Inspection on 08/02/06 for Straven House

This inspection was carried out on 8th February 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Straven House 28/11/07

Straven House 22/02/07

Straven House 22/04/05

Straven House 02/12/04

Straven House 11/05/04

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

CARE HOMES FOR OLDER PEOPLE Straven House Queens Road Ilkley West Yorkshire LS29 9QL Lead Inspector Nadia Jejna Unannounced Inspection 12:30 8 February 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 Straven House DS0000001170.V272867.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. Straven House DS0000001170.V272867.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Straven House Address Queens Road Ilkley West Yorkshire LS29 9QL 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) 01943 607063 01943 600708 BUPA Care Homes (GL) Ltd Mrs Jennifer Bland Care Home 24 Category(ies) of Dementia - over 65 years of age (2), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (1), Old age, not falling within any other category (21), Physical disability over 65 years of age (1) Straven House DS0000001170.V272867.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The place for MD(E) is only for the use of the service user named in connection with the variation application of 13.1.05 22nd April 2005 Date of last inspection Brief Description of the Service: The home is an adapted detached property set in its own grounds on the outskirts of Ilkley. It is registered to provide care to twenty-four residents of either sex over the age of 65, care can be provided for up to two people with dementia and one person with a physical disability. Nursing care is not provided. Two shared rooms are used as singles therefore occupancy is limited operationally to twenty-two. Accommodation is provided on the ground and first floors. There is a passenger lift, which can be used by residents to access the first floor and the lower ground floor where the dining room, kitchen and laundry are located. There are large attractive gardens but not all areas are accessible to residents; three patio areas have been provided, one of which has raised flower beds and another which can be accessed via the dining room has views across the valley. Ramps are available in the gardens and provide level access for wheelchair users into the building. A local bus route is near by and Ilkley town centre is within walking distance although this is a steep road. Straven House DS0000001170.V272867.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Over an inspection year from April until March, care homes have a minimum of two inspections a year; these may be announced or unannounced. The last inspection was unannounced and took place on the 18th October 2005. This inspection was unannounced. It started at 10:15am and ended at 3:00pm on 8th February 2006. The people who live in the home prefer the term residents, and this is the term that will be used throughout this report. The purpose of this inspection was to monitor the home’s progress and to assess whether the care given to residents meets minimum standards. The manager had completed a pre inspection questionnaire (PIQ), which provided information about the home including maintenance schedules, staff details, training given and policies and procedures. During the inspection records were examined and care staff were seen carrying out their work. Discussions were held with members of staff, the manager, residents and visitors. Comment cards/questionnaires were left for residents and visitors so that they can share their views of the home with the CSCI. None had been returned when this report was written. What the service does well: The home provides a good standard of care to residents in a comfortable and well-maintained environment. Current and potential residents can easily access information about the home and services provided. Residents said that they were happy with the care provided, that the food was good and the home was always clean and tidy. They said that the staff were kind and caring, polite and respectful and that staff always knock on doors before entering rooms. It was clear that there were good relationships between residents and staff. One of the residents could not think of anything that could make their experience of living in the home better, apart from better weather so they could get outside more, as it was all good. Visitors said that they could visit at any time and that they were always welcomed. They were satisfied with the care and services being provided to their relatives. The manager and staff work closely with GP’s and other healthcare professionals to make sure that resident’s healthcare needs are met. Straven House DS0000001170.V272867.R01.S.doc Version 5.0 Page 6 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. Straven House DS0000001170.V272867.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 Straven House DS0000001170.V272867.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 Residents are provided with information to enable them to make an informed choice about the home. EVIDENCE: Current and potential residents can easily access information about the home. All bedrooms have a file containing useful information, which includes the Statement of Purpose and Service User Guide as well as the terms and conditions of residence and an introduction to the home and services provided. Straven House DS0000001170.V272867.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 and 10 Resident’s needs are met but the care plans would show this more clearly if they contained detailed information. Staff treat residents with dignity, maintain their privacy at all times. EVIDENCE: Two care plans were looked at. These showed that staff had worked hard to improve the information they provide and that either the resident and or their relatives had been involved. Plans were in place for most residents identified needs and it was clear that they were moving towards providing more detailed, individual, person centred care plans. The manager said that this would continue and that care planning training was going to be provided. One of the plans seen showed that the falls prevention team had been contacted for advice about a resident who had fallen frequently. Their advice to help reduce the risk of falling was being followed. The relatives were aware of all actions taken. This is good practice. If residents are identified as at risk of developing pressure sores the district nurses are contacted for advice, support and supply of pressure relieving Straven House DS0000001170.V272867.R01.S.doc Version 5.0 Page 10 equipment. One of the residents had been supplied with a special air mattress and appropriate care plans were in place. Residents said that the staff were polite, respected their privacy and would always knock on doors before entering rooms. This was seen in practice. It was clear that there were good relationships between residents and staff. Straven House DS0000001170.V272867.