Inspection on 10/01/07 for South Efford House

This inspection was carried out on 10th January 2007.

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 07/03/06

South Efford House 01/09/05

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 Devon TQ7 4NX Lead Inspector Margaret Crowley Unannounced Inspection 10th January 2007 10:00 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 South Efford House DS0000061893.V310914.R01.S.doc Version 5.2 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. South Efford House DS0000061893.V310914.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service South Efford House Address Bridge End Aveton Gifford Kingsbridge Devon TQ7 4NX 01548 550141 F/P 01548 550141 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) Crocus Care Limited Ms Linda Elizabeth Dodd 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 DS0000061893.V310914.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th March 2006 Brief Description of the Service: South Efford House is a care home providing accommodation and personal care for 22 older people aged over 65 years, who may also have physical disabilities and/or dementia. It is has been owned since 2004 by Crocus Care Ltd, which also owns three other care homes in South Devon. The Responsible Individual is Ms Clare Hunt. The home is a detached, period property, situated close to the riverbank outside village of Aveton Gifford, near Kingsbridge in the South Hams. The house has three storeys, but accommodation for residents is provided on the ground and first floors. There is a passenger lift and a stair lift to the first floor. There are sixteen single rooms and three shared rooms. The bedrooms are generally of a good size and most have an en suite toilet. Some also have an en suite bath or shower, but these are not adapted for use by people with disabilities. There are two bathrooms with assisted baths and appropriate aids are in place. The lounge and a separate dining room are situated on the ground floor. The premises have extensive grounds to the front and rear, with level lawns. Many rooms have pleasant views over the gardens and the surrounding countryside Parking space is available at the front of the house. Staff accommodation is currently provided in a self-contained adjoining annex. Fees currently range from £270 to £500 per week. Written information regarding the home and the services provided is on display and is given to prospective and new residents. A copy of the most recent CSCI Inspection report is available. South Efford House DS0000061893.V310914.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place took place over 7 hours on 10th January 2007. Linda Dodd, the registered manager, was on duty throughout the inspection. A tour of the premises was made. Ten of the 17 residents in the home on that day were spoken with, including 4 in more depth, regarding the lifestyle in the home and the care services they receive. Four staff on duty were observed and spoken with in the course of their daily duties. In addition, 3 relatives were spoken with during the inspection. Records were inspected including care and staff records. Comment cards were received from the community nursing service and social services. Feedback questionnaires were received from 2 residents and 4 relatives. Feedback questionnaires were also received from 3 staff. What the service does well: What has improved since the last inspection? Closer links have been developed with the village community and local church, which has enabled residents to take part in shared social events. The proprietors are continuing to upgrade the home. A new stair lift has been installed from the ground floor to the first floor to improve residents’ access to some rooms that previously could only be accessed via steps. Several bedrooms have been redecorated to make them more attractive for residents. South Efford House DS0000061893.V310914.R01.S.doc Version 5.2 Page 6 A new washer/dryer with a sluice facility has been installed to improve the hygiene and efficiency of the laundry facilities. 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. The summary of this inspection report can be made available in other formats on request. South Efford House DS0000061893.V310914.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection South Efford House DS0000061893.V310914.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives can be confident that they will be given information to help them make a choice about this home. Admission procedures ensure that residents’ needs are assessed and known prior to their admission. EVIDENCE: A resident who had been admitted recently said that staff had been welcoming and kind when they had arrived and had helped them to settle in. Prospective and new residents are provided with a residents’ guide and a statement of purpose, which are reviewed regularly. A sample of service users’ records was examined and evidence was seen of informative pre- admission assessments undertaken with residents. Discussion with the registered manager and residents, as well as observation, showed that staff are aware of the needs of the residents. The home does not provide intermediate care. South Efford House DS0000061893.V310914.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can feel confident that their personal and health care needs will be met. EVIDENCE: Residents and visitors spoken with and responses in questionnaires showed that residents feel they receive the care and support they need. A relative said the manager and staff had responded promptly and well when they requested additional assistance for the resident. Residents said that staff respect their privacy and dignity when assisting them with their personal care. Staff were described as “always polite and helpful”. The inspector observed that staff speak to residents in an appropriate and friendly manner, and knock on bedroom doors before entering. A sample of residents’ records was inspected and these contained a care plan, current review, risk assessment, and daily records. Records were clear and concise. Care plans are reviewed monthly and relatives are written to and informed of the date of the review so they can attend, if appropriate. South Efford House DS0000061893.V310914.R01.S.doc Version 5.2 Page 10 There was evidence of good liaison with community health services, which was commented on in feedback from professionals and a relative. Records inspected and observations during the inspection demonstrated that systems are in place to ensure that resident’s health needs are clearly identified and met in a timely manner. Discussion took place with the registered manager regarding including more information regarding residents’ former lifestyles, interests and preferences in the care plans. A new, more comprehensive care plan format is to be piloted. There are clear procedures for the administration and storage of medicines. Medication records were found to be satisfactory. Staff who administer medicines have received training. The medicines refrigerator was not currently working and medicines that need to be stored in a refrigerator were kept in the main refrigerator, but not in a secured, locked, non-metallic container. South Efford House DS0000061893.V310914.