Inspection on 29/09/05 for Sovereign House

This inspection was carried out on 29th 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

Sovereign House 18/05/09

Sovereign House 17/04/07

Sovereign House 09/01/06

Sovereign House 11/01/05

Sovereign House 21/06/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Sovereign House 30 Canterbury Road Herne Bay Kent CT6 5DJ Lead Inspector Tina Thomas Announced 29/09/05 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. Sovereign House H56-H05 S23564 Sovereign House V241037 290905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Sovereign House Address 30 Canterbury Road, Herne Bay, Kent, CT6 5DJ 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) 01227 368796 01227 368796 Mr Hassan Ibrahim Mrs Louise Ibrahim Registered Care Home 10 Category(ies) of Care Home for Older People registration, with number of places Sovereign House H56-H05 S23564 Sovereign House V241037 290905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11/01/05 Brief Description of the Service: Sovereign House is a detached Property. It is situated only two minutes from the Beach or Town. The Home is Registered for Ten Service Users. The Home has eight en-suite single rooms and two rooms with adjoining bathrooms. Accommodation is situated on three floors. The Home is well decorated and maintained. The Home has a shaft lift. The Home has a grassed front garden and a concreted rear garden. The Home is owned by Mr and Mrs Ibrahim and they are the Registered Providers, Mrs Ibrahim is the Registered Manager. Sovereign House H56-H05 S23564 Sovereign House V241037 290905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspector conducted this inspection over a one day period. The inspector spoke with the Manager, people who live in the home and staff. The inspector viewed documentation including staff files, care plans of the people that live in the home and policies. Of the Standards that were inspected all except one was met. 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. Sovereign House H56-H05 S23564 Sovereign House V241037 290905 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 Sovereign House H56-H05 S23564 Sovereign House V241037 290905 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) 3 People move into the home knowing that their needs can be met and that their independence will be maximised and promoted. This home does not provide the service described in standard 6. EVIDENCE: The inspector viewed care plans, which showed clearly that pre admission assessment visits had been completed. The manager together with one of the two senior carers completes the pre admission assessments. They visit people in their own homes or as is becoming more frequent, visit people in hospital. The Manager often visits people in hospital more that once, to ensure that they get to know her, and the ethos of the home. This is also to allow both parties to make an informed decision. The Manager also obtains a summary of the Care Management assessment. The inspector viewed the pre-admission assessment tool used by the home. Information gathered is of good quality. The inspector discussed with the manager areas that she might choose to strengthen. Sovereign House H56-H05 S23564 Sovereign House V241037 290905 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) 7,8,9,10 The care planning system is clear and consistent and provides staff with the information they need to meet the health and social needs of people that live in the home. However, the psychological needs are not. People that live in the home feel that they are treated with dignity and respect. The home has policies and procedures for the administration of medication. EVIDENCE: The inspector viewed a selection of care plans and found them to be of good quality. Personal goals are reflected in individual plans, which describe how staff should assist and enable people who live in the home, any potential risks are suitably managed. For example care plans have manual handling risk assessments. Care plans are regularly reviewed on a monthly basis. Visits by other health care professionals are recorded. One care plan showed that a person in the home was having acupuncture treatment. Each person has in his or her care plan a social activities report. People that live at the home have signed agreement of their care plans. The inspector discussed with the manager that the home seek further guidance regarding one persons mental health needs, so that they can more suitably plan this persons care. Recommendation made regarding this matter. (Recommendation 1 Part A). It may also be necessary to apply for a variation of registration. Sovereign House H56-H05 S23564 Sovereign House V241037 290905 Stage 4.doc Version 1.40 Page 9 The inspector noted that one entry on a daily record sheet had been covered over by tippex. This is considered to be poor practice. All errors should be scored through once and initialled. Recommendation made regarding this matter. (Recommendation 2 Part A). Sovereign House H56-H05 S23564 Sovereign House V241037 290905 Stage 4.doc Version 1.40 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) 12,13,14, People who live in the home find the lifestyle experience matches their expectations. They are helped to exercise choice and control over their lives. Social, cultural, religious and recreational interests and needs are met. Service users maintain contact with people of their choice, and the local community as they wish. EVIDENCE: The inspector spoke to a person who lived in the home who expressed that she was contented in the home and it exceeded her expectations of life in a home. The Manager, staff and a service user confirmed that people that live in the home are encouraged to have choice. They choose when they get up, go to bed, what they wear and what they eat. Their likes and dislikes are recorded in their care plans. The home has regular, recorded and actioned meetings for the people that live there so that they can influence matters at the home. All the people that live in the home or their families with the exception of one person looks after their own finances. Within the service user guide and on the notice board there is guidance on how to contact an outside advocate if necessary. Sovereign House H56-H05 S23564 Sovereign House V241037 290905 Stage 4.doc Version 1.40 Page 11 The inspector saw that people who live in the home bought with them some items of their own furniture or possessions so that they could personalise their own rooms. People that live in the home can have visitors when they choose. Eight visitors completed a Commission comment card. Each reflected that they were always made welcome at the home. Sovereign House H56-H05 S23564 Sovereign House V241037 290905 Stage 4.doc Version 1.40 Page 12 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 The home investigates complaints in a suitable manner in line with its own complaints procedure. Service users are protected from abuse. EVIDENCE: The home has had no complaints since the last inspection. The Manager is in daily contact with the people in the home. One person expressed that ‘Louise and Hassan (Mr and Mrs Ibrahim) would bend over backwards to get you anything you want’ Relatives comment cards and comment cards form people that live in the home indicate that people know about the homes complaints procedure and would feel comfortable to approach the Manager if they had a complaint. One comment card reflected ‘ I have the sense that the manager is very discreet, I feel able to discuss sensitive issues with her.’ Staff have been trained in the prevention of adult abuse. This has been a combination of modules completed within their N.V.Q training and some stand alone training. Staff the inspector spoke with demonstrated an understanding of adult protection protocols. The inspector viewed the homes Whistle-blowing policy and found it to be adequate. Sovereign House H56-H05 S23564 Sovereign House V241037 290905 Stage 4.doc Version 1.40 Page 13 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, 20,21,23,24,25,26 The standard of the environment within the home is good providing Service Users with an attractive, safe and homely place to live. EVIDENCE: The home is suitable for its purpose. The home is clean and well maintained. Furnishings, carpets and decoration were of good quality. There are no offensive odours throughout. People that live in the home have access to a communal lounge and a dinning room. The Home has a passenger lift to enable people to access all parts of the home. Eight of the Service Users rooms are en-suite. The remaining two both have adjoining bathrooms. The Inspector viewed bathrooms and toilets within the Home; they were all clean and tidy. Radiators are all covered so as to prevent risk of scalds and burns. Sovereign House H56-H05 S23564 Sovereign House V241037 290905 Stage 4.doc Version 1.40 Page 14 Individual bedrooms are clean, homely and personalised. People the inspector spoke with said they found them suitable for their needs and were happy with their rooms. The Home has a small purpose built laundry. The laundry floor and finishes are impermeable and walls easily cleaned. The washing machines have the specified programming ability to meet disinfection standards. Sovereign House H56-H05 S23564 Sovereign House V241037 290905 Stage 4.doc Version 1.40 Page 15 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 The needs of those living at the home are met by appropriate numbers and skill mix of staff. The homes recruitment and selection process protects people that live at the home. Staff are trained and competent to do their jobs. EVIDENCE: The staff rota indicates that staffing numbers and skill mix of staff are appropriate to the assessed needs of the service users, the size, layout and purpose of the home. The Inspector spoke with staff that indicated that they thought the home was always adequately staffed and that they had suitable time to spend with the people who live in the home. 40 of staff are Qualified to NVQ Level 2 or above. The Manager is aware that 50 of staff need to be qualified to NVQ Level 2 by the end of 2005 to meet with National Minimum Standards. All new staff complete a TOPSS certified one day training course. The homes induction is linked to TOPSS (now known as Skills for care). The home has a robust recruitment procedure based on equal opportunities and ensuring the protection of service users. Each member of staff has a CRB check and two references in place, prior to confirmation of post. Sovereign House H56-H05 S23564 Sovereign House V241037 290905 Stage 4.doc Version 1.40 Page 16 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) 33,35,38 The home is run in the best interests of the people that live there. People that live in the homes financial interests are safeguarded. The health, safety and welfare of service users is promoted and protected. EVIDENCE: The home endeavours to ensure a quality assurance process. The Manager has implemented a questionnaire. The results are formatted into a pie chart. These are discussed with staff. Supervision, team meetings, resident meetings and inspections also play a role in the homes quality assurance process. As previously mentioned the home only assists one service user with their finances. Written records of all transactions are maintained. Where the money of individuals is handled, the manager ensures that the personal allowances of these service users are not pooled and appropriate records and receipts are kept. All transactions are double signed. Staff are well trained and supervised. The Manager meets with the people that live in the home on a daily basis when she is on duty. Sovereign House H56-H05 S23564 Sovereign House V241037 290905 Stage 4.doc Version 1.40 Page 17 The inspector viewed a number of records including staff and service user files that were well maintained in line with the homes own policies. The Inspector observed that the Home is kept in a secure manner. The Manager as far as reasonably practicable ensures compliance with relevant legislation to ensure that the health, safety and welfare of Service User and staff is promoted and protected. The Inspector noted that whilst carers have training in manual handling it has considerable shortfalls. This was discussed with the Manager. Requirement made regarding this matter. (Requirement 1 Part A). Sovereign House H56-H05 S23564 Sovereign House V241037 290905 Stage 4.doc Version 1.40 Page 18 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 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 3 3 x 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x 3 x x 2 Sovereign House H56-H05 S23564 Sovereign House V241037 290905 Stage 4.doc Version 1.40 Page 19 NO 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 38 Regulation 13 (5) Requirement All staff must have suitable manual handling training. Timescale for action 29/11/05 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. 2. Refer to Standard 7 7 Good Practice Recommendations The home should seek further guidance regarding one persons mental health needs so that they can more accuratly monitor and record and plan this persons care. Mistakes on daily records should not be obliterated by tippex Sovereign House H56-H05 S23564 Sovereign House V241037 290905 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection 11th Floor International House Dover Place Ashford Kent TN23 1HU 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 Sovereign House H56-H05 S23564 Sovereign House V241037 290905 Stage 4.doc Version 1.40 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!