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 14 and 15. Residents’ choices are respected and contact with family and friends is encouraged. EVIDENCE: Residents said that the food provided was good. One said that they enjoyed the home made soups at tea time. The systems for ordering meals have been changed and residents now make their meal requests the day before. Suitable alternatives are offered if they do not like or want what is on the menu. The PIQ and the chef said that the menus are changed every four weeks; reflect seasonal changes and fresh produce is used as much as possible. The kitchen was clean, tidy and well organised. Residents said that they could choose how to spend their time, when to get up, when to go to bed and where to eat their meals. They said that the staff were kind and attentive and did what they could to meet their needs. One of the residents could not think of anything that could make their experience of living in the home better, apart from better weather so they could get outside more, as it was all good. Straven House DS0000001170.V272867.R01.S.doc Version 5.0 Page 12 Visitors said that they could visit at any time and that they were always welcomed. They were satisfied with the care and services being provided to their relatives. Straven House DS0000001170.V272867.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Residents are aware of the complaints procedure and how to use it. EVIDENCE: A complaints procedure was in place. This is made available to all residents as part of the Statement of Purpose and the useful information file that is kept in every bedroom. The PIQ showed that no complaints had been received since the last inspection. Residents said that they knew what to do and who to speak to should they have cause to complain. Straven House DS0000001170.V272867.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26. Residents are living in a clean, tidy, safe and well-maintained home, which is suitable for their needs. EVIDENCE: The home was clean and tidy. Residents were happy with their rooms and said that they were kept clean and free from smells. The rooms seen were nicely decorated and furnished. It was clear that residents are able to bring their own belongings, and furniture where possible, to personalise their rooms. Straven House DS0000001170.V272867.R01.S.doc Version 5.0 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 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 and 30 Staffing levels in the home did not take into account the physical and psychological needs of residents or the size and layout of the building. EVIDENCE: Residents said that at times the home was short staffed and that the manager was working with the care staff. They said that they did not want to trouble the staff at these times because they were so busy. Staff rotas showed that at weekends there would be two care workers on duty all day. During the week there would be three staff up until 2.00pm and then two until the following morning. The manager often had to work on the floor to make numbers up to three. This is having an impact on her managerial responsibilities. The manager said that resident numbers had dropped to 15 and that this was the reason why staffing levels were reduced. It was clear from the care plans and residents seen that a small number of residents have a high level of physical needs and at least three more residents need a lot of psychological support from staff. One of these residents is at high risk of falling and staff have to check her half hourly when she is restless. The staffing levels in the home did not reflect the needs and numbers of residents or take into account the size and layout of the home. The PIQ showed that five staff have achieved National Vocational Qualification (NVQ) level 2. Four more are working towards it and when they have achieved this the home will have over 50 of staff with NVQ 2 or higher. Straven House DS0000001170.V272867.R01.S.doc Version 5.0 Page 16 The manager said that all staff have now done some training on dementia and some have attended palliative care training. Plans are in place to update training on health and safety related topics as well as to provide training around abuse awareness, nutrition and sight problems. Training about other resident related conditions that must be provided includes arthritis and diabetes. Straven House DS0000001170.V272867.R01.S.doc Version 5.0 Page 17 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): 33, 35 and 38 The home is well managed, the interests of the residents are seen as very important to the manager and staff and are safeguarded at all times. EVIDENCE: Internal quality assurance audits are carried out of systems used in the home and detailed records are kept of the findings and any actions taken as a result. Quality assurance surveys of resident’s views were carried out last year. The results have been collated and are available to interested parties. The manager said that the home does not act as agent or appointee for any of the residents. The PIQ said that one resident handles their own finances. The home will hold money in safekeeping for residents. Appropriate records are kept of the amounts held, spent and returned. Records seen showed that all staff had received fire safety training updates in January 2006. Straven House DS0000001170.V272867.R01.S.doc Version 5.0 Page 18 Accident records are kept; these are audited monthly by the manager and quarterly by head office. These records would benefit from additional information as to when the person was last seen and by who. It was clear from those seen appropriate actions are taken when a trend is identified. Regulation 37 notifications are sent to the CSCI as required. The PIQ showed that electrical and gas appliances and installations were service and maintained at regular intervals by appropriately qualified personnel. Straven House DS0000001170.V272867.R01.S.doc Version 5.0 Page 19 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 4 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 4 X X X X 4 X 4 STAFFING Standard No Score 27 1 28 3 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 3 Straven House DS0000001170.V272867.R01.S.doc Version 5.0 Page 20 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 The registered person must ensure that detailed care plans are in place around meeting service users individual physical, psychological and social care needs. The registered person must make sure that at all times there are enough staff on duty as are needed to maintain the health and welfare of residents. The psychological needs of residents and the size and layout of the building must be taken into consideration. The registered person must ensure that the staff training programme includes mental health and other specialist care needs of service users. Timescale for action 31/08/06 2 OP27 18 25/02/06 3. OP30 18 31/08/06 Straven House DS0000001170.V272867.R01.S.doc Version 5.0 Page 21 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 OP7 OP38 Good Practice Recommendations The registered person should make provision for staff to receive training around person centred care planning. The accident records should include details as to when the accident victim was last seen and by whom. Straven House DS0000001170.V272867.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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. 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