Inspection on 14/12/06 for Staveley House Residential Care Home

This inspection was carried out on 14th December 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

Staveley House Residential Care... 16/12/09

Staveley House Residential Care... 17/09/07

Staveley House Residential Care... 21/11/05

Staveley House Residential Care... 10/08/05

Staveley House Residential Care... 12/01/05

Staveley House Residential Care... 02/06/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Staveley House Residential Care Home Greystone Lane Dalton-in-Furness Cumbria LA15 8QQ Lead Inspector Ray Mowat Unannounced Inspection 08:00 14 December 2006 th 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 Staveley House Residential Care Home DS0000022661.V312781.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. Staveley House Residential Care Home DS0000022661.V312781.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Staveley House Residential Care Home Address Greystone Lane Dalton-in-Furness Cumbria LA15 8QQ 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) 01229 468210 Abbeyfield Furness Extra Care Society Limited Mrs Carmela McCullagh Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Staveley House Residential Care Home DS0000022661.V312781.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st November 2005 Brief Description of the Service: Staveley House is registered to provide residential accommodation and personal care for up to 31 older people. It is owned and operated by the Abbeyfield Furness Extra Care Society Limited, through a volunteer executive committee and is member of the national Abbeyfield charity. The home is situated on the edge of a residential housing estate, on the outskirts of Dalton-in-Furness, Cumbria. It is a purpose built two-storey building, with two passenger lifts giving access to the first floor. All the rooms are single occupancy and have en-suite shower and toilet facilities. There are also two communal bathrooms with accessible bathing facilities. There are two large lounges, one on each floor, with a further four smaller lounges, one of which is a dedicated smoking area. In addition there is a spacious dining room. There is ample parking to the side of the home and a large, private well-kept garden area to the rear, which is fully accessible, with seating and patio areas, which are used extensively in the summer months. The home provides suitable information to prospective residents in an informative brochure and residents handbook. The current level of fees charged range from £363 to £398, with additional charges for personal expenses such as hairdressing and toiletries. Staveley House Residential Care Home DS0000022661.V312781.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on the 14th December at 8am. This enabled me to see the morning routines of the home. During the day I met with many of the residents, either in the communal areas of the home or in their own rooms. I also joined a group of residents for lunch in the dining room. As part of this inspection surveys were received from residents and relatives.I spent time talking to staff as they went about their duties and also met with staff on their own. I spent time with the manager and assistant manager and looked at records relating to the running of the home. What the service does well: What has improved since the last inspection? What they could do better: The daily notes recorded by staff should describe the care provided during that shift. The records relating to pressure care should describe what treatment is required and how it should be done. Staveley House Residential Care Home DS0000022661.V312781.R01.S.doc Version 5.2 Page 6 Some of the policies in the home that guide staff about how they do their job should be looked at on a regular basis to make sure they are up to date. When risk assessments are looked at and changes have happened the risk assessment should be updated. 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. Staveley House Residential Care Home DS0000022661.V312781.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 Staveley House Residential Care Home DS0000022661.V312781.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): 1, 2, 3, 4, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. It was evident the home has good systems in place to make sure they can meet the needs of residents. People were making informed choices about moving into the home. EVIDENCE: The home provides residents and prospective residents with a resident’s handbook and brochure that gives people all the information they need to know to make an informed choice about moving into the home. The home also has two respite care beds, which enables people to “test drive” the home before choosing to move in. Since the last inspection the manager has closely monitored the needs of people using the respite service to ensure the resources within the home can meet their needs. The manager or assistant manager complete a detailed assessment prior to people being offered a place. This is in addition to a Social Work assessment or any other specialist assessments in place. This records information relating to people’s personal and healthcare needs and provides the home with enough information to make a judgement about the home’s ability to provide a suitable Staveley House Residential Care Home DS0000022661.V312781.R01.S.doc Version 5.2 Page 9 service. In the three files I examined, including a resident who had only recently moved into the home, assessments were completed including manual handling risk assessments and contracts of terms and conditions had been agreed and signed. Two of the residents I spoke with explained how they had chosen the home, one had previous experience of the home and the other had “arranged a visit”. Staveley House Residential Care Home DS0000022661.V312781.R01.S.doc Version 5.2 Page 10 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): 7, 8, 9, 10, 11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. On the whole the home ensures individuals personal and healthcare needs are recorded and responded to appropriately. Daily recordings and pressure care information need to be strengthened. EVIDENCE: Using information from the various assessments the home develop and agree with residents an individual care plan. These also include a brief pen picture, which gives staff an insight to the residents past and things