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards12, 13, 14, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are enabled to live a flexible lifestyle with activities available to provide interest for them. Residents are provided with a nutritious and well-balanced diet. EVIDENCE: Residents said that they can choose how they spend their time and that they are encouraged to make suggestions regarding the choice of activities. A monthly programme of activities is now displayed, with themed events taking place. A new activities organiser visits the home weekly. Some residents spoken with said they likes going out for walks and or into the grounds, when the weather permits. Shopping trips are provided by car to Kingsbridge, and local places of interest. A minority of residents said they prefer to spend time in their own room and like informal time spent individually with staff. During the inspection some residents were observed enjoying having their fingernails painted and manicured, and others welcomed the visit from the mobile library. The registered manager has improved links with the local village community and the village church, and actively encourages participation in social events. Visitors said that the manager and staff always make them very welcome. South Efford House DS0000061893.V310914.R01.S.doc Version 5.2 Page 12 Residents said that they liked the food and relatives also confirmed that the meals were of a good standard. Meals seen during the inspection looked appetising and the range of homemade cake available at tea time was praised Alternatives are available to the main meal and special diets are catered for. South Efford House DS0000061893.V310914.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can feel confident that there are systems in place to address issues of concern, complaints or allegations of abuse. EVIDENCE: The home has a written complaints procedure and residents know how to make a complaint should they need to. Residents spoken with said they would raise concerns with the manager or senior staff, either by themselves or via a relative. Feedback from relatives said that the registered manager quickly addresses any issues raised. The Commission for Social Care Inspection has not received any complaints since the last inspection. Three complaints had been received by the management and addressed via the home’s complaints procedure. Complaints are filed in a folder and the manager was advised to serial number the complints, or to enter brief details in a complaints book to maintain a chronological record. There is an adult protection policy and procedure which is accessible to staff. Staff receive training in adult protection. South Efford House DS0000061893.V310914.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards19, 24, 26 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users live in a home that is clean and comfortable, but the lack of attention to some maintenance tasks could place service users at risk. EVIDENCE: A tour of the premises took place and all rooms were seen. The lounge and dining room were pleasantly decorated and comfortably furnished. The carpet in the dining room required attention to prevent a trip hazard. The registered manager has since informed the inspector that this has been addressed. The manager said that the proprietor intends replacing the dining room and lounge carpets within the next 12 months. Residents were comfortable and personalised to their taste. As part of the ongoing programme to upgrade the premises some rooms have been redecorated when they become vacant to make them more attractive. South Efford House DS0000061893.V310914.R01.S.doc Version 5.2 Page 15 There were various aids and adaptations in place to assist residents such as a bath lift, mobile hoists, grab and handrails and raised toilet seats. The home has a shaft lift to the 1st floor. A stair lift has been fitted on the back stairs to make some of the bedrooms on the 1st floor more accessible to residents. The home has two assisted baths, one situated on each floor. The ground floor bathroom contains a Parker Bath, which is used by a small minority of residents. This room is cold looking and unappealing, and has not been redecorated and made more comfortable for residents, as recommended at previous inspections. When funds allow consideration should be given to installing an en suite toilet in the bedroom on the ground floor that opens onto the dining room and where the resident has to access the toilet by crossing the dining room. This would promote the privacy and dignity of the resident in that room. Although temperature control valves had been fitted to all hot water outlets accessible to service users to prevent the risk of scalds, four valves have been removed because of problems encountered with the hot water system. Risk assessments have been carried out in the rooms affected and large print warning signs are now in place by these outlets. The hot water temperature in baths is monitored regularly to ensure that the temperature is maintained around 43°C. The registered manager said that all windows above ground floor level had been fitted with restrictors, but the restrictor on one bedroom window was broken. No progress has been made in fitting bedroom doors with locks to aid residents’ privacy and the security of their belongings should they be absent from the home. Any lock fitted should be suited to residents’ capabilities and accessible to staff in an emergency. The home was clean and free from unpleasant odours, other than in a vacant bedroom, which had an odour of urine. The manager has since informed the inspector that the carpet has been cleaned again and the odour removed. A new washer/dryer with a sluice facility has been installed to improve the hygiene and efficiency of the laundry facilities. The environmental health officer had visited in the week prior to the inspection and had made recommendations which included replacing the rusty shelving in the refrigerator, repairing the fan in the kitchen and attending to part of the kitchen ceiling which needed repainting. The registered manager said that the proprietors were purchasing a new refrigerator and the fan was attended to on the day of the inspection. South Efford House DS0000061893.V310914.