Inspection on 07/11/05 for Strathmore House

This inspection was carried out on 7th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Strathmore House 08/09/08

Strathmore House 11/10/07

Strathmore House 18/04/07

Strathmore House 10/11/06

Strathmore House 19/04/06

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Strathmore House Friday Bridge Road Elm Near Wisbech Cambridgeshire PE14 0AU Lead Inspector Mrs Jenny Cangy Unannounced Inspection 7th November 2005 12:00 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 Strathmore House DS0000066352.V265237.R01.S.doc Version 5.0 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. Strathmore House DS0000066352.V265237.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Strathmore House Address Friday Bridge Road Elm Near Wisbech Cambridgeshire PE14 0AU 01945 860569 01945 860202 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) Ashbourne (Eton) Limited Care Home 46 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (46), of places Terminally ill over 65 years of age (25) Strathmore House DS0000066352.V265237.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Maximum of 25 TI(E) beds Maximum of 20 DE(E) beds Maximum of 46 OP Date of last inspection 14/06/05 Brief Description of the Service: Strathmore House is situated in secluded mature gardens set back from the road between the villages of Elm and Friday Bridge. It is a large 18th century house that has been extended beyond its original to provide the present facilities. Accommodation in the old house is on two floors with the first floor being accessed by a shaft lift There is a variety of sitting areas and a dining room. The extended area of the house is single story and within this area is a self contained unit for older people with dementia. A detached bungalow next to the main house has accommodation for six people. Strathmore House DS0000066352.V265237.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection which was unannounced commenced at 12 noon with the inspector and the acting manager who is also the care manager/deputy. A follow up of the requirements from the last inspection and check of some records took place in the managers office. A discussion of the outcome and progress following recent Protection of Vulnerable Adults (POVA) action when a decision was taken by both Cambridgeshire and Norfolk local authorities to suspend placements at the home. A tour of the home followed with some discussion with staff and service users during the tour. There is currently no registered manager. Ashbourne (Eton) Limited became the registered provider since the last inspection. What the service does well: What has improved since the last inspection? There has been a great improvement in the corridor of the dementia care unit. This has been redecorated and the badly stained carpets replaced with light laminated flooring. Damage to doors and doorframes have been repaired and doors are now clearly marked with numbers and the names and photographs of the occupants. The front entrance area and stairs have been re-carpeted greatly improving the appearance. The garden serving the dementia care unit has been made secure and raised flower beds are in place for future use. All care plans have been updated and transferred to Ashbourne Care Homes corporate format. New staff induction training is in place as is ongoing staff training. The dementia care unit staffing has greatly improved. Strathmore House DS0000066352.V265237.R01.S.doc Version 5.0 Page 6 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. Strathmore House DS0000066352.V265237.R01.S.doc Version 5.0 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 Strathmore House DS0000066352.V265237.R01.S.doc Version 5.0 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): 1,3 & 4 Service users and their representatives have sufficient information to know their social and care needs can be met. Intermediate care is not provided. EVIDENCE: The statement of purpose and service user guide is in each bedroom and contains the required information. All prospective service users have a needs led assessment prior to admission conducted by the care manager and a senior carer or nurse. A letter confirming that the home is able to meet their needs is sent to each new service user. Strathmore House DS0000066352.V265237.R01.S.doc Version 5.0 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, 9, 10 & 11 All health care needs are met but care planning in incomplete in some cases. EVIDENCE: All service users have access to all community health care services as required. Care plans are informative and detailed. However there is no evidence that the care plans are compiled with the service user or their representative or that they have been agreed by them. Although there is a care plan format in respect of final illness, death and dying on the whole these have not been completed. This is unacceptable especially in a home that is registered to provide care for terminal illness. Palliative care training should be in place and care plans detailed to evidence this. Strathmore House DS0000066352.V265237.R01.S.doc Version 5.0 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 & 15 Service users have opportunities to participate in social, religious and cultural activities. Food provided meets requirements. EVIDENCE: Catering is provided by a contract catering company. Menus are varied and offer choices to service users. The menus reflect a well balanced diet. The acting manager stated that there are plans to alter meal times slightly to ensure the time between meals is more evenly balanced. The activity co-ordinator was leaving at the end of the week and another has been recruited to replace her. Activities will be inspected again at the next inspection to ensure an adequate programme of activities is in effect following this key staff change. On the day of inspection it was observed that the activity co-ordinator was visiting the home with pet cats for the service users to interact with and the service users were enjoying this. Strathmore House DS0000066352.V265237.R01.S.doc Version 5.0 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 Formal complaints are acted on according to the company complaint procedure. EVIDENCE: Following discussion with