that are important to them and that they value. They also contained detailed manual handling risk assessments and falls risk assessments. These were useful in guiding staff to support residents in a safe and consistent manner. A record of all health related interventions were in place with the outcome of the visit or appointment recorded. These included visits from the GP, District Nurse, Continence Nurse and the Chiropodist. Residents I met said “they can contact their GP anytime, the staff are always helpful”. Daily diary notes are used to monitor situations on a day-to-day basis between shifts. Some of these had relevant recordings in them, however some only had brief notes such as “uneventful shift”. This is not good practice Staveley House Residential Care Home DS0000022661.V312781.R01.S.doc Version 5.2 Page 11 and does not provide enough detail for the next staff group coming on shift. It is recommended the home review their practice and ensure all staff are making appropriate recordings with sufficient detail about the care provided. The home records and monitors the weight of all residents ensuring appropriate action is taken in response to fluctuations in weight. It was evident from the notes in one residents file that they were at risk from pressure sores, although the home had taken action and involved other agencies, the pressure care records/management plan in the care plan needs to be improved. It is recommended that anyone at risk from pressure sores should have an appropriate management plan, including advice and treatment, to guide staff. The home has sound systems in place to manage and administer the medication held in the home. Residents choosing to self medicate have a risk assessment completed. I examined the medication records and found these to be up to date and in order. Residents’ religion and beliefs including wishes upon death are also recorded in the care plan. Staveley House Residential Care Home DS0000022661.V312781.R01.S.doc Version 5.2 Page 12 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): 12, 13, 14, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home supports and encourages residents to pursue a fulfilling and independent lifestyle. EVIDENCE: Based on my own observations and discussions with residents the home on the whole provides a good range of activities, both in the community and in the home. They have an active group of volunteers who support the staff in providing activities and supporting residents. There were photographs of a recent musical show performed by the staff for the residents. A lot of thought and effort had been put in by the staff to make this a success, which was obviously appreciated by the residents. Other Christmas activities were planned such as Christmas shopping, a Christmas party night, another Christmas concert by a visiting group and a carol service in the home by the local school choir. There were also plans for a couple of trips, one to the local church and another for a meal to a local hotel. Residents were aware of and looking forward to these events. Residents also talked about other activities they enjoyed which included movement to music exercise sessions, flower arranging and craft activities. Staveley House Residential Care Home DS0000022661.V312781.R01.S.doc Version 5.2 Page 13 I joined a group of residents for lunch in the dining room. There was a choice of two hot meals and a dessert. Residents I spoke to all agreed that the food was “good and varied”. The kitchen is well equipped and managed and was found to be clean and hygienic. There were good systems in place to maintain the safety and cleanliness of the kitchen and the storage and cooking of the food. The home has a four-week rolling menu, which has been agreed with residents based on feedback from residents meetings, surveys and individual comments. Special diets such as low fat and diabetic are catered for with clear records maintained of all the food provided. The cooks use a message book to communicate changes or issues of concern. Staveley House Residential Care Home DS0000022661.V312781.R01.S.doc Version 5.2 Page 14 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): 16, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although the mistreatment policy is in need of updating there was evidence that resident’s complaints are listened to and people are safeguarded from abuse. EVIDENCE: The home’s complaints procedure is displayed in the hall and is included in the information in the resident’s handbook. There have been three complaints recorded since the last inspection. These had been investigated by the manager, with a record of the investigation and outcome recorded on the file. The home had obtained copies for all the staff of the new local authority multiagency procedure and guidelines for safeguarding vulnerable adults. There was evidence of staff receiving specific training in this area as well as staff covering this subject as part of their NVQ qualification. Based on discussions with staff they were aware of their responsibilities in identifying and reporting abuse. I examined the home’s policy and procedure relating to mistreatment and abuse of vulnerable adults. It was evident the policy and procedure need to be reviewed and updated to ensure they are in line with recent legislation and good practice guidance. Staveley House Residential Care Home DS0000022661.V312781.R01.S.doc Version 5.2 Page 15 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): 19, 20, 21, 22, 23, 24, 25, 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staveley house provides a high quality living environment that is well maintained and suitable for the needs of the current residents. EVIDENCE: Staveley House provides a good quality living environment for the residents. It is decorated and furnished to a good standard throughout. It is well maintained with a handyman available on a regular basis to respond to repairs and maintenance issues. There is a good choice of communal space in the home, which provides a range of different environments for the residents to relax and socialise. There is also a designated smoking area in one of the small lounges. Access throughout the home is good with two passenger lifts to the first floor. On the first floor there is a kitchenette for residents to use to make drinks and snacks, which encourages people to retain their independence. Specialist equipment is in