Inspection on 01/09/05 for South Efford House

This inspection was carried out on 1st September 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.

Other inspections for this house

South Efford House 10/01/07

South Efford House 07/03/06

South Efford House 15/02/05

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE South Efford House Bridge End Aveton Gifford Kingsbridge TQ7 4NX Lead Inspector Margaret Crowley Announced 1 September 2005 st 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. South Efford House D54-D07 S61893 South Efford V239820 010905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service South Efford House Address Bridge End, Aveton Gifford, Kingsbridge, Devon, TQ7 4NX 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) 01803 607604 01803 606532 Crocus Care Limited Care Home 22 Category(ies) of Dementia - over 65 years of age (22), Old age, registration, with number not falling within any other category (22), of places Physical disability over 65 years of age (22) South Efford House D54-D07 S61893 South Efford V239820 010905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 15/02/05 Brief Description of the Service: South Efford House is a detached, period property, situated outside of the South Hams village of Aveton Gifford, close to the riverbank.It provides accommodation for up to 22 Service users who are older persons who may or may not have a physical disability or some degree of dementia. The home comprises accommodation on two floors accessed via a passenger lift. Staff accommodation is on the second floor.There are extensive grounds to the front and rear of the home, and parking to the front. Communal areas are situated on the ground floor, along with service areas. There are 19 bedrooms, which are mostly en suite. South Efford House D54-D07 S61893 South Efford V239820 010905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and took place over one day on 1st September 2005. A tour of the premises took place, and records were inspected. Service users and visitors were spoken with. Staff on duty were observed and spoken with in the course of their daily duties. Discussions took place with Clare Hunter, responsible person, who was present for part of the inspection and Linda Dodd acting manager. 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. South Efford House D54-D07 S61893 South Efford V239820 010905 Stage 4.doc Version 1.40 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 South Efford House D54-D07 S61893 South Efford V239820 010905 Stage 4.doc Version 1.40 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) 1,3 Prospective service users are provided with information to assist them in choosing to live at South Efford House. The admission procedure ensures that service users needs are assessed and can be met. EVIDENCE: The statement of purpose and the service user guide have been revised since the last inspection. The statement of purpose should provide more information regarding the deployment, numbers and qualifications of staff currently employed and the numbers and sizes of rooms, including communal rooms. When new service users are admitted their needs are assessed prior to admission. Evidence was seen of the assessments undertaken. The management should inform service users or their representative in writing that their assessed needs can be met. South Efford House D54-D07 S61893 South Efford V239820 010905 Stage 4.doc Version 1.40 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) 7,8,9 Service users have care plans, which are reviewed and enable their needs to be met. The systems for the administration of medication are satisfactory with arrangements in place to ensure that service users’ medication needs are met. EVIDENCE: Evidence was seen of risk assessments and care plans, and a review system. Daily records showed that any concerns are recorded and addressed. South Efford House maintains good working relationships with primary care and care management staff. The district nurse and a visiting care manager said the quality of the care provided has improved. Care staff are more visible and the premises no longer smelled of urine. Where service users needs have increased advice and assistance is sought from community services, including the psychiatric service Service users spoken with said that they are well are cared for and that staff are kind and helpful. There are clear policies and procedures for the administration and storage of medicines. Medication records were found to be satisfactory. Those staff who administer medicines have received training. A medicines refrigerator has been provided since the last inspection. South Efford House D54-D07 S61893 South Efford V239820 010905 Stage 4.doc Version 1.40 Page 9 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) 12,13,15 Service users are provided with a flexible life style, with some activities provided for those who wish to participate EVIDENCE: South Efford House caters for service users with a range of abilities including those with dementia. An activities provider now visits regularly to provide recreational activities. Some service users spoken with enjoy spending time in the grounds or going out for walks. Some of the more able service users prefer to spend time in their rooms rather than in communal areas. There is an open visiting policy and it was confirmed that visitors are made welcome. There is a varied rotating menu, which is adapted to suit service users’ dietary needs. A new cook has recently been appointed. Service users said the quality of the meals was usually of a satisfactory standard, but had fallen in the interim when there was no designated cook. South Efford House D54-D07 S61893 South Efford V239820 010905 Stage 4.doc Version 1.40 Page 10 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 Procedures are in place to enable service users to complain and to protect them from abuse. EVIDENCE: No complaints have been received since the last inspection. There is a complaints policy and procedure and service users spoken with were aware of how to complain. There is an adult protection policy and procedure which is accessible to staff. It is recommended that all staff receive multi agency adult protection training. South Efford House D54-D07 S61893 South Efford V239820 010905 Stage 4.doc Version 1.40 Page 11 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) 19,20,21,26 Service users are provided with accommodation that is comfortable, homely and clean. EVIDENCE: Since becoming the new proprietors of South Efford House, Crocus Care Limited have begun to upgrade the premises. The priority has been to make the premises more attractive for service users and safe. However, from discussions with the management it appears that the full extent of improvements required are more extensive than initially anticipated, due to the age of the property. These include attention to the heating and plumbing systems. Service user rooms are redecorated and refurbished