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient staff are employed to meet the care needs of the current residents. Staff are provided with training opportunities to enable them to develop their knowledge and skills in caring for residents. EVIDENCE: Residents spoken to and feedback from relatives said that staff were kind, accessible and available without undue delays. Communication observed between staff and residents was friendly and positive. There were 17 residents in the home on the day of the inspection. Staff on duty comprised the registered manager, 3 care staff, which included a designated head of care, a cook and a domestic, with two staff on duty at night time. The manager was currently seeking to recruit a domestic and a maintenance person. The registered manager said that there was currently sufficient staff employed to meet residents needs. Staff confirmed this, although one of the 3 replies to the staff questionnaire said that an additional staff member was needed. Staff interviewed and feedback from questionnaires was very positive regarding the quality of support and supervision they receive from the registered manager. Staff said that they work together well as a team for the benefit of the residents. South Efford House DS0000061893.V310914.R01.S.doc Version 5.2 Page 17 Staff value their access to training. The Registered Manager confirmed that staff are provided with training opportunities. Evidence was seen of induction training, and the training plan showed mandatory training in safe working practices takes place. All staff members are encouraged to complete National Vocational Qualifications, with 55 currently qualified to NVQ level 2. In addition 4 staff are currently undergoing this training. The Registered Manager confirmed that recruitment processes were robust. Two written references are obtained and a check made against the Protection of Vulnerable Adults (POVA) list and a Criminal Records Bureau (CRB) check. The manager said that no staff are left unsupervised until a satisfactory CRB check is obtained. The inspector advised the registered manager to keep a record available for inspection of Criminal Records Bureau checks applied for, and the serial number and date that the result of the check is received. She was referred to guidance provided on the CSCI website. South Efford House DS0000061893.V310914.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35,38 Quality in this outcome area is good . This judgement has been made using available evidence including a visit to this service. The registered manager continues to a good understanding of where the home needs to improve and works with the proprietors to facilitate this. EVIDENCE: The registered manager holds The National Vocational Qualification at level 3 in Care and continues to work towards NVQ level 4.Once completed she intends to commence the Registered Manager’s Award. Residents, relatives and staff said they recognise the progress made since she has been in post. The management and staff team have created a homely and open environment. There is a quality assurance system and residents, relatives and staff’s views are sought. The responsible individual for the company visits the home on a monthly basis copies of the written reports are sent to CSCI. South Efford House DS0000061893.V310914.R01.S.doc Version 5.2 Page 19 Residents or their representatives manage their financial affairs. Where monies are held in safekeeping for residents there was clear evidence of records kept of incoming and outgoing payments. Fire prevention measures were in place and the fire logbook was being maintained which detailed checks and tests of fire safety equipment, as well as fire safety training for staff. Slippery algae was found on external fire exits at the rear or the premises, which could cause a fall. This had been also been identified at the last inspection. The manager has informed the inspector that these have since been made safe. . South Efford House DS0000061893.V310914.R01.S.doc Version 5.2 Page 20 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x 2 x x 2 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 3 x 3 x 3 x x 2 South Efford House DS0000061893.V310914.R01.S.doc Version 5.2 Page 21 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 OP21 Regulation 23(2)(d) Requirement All parts of the care home are kept clean and reasonably decorated. re refurbishment of the ground floor bathroom The premises to be used as the care home are of sound construction and kept in a good state of repair externally and internally. re external fire exits, window restrictor. Timescale for action 10/05/07 2 OP19 23(2)(b) 10/02/07 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 OP21 Good Practice Recommendations The Registered Provider should consider installing an en suite toilet in the bedroom on the ground floor that does not have one. The Registered Provider should install locks on bedroom doors suited to service users’ capabilities and accessible to staff in an emergency. DS0000061893.V310914.R01.S.doc Version 5.2 Page 22 2. OP24 South Efford House 3 OP9 Medicines that need to be stored in a refrigerator should be stored in a medicines refrigerator or if kept in the kitchen refrigerator secured in a locked, non-metallic container. South Efford House DS0000061893.V310914.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000061893.V310914.R01.S.doc Version 5.2 Page 24 - 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!