the acting manager it was evident that formal complaints are investigated and followed up in accordance with the complaint procedure. However there is no evidence that there is a system for ensuring that informal and verbal complaints are adequately recorded or acted on unless they are taken directly to the management team. This was discussed with the acting manager who stated she would ensure a method of recording and investigating these complaint will be put into place and staff instructed accordingly. Strathmore House DS0000066352.V265237.R01.S.doc Version 5.0 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, 23, 24, 25 & 26 Some improvement in the standards of the environment is still needed although there has been a significant improvement. EVIDENCE: Some areas of the home have been redecorated and re-carpeted making a significant improvement in the appearance. However there is still a lot of outstanding work required. The acting manager stated a programme is in place. The call bell system is not fully functional and is awaiting replacement. This should be completed as a matter of urgency. The access to the gardens remain hazardous with ramps too steep and drops at the edges of the ramp presenting a tripping hazard to anyone in the garden and a risk of falling to anyone using the ramps unattended. Some improvement to the garden s has been made with raised flower beds in place. There are three shared rooms and portable screens are available in each of these rooms. Not all bedrooms are fitted with locks to ensure service users have privacy. The entrance to Snowdrop Cottage has an uneven surface caused by a deep mat well. The mat in place is too thin creating a tripping hazard. A mat of the correct thickness or a levelling of the surface is urgently needed. All areas of the home were clean and fresh. Strathmore House DS0000066352.V265237.R01.S.doc Version 5.0 Page 13 Strathmore House DS0000066352.V265237.R01.S.doc Version 5.0 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, 29 & 30 The home is adequately staffed by a good skill mix of staff. EVIDENCE: Staff are employed in sufficient numbers to ensure all service users needs can be met. These are made up of qualified nurses care staff domestic and catering staff. There are a minimum of seven staff on duty in the home during the day and 5 in the evening and overnight. Any shortfalls in staffing due to annual leave or sickness are made up with the use of agency staff. All prospective staff have to give two references, proof of identity and have a Protection of Vulnerable Adults register and Criminal Records Bureau enhanced check and gaps in employment history are explored. All staff undergo induction training and there is an ongoing training programme in place including NVQ in care. On the day of inspection good staffing levels were observed. Strathmore House DS0000066352.V265237.R01.S.doc Version 5.0 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, 32, 33, 35 & 36 There is no manager in post but the Acting Manager is also the care manager/deputy and is familiar with the home and providing adequate management. EVIDENCE: The home is without a registered manager. An application to register a manager should be submitted to the Commission. The acting manager is familiar with the home, staff and service users and has been in post for over a year. With the support of her line manager and a manager of another home Strathmore House is being adequately managed while a new manager is being recruited. The Proprietors are taking steps to ensure the home is upgraded to meet the highest standards although this work is not yet complete. The acting manager had no knowledge of any current quality assurance programme and formal staff supervision is not as regular as it should be at the moment. Strathmore House DS0000066352.V265237.R01.S.doc Version 5.0 Page 16 Service users financial interests are safeguarded by the company policies and procedures. Strathmore House DS0000066352.V265237.R01.S.doc Version 5.0 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 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X 2 2 X X 3 2 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 2 2 1 X 3 2 X X Strathmore House DS0000066352.V265237.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? yes 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 OP7 Regulation 15 Requirement Care plans must show evidence that they have been compiled and/or reviewed with the knowledge and agreement of the service user in the form of a signature of the service user or their representative Care plans must include a plan showing the service users wishes regarding final illness, death and dying A method of recording and investigating minor and verbal complaints must be established to ensure all complaints are acted on. Staff must all be aware of this method and ensure all complaints are recorded appropriately All areas of the home must be well maintained and decorated The gardens must be maintained and kept safe and accessible to all service users. The gardens must be accessible to service users before Summer 2006 with safe ramps to access the garden. This is outstanding from the last inspection with a DS0000066352.V265237.R01.S.doc Timescale for action 30/12/05 2 OP11 12(3) 30/12/05 3 OP16 22 30/12/05 4 5 OP19 OP20 23(2(b)) 23(2(b)) 30/12/05 01/05/06 Strathmore House Version 5.0 Page 19 6 OP24 23(2(e)) 7 OP33 24 8 OP31 8 completion date of 30th July 2005 any further failure to comply will result in regulatory action being taken. All service users must be able to lock their doors from both within and out if they wish to. The Registered person must provide a programme of action to the CSCI to demonstrate this is in hand. The registered person must provide the CSCI with a copy of the quality assurance programme and the latest report. An application to register a manager should be submitted to the Commission 30/01/06 30/01/06 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Strathmore House DS0000066352.V265237.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE 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 Strathmore House DS0000066352.V265237.R01.S.doc Version 5.0 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. 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