Inspection on 07/03/06 for South Efford House

This inspection was carried out on 7th March 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

South Efford House 10/01/07

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 Antonia Reynolds Unannounced Inspection 7th March 2006 10:25 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.V285288.R01.S.doc Version 5.1 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.V285288.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service South Efford House Address Bridge End Aveton Gifford Kingsbridge Devon TQ7 4NX 01803 607604 01803 606532 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.V285288.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st September 2005 Brief Description of the Service: South Efford House is a care home providing accommodation and personal care for 22 older people, aged over 65, who may also have physical disabilities and/or dementia. It is privately owned 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 outside the South Hams village of Aveton Gifford, close to the riverbank. The present owners took over the running of the home in October 2004. The house has three floors but accommodation for service users is only on the ground and 1st floors. Most of the 1st floor can be accessed via a passenger lift, although there are a few steps to some rooms. Staff accommodation is on the 2nd floor. Sixteen bedrooms are single rooms and three are shared rooms. The bedrooms are generally of a good size and most of them have en suite toilets and some also have en suite baths or showers. There are two assisted bathrooms and appropriate aids and adaptations are in place. The home has separate lounge and dining rooms on the ground floor and there are extensive grounds to the front and rear of the home. Parking space is available at the front of the house. All areas are accessible to the service users. South Efford House DS0000061893.V285288.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took the form of a visit between 10.25am and 2.35 pm on Tuesday, 7th March 2006, and follow up telephone calls to confirm information that was not available during the visit. The Registered Manager, Linda Dodd, was present throughout the inspection. A tour of the premises took place and records relating to care, staff and the home were inspected. Ten of the eighteen service users were observed and spoken with during the visit. Staff on duty were observed and spoken with in the course of their daily duties. What the service does well: What has improved since the last inspection? What they could do better: Bedroom doors need to be fitted with locks, suited to service users’ capabilities and accessible to staff in emergencies, to allow service users privacy and security of their belongings should they be absent from the home. Consideration should be given to installing an en suite toilet in the bedroom on the ground floor that does not have one, to promote the privacy and dignity of the service user in that room. The existing unused bathroom on the ground South Efford House DS0000061893.V285288.R01.S.doc Version 5.1 Page 6 floor should be made more comfortable or consideration given to creating another bathroom on the ground floor that service users will be happy to use. Advice was given to: • • • • sign and date all documents so that everyone is clear about which is the most recent one ensure that steps on all external fire exits are kept clear of slippery algae to reduce the likelihood of an accident keep copies of the monthly provider visit reports in the home and send a copy to the Commission for Social Care Inspection obtain a screen for each shared bedroom that can be kept in the rooms to allow some privacy for service users should they become shared 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 DS0000061893.V285288.R01.S.doc Version 5.1 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.V285288.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 4 Prospective service users and their representatives can be confident that they will be given information to help them make a choice about this home. EVIDENCE: A Statement of Purpose and Service User Guide were available for prospective service users and provided a description of the services offered. The Statement of Purpose has been updated since the last inspection and contained more detail about the staffing complement and room sizes. Discussion the Registered Manager and service users, as well as observation, showed that staff were aware of the needs of the service users. The home did not provide intermediate care. South Efford House DS0000061893.V285288.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 10 Service users can feel confident that their personal and health care needs will be met. EVIDENCE: Service users’ files contained care plans and risk assessments that were regularly reviewed. Discussion with service users and the Registered Manager, as well as observation, confirmed that personal care was maintained and service users were encouraged to be as independent as possible. Service users had access to health care service services such as doctors, district nurses and the mental health team. Service users were treated with dignity and privacy was respected. The home did not have portable telephones for service users to use, because reception is poor in parts of the building. However, the Registered Manager confirmed that service users could have private telephones in their bedrooms (at their own expense) or could use the home’s ‘phone privately in the office. The Registered