when they become vacant. Two bedrooms have recently been redecorated and re-carpeted. The lounge and dining room have also been redecorated and new carpets are to be fitted. The carpet in one identified bedroom and the first floor landing must be repaired to prevent a trip hazard. The bathroom on the first floor has been redecorated. The bathroom on the ground floor, which has a Parker bath, should also be improved and made more homely. The manager says that this bathroom is not popular with the South Efford House D54-D07 S61893 South Efford V239820 010905 Stage 4.doc Version 1.40 Page 12 service users. However, there are only two assisted bathing facilities within the home. The premises were clean and free from odours. New laundry equipment has been purchased with a sluice facility. It is planned to upgrade the laundry room. Risk assessments must be undertaken to ascertain whether hot water outlets accessible to service users are restricted to a temperature of 43 degrees centigrade. A programme to fit temperature control valves should be put in place commencing with the rooms of those service users at the highest risk of scalds. Design solutions must be in place and testing undertaken to prevent the risk of Legionella. The proprietors should produce an improvement and maintenance plan for the premises with timescales. A copy of this should be sent to the Commission for Social Care Inspection. South Efford House D54-D07 S61893 South Efford V239820 010905 Stage 4.doc Version 1.40 Page 13 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) 27,29,30 An adequate number of staff are employed to meet the care needs of the current service users, but recruitment procedures to ensure the protection of service users are not always adhered to. EVIDENCE: The manager said that there are sufficient staff employed to meet service users needs by day and by night. Staff rotas were seen and staff confirmed that there are enough staff on duty to meet the care needs of the current service users, some of whom have dementia. Staff spoken with were positive about their work and said they are encouraged to undertake training. Staff have participated in a range of training since the last inspection, which includes mandatory training in fire safety, health and safety, moving and handling and infection control; and dementia awareness safe handling of medicines. An examination of the records of staff most recently employed revealed that 2 written references and CRB checks were not available for all staff. The manager was reminded that written references must be obtained for all staff prior to employment. A CRB disclosure and POVA check must also be obtained, or a system of chaperoning by named staff put in place, until these are available. . South Efford House D54-D07 S61893 South Efford V239820 010905 Stage 4.doc Version 1.40 Page 14 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) 32,33,35,38 Following a period of instability, the manager and staff team are working together to provide consistency of care for the service users. EVIDENCE: Linda Dodd was appointed acting manager in December 2004. An application to register her as the manager has now been received by the Commission. There have been some changes in staff since the last inspection, many as a consequence of the changes in management systems. Staff spoken with said that the manager was supportive and listened to their views Staff morale has improved and the management and staff team are working together to create a homely and open environment. Service users and their relatives value this. A quality assurance system is in place and service users views are sought. Service user meetings and staff meetings are held and minuted. Monthly, quality audits are undertaken by the responsible individual to ensure that standards are maintained. The management do not manage service users financial affairs. These are handled by the service users themselves or their representatives. Where South Efford House D54-D07 S61893 South Efford V239820 010905 Stage 4.doc Version 1.40 Page 15 monies are held in safekeeping for service users there are clear records kept of incoming and outgoing payments. Routine health and safety issues are managed satisfactorily. Fire prevention measures are in place, and it was evidenced that equipment is regularly tested. It is recommended that all staff receive fire prevention training a minimum of six-monthly, and more frequently for staff on duty at nighttimes. The manager said that there are sufficient staff with an in-date first aid certificate. The environmental health officer has visited the home recently and his recommendations regarding the storage of food should be addressed. South Efford House D54-D07 S61893 South Efford V239820 010905 Stage 4.doc Version 1.40 Page 16 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 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 3 x 2 x x 2 2 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x 3 3 x 3 x x 2 South Efford House D54-D07 S61893 South Efford V239820 010905 Stage 4.doc Version 1.40 Page 17 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 OP24 Regulation 23 Requirement The carpet in one identified bedroom and the first floor landing must be repaired to prevent a trip hazard Risk assessments must be undertaken to ascertain whether hot water outlets accessible to service users are restricted to a temperature of 43 degrees centigrade. A programme to fit temperature control valves should be put in place commencing with the rooms of those service users at the highest risk of scalds. Design solutions must be in place and testing undertaken to prevent the risk of Legionella Recruitment procedures must be adhered to Timescale for action 01/10/05 2. OP25 23 01/12/05 3. 4. OP25 29 23 19 01/02/06 02/09/05 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 OP1 Good Practice Recommendations The statement of purpose should provide more information D54-D07 S61893 South Efford V239820 010905 Stage 4.doc Version 1.40 Page 18 South Efford House 2. 3. 4. 5. OP18 OP21 OP19 OP38 regarding the deployment, numbers and qualifications of staff currently employed and the numbers and sizes of rooms, including communal rooms. All care staff should receive multi agency adult protection training The bathroom on the ground floor should be improved and made more homely. The proprietors should produce an improvement and maintenance plan for the premises with timescales. All staff should receive fire prevention training a minimum of six-monthly, and more frequently for staff on duty at nighttimes South Efford House D54-D07 S61893 South Efford V239820 010905 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection Unit D1 Liinhay Business Park Ashburton TQ13 7UP 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 South Efford House D54-D07 S61893 South Efford V239820 010905 Stage 4.doc Version 1.40 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. 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