place to maintain resident’s mobility and independence. Staveley House Residential Care Home DS0000022661.V312781.R01.S.doc Version 5.2 Page 16 Staff have their own locker and there is a well equipped staff room where breaks can be taken. The laundry is well ordered with suitable industrial size machines to cope with all the laundry from the home. The resident’s rooms were nicely decorated with residents personalising the rooms with their own furniture and belongings. The home had been tastefully decorated for the Christmas festivities, which the residents appreciated. Staveley House Residential Care Home DS0000022661.V312781.R01.S.doc Version 5.2 Page 17 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): 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. Staveley House have a well-trained and knowledgeable staff team who provide a safe and reliable service that meets the resident’s needs. EVIDENCE: Based on the staff rotas the home has maintained an appropriate level of staff to meet the needs of the residents. On the whole there is a long-standing staff team with a low turnover of care staff. There are also dedicated teams of staff for the cleaning and domestic roles. New staff are fully inducted to the routines of the home and the residents. I examined staff records for all the staff that have been appointed since my last inspection. These were all up to date and contained all relevant information as required by the National Minimum Standards. Contracts had been issued and signed and job descriptions were in place. There are regular staff meetings held to enable staff to raise issues of concern or good practice and also to keep each other up to date on events and changes in the home. A newsletter is also produced on a regular basis, which reinforces the information from the meetings and notifies the team of any other relevant events and information. Senior staff also meet on a regular basis separate to this meeting. Staveley House Residential Care Home DS0000022661.V312781.R01.S.doc Version 5.2 Page 18 All staff have a file for recording their training and development needs and courses attended, with copies of certificates held on file. These records reflected a good level of training being provided in both the core subjects and in specialist areas. Residents and relative’s comment cards talked about a “thoughtful and caring staff team who make it an excellent home”. Staveley House Residential Care Home DS0000022661.V312781.R01.S.doc Version 5.2 Page 19 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): 31, 33, 35, 36, 37, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed effectively, with the manager working closely with the senior team. Residents feel safe and are contributing to the day to day running of the home. EVIDENCE: The manager is suitably experienced and qualified to manage the home efficiently and effectively. She works closely with the deputy and senior staff to ensure residents receive a consistent and reliable service. An annual quality assurance survey is issued each year, which gives people the opportunity to feedback to the management about the quality of the service received. Regular residents meetings are also held in addition to staff consulting with people on an individual basis. I examined the minutes of meetings that included discussions about future plans for the home, day trips and activities. There was also a note about the recent 50th anniversary celebration tea, which had been enjoyed by residents and friends. Staveley House Residential Care Home DS0000022661.V312781.R01.S.doc Version 5.2 Page 20 I looked at records required by regulation for the running of the home. All servicing and maintenance records were up to date and accurate ensuring the safety of residents and staff. This included gas, electric and water services as well as the equipment within the home. The home has appropriate risk assessments in place to maintain a safe environment. However it is recommended when the risk assessments are reviewed and changes are recorded on the review sheet, these changes are incorporated into the assessment. This had not happened on some manual handling and falls risk assessments examined, which will cause confusion and could impact on residents care. The home was aware of the changes to the Fire regulations and has produced a risk assessment in line with the new guidance. The fire logbook was checked and was also up to date and in order with servicing of fire equipment completed. Training and drills with residents and staff had taken place in addition to staff completing a questionnaire to test out their competence and understanding. The staff notice board displayed appropriate notices and polices to keep staff informed. However when examining the policies and procedures file of the home it was evident that some of them are in need of review. It is recommended policies be reviewed at least annually. Staveley House Residential Care Home DS0000022661.V312781.R01.S.doc Version 5.2 Page 21 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 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 3 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 4 4 4 4 3 4 4 4 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 2 2 Staveley House Residential Care Home DS0000022661.V312781.R01.S.doc Version 5.2 Page 22 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 2 3 Refer to Standard OP7 OP8 OP18 Good Practice Recommendations It is recommended the home review the content of daily diary notes and ensure all staff are making appropriate recordings with sufficient detail about the care provided. It is recommended that anyone at risk from pressure sores should have an appropriate management plan, including advice and treatment, to guide staff. It is recommended the home’s mistreatment and abuse of vulnerable adults policy and procedure, need to be reviewed and updated to ensure they are in line with recent legislation and good practice guidance. It is recommended the policies of the home be reviewed at least annually. It is recommended when the risk assessments are reviewed and changes are recorded on the review sheet, these changes are incorporated into the assessment. 4 5 OP37 OP38 Staveley House Residential Care Home DS0000022661.V312781.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP 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. 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