Manager confirmed that one screen was available for the shared rooms and a discussion took place about providing a screen for each of the shared bedrooms so that staff did not have to move the screen around. Service users spoken with said that they were well are cared for and that staff were kind and helpful. South Efford House DS0000061893.V285288.R01.S.doc Version 5.1 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 and 15 Service users are enabled to make choices about their lifestyle within and outside the home. Dietary needs of service users are well catered for with a balanced and varied selection of food available. EVIDENCE: The Registered Manager confirmed that activities in the home were arranged every day and that trips out for small groups of service users were arranged monthly. Designated staff cars were used for these outings and the Registered Manager confirmed that the cars were appropriately insured. The Registered Manager was working at creating links with the local community, such as encouraging service users to attend local luncheon clubs and inviting visitors, such as representatives from the donkey sanctuary. Some service users spoken with enjoyed spending time in the grounds or going out for walks. Service users confirmed that they liked the food and the lunchtime meal on the day of inspection looked appetising. The Registered Manager said that there were a range of options available as alternatives to the main meal and that specialised diets, including liquidised meals, were provided. South Efford House DS0000061893.V285288.R01.S.doc Version 5.1 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 and 18 Service users can feel confident that any complaints they have will be taken seriously and that their views are listened to and acted on. EVIDENCE: The home had a written complaints procedure and service users knew how, and to whom, to make a complaint should they need to. Neither the home nor the Commission for Social Care Inspection have received any complaints since the last inspection. Service users said they had no complaints about the home or the care they received. Those able to give an account said they felt confident to ask the staff to sort out any problems as they arose. The Registered Manager confirmed that adult protection training is planned for senior staff members and that all staff had watched a video relating to adult protection issues. The home kept a visitors book to record dates, times and names of all visitors to the home. South Efford House DS0000061893.V285288.R01.S.doc Version 5.1 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, 21, 22, 23, 24, 25 and 26 Service users are provided with accommodation that is comfortable, homely and clean. EVIDENCE: The communal rooms were on the ground floor and consisted of separate lounge and dining rooms, which were connected. The rooms were pleasantly decorated and furnished. The home had a call alarm system that could be cancelled at the point of call. There were various aids and adaptations in place to assist service users such as bath lifts, mobile hoists, grab and handrails and raised toilet seats. As well as stairs, the home had a shaft lift to the 1st floor. The Registered Manager confirmed that consideration was being given to installing a stair lift on the back stairs to make some of the bedrooms on the 1st floor accessible to more service users. There were four single and two double bedrooms on the ground floor and twelve single rooms and one double room on the 1st floor. One screen was available to use in the shared rooms to provide some privacy and a discussion took place with the Registered Manager about obtaining a screen for each South Efford House DS0000061893.V285288.R01.S.doc Version 5.1 Page 13 shared bedroom, although two of these were being used as single rooms on the day of inspection. Bedrooms were individually decorated and furnished and contained many personal belongings. Bedroom doors were not fitted with suitable locks and this needs to be addressed to allow service users privacy and security of their belongings should they be absent from the home. Sixteen of the bedrooms had en suite toilet facilities, five of these had en suite baths and four had en suite showers. However the Registered Manager confirmed that the present service users did not use these baths/showers. One of the bedrooms on the ground floor did not have an en suite toilet and the service user in that room had to go through the dining room to the nearest toilet. Consideration should be given to providing that bedroom with an en suite facility to promote the privacy and dignity of the service user. On the ground floor there was a bathroom with an assisted bath (Parker bath) but the Registered Manager said that this bathroom was never used, as the service users did not like it. The bathroom was not in a very good position as it was situated off the dining room. Consideration needs to be given to either creating another bathroom on the ground floor or making this bathroom more comfortable and homely. On the 1st floor there was another assisted bathroom. This bathroom did not contain a central heating radiator so had to be heated using two wall mounted electric heaters prior to service users having a bath. Bathrooms and toilets were fitted with appropriate locks that could be opened from the outside by staff in an emergency. The Registered Manager confirmed that temperature control valves have been fitted to all hot water outlets accessible by service users to ensure that the hot water is regulated to about 43°C. Records showed that regular