D02 S8057 Somerset House V226829 140605 Stage 4.doc Version 1.30 Page 16 The inspector discussed supervision with the manager. The manager explained the home had an informal “open door” procedure. On checking records the inspector was unable to find documentary evidence of a regular program of supervision or any outcomes based upon supervision sessions. The inspector outlined the process of supervision its function. The manager has agreed to implement a regular program of supervision cascading supervision from senior carers down. The inspector accepts that informal supervision occurs but would advise the manager and owner that current method does not meet current good practice or the national minimum standards. Given that the manager is addressing this issue no requirements have been made. Somerset House D53-D02 S8057 Somerset House V226829 140605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x 3 2 x 3 STAFFING Standard No Score 27 x 28 x 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 x 3 x x 2 x x Somerset House D53-D02 S8057 Somerset House V226829 140605 Stage 4.doc Version 1.30 Page 18 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 19 Regulation 23 (2) b,d Requirement The Inspector requires the downstairs (Apollo) bathroom have a new floor covering or carpet fitted. The inspector requires the carpets in bedrooms 11 and 12 be replaced by carpet or an appropriate waterproof floor covering as the manager feels is appropriate. The registered person must not employ persons to work at the home unless they have in respect of that person documents as specified in paragraphs 1 to 7 of schedule 2. Care plans must be reviewed monthly. Timescale for action 31.1.06 2. 24 23(2) b,c 31.1.06 3. 29 19 (1) b 1 21/12/04 4. 7 15 21/12/04 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 Care plans were based on an appropriate assessment process. On the whole care plans addressed basic needs and ommited social or emotional issues for the service D53-D02 S8057 Somerset House V226829 140605 Stage 4.doc Version 1.30 Page 19 Somerset House users. The inspector would reccomend the manager review the assessment and care planning process to incorporate a more wholistic, contemporary approach to care. 2. Somerset House D53-D02 S8057 Somerset House V226829 140605 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection Riverside Chambers Castle Street Tangier 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 D53-D02 S8057 Somerset House V226829 140605 Stage 4.doc Version 1.30 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!