checks were made of the hot water temperature at all the outlets to ensure the valves were working correctly. Throughout the home, cleanliness and hygiene were of a good standard and staff were extremely diligent in cleaning and removing any offensive odours. Infection control procedures described by the Registered Manager were satisfactory. Facilities for staff consisted of an office and toilet on the ground floor and sleeping in facilities on the 2nd floor. South Efford House DS0000061893.V285288.R01.S.doc Version 5.1 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, 28, 29 and 30 Service users can be confident that the staff group will have a good understanding of their care needs. EVIDENCE: Observation and discussion with service users and staff confirmed that the staff team were respectful, polite, attentive and responsive to service users needs. The Registered Manager, as well as staffing rotas, confirmed that there were three care staff on duty from 8am to 8pm, with one waking and one sleeping staff member at night. In addition to the care staff there were staff on duty who carried out catering and domestic tasks. The Registered Manager confirmed that staff undertook induction training when they first took up employment at the home and were expected to attend various training courses such as health and safety, manual handling, fire safety, protection of vulnerable adults and dementia awareness. All staff members were encouraged to complete National Vocational Qualifications (NVQs). The Registered Manager confirmed that recruitment processes were robust in that two written and two verbal references were obtained, as well as a check against the Protection of Vulnerable Adults (POVA) list and a Criminal Records Bureau (CRB) check. She confirmed that no staff were left unsupervised until a satisfactory CRB check was obtained. South Efford House DS0000061893.V285288.R01.S.doc Version 5.1 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, 33, 35, 36 and 38 The Registered Manager has a good understanding of where the home needs to improve and works closely with the owners to ensure the improvements take place. EVIDENCE: The Registered Manager has been managing the home since December 2004 and was registered with the Commission for Social Care Inspection in February 2006. She was undertaking a National Vocational Qualification (NVQ) in Care and expects to complete this in April 2006. Once completed she intends to commence the Registered Manager’s Award. Service users’ meetings have been held in the past but these were not successful therefore the Registered Manager now talks to service users individually to seek their views. A discussion took place about arranging meetings in a more informal way, for example, during meal times. The South Efford House DS0000061893.V285288.R01.S.doc Version 5.1 Page 16 Registered Manager confirmed that staff meetings were held and one-to-one supervision took place with all staff members. The service users’ financial affairs were managed by the service users themselves or their representatives. Service users were provided with staff support and transport to access financial institutions in the local town of Kingsbridge. Where monies were held in safekeeping for service users there were clear records kept of incoming and outgoing payments. Routine health and safety issues were managed satisfactorily. 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. The Registered Manager confirmed that all staff had received fire safety training within the last few months. Advice was given to make sure that the steps of external fire exits were kept free of algae as these may become slippery. Staff also received training in manual handling and first aid. Substances hazardous to health were locked away safely. The Registered Manager confirmed that temperature control valves have been fitted to all hot water outlets accessible to service users. Records showed that the temperature of the hot water was being checked regularly to ensure that the water was around 43°C. The Registered Manager confirmed that a local contractor has carried out legionella testing. A new gas supply has been connected to the property and kitchen equipment has been upgraded. The Registered Manager confirmed that the Responsible Individual for the company visits the home on a monthly basis to ensure that standards are maintained, however copies of the written reports of these visits were not available in the home. South Efford House DS0000061893.V285288.R01.S.doc Version 5.1 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 X 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 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 3 3 2 3 3 2 3 3 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 3 X 3 South Efford House DS0000061893.V285288.R01.S.doc Version 5.1 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. Standard Regulation Requirement Timescale for action 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. Consideration should be given to creating another assisted bathroom on the ground floor or making the existing bathroom more comfortable and useable. The Registered Provider should install locks on bedroom doors suited to service users’ capabilities and accessible to staff in an emergency. 2. OP24 South Efford House DS0000061893.V285288.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay 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 DS0000061893.V285288.R01.S.doc Version 5.1 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. 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!