Inspection on 18/01/06 for Summerhayes Residential Home

This inspection was carried out on 18th January 2006.

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

Summerhayes Residential Home 16/03/07

Summerhayes Residential Home 03/03/05

Summerhayes Residential Home 18/08/04

Summerhayes Residential Home 04/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Summerhayes 1700 Wimborne Road Bear Cross Bournemouth Dorset BH11 9AN Lead Inspector Jo Palmer Unannounced Inspection 10:30 18 January 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 DS0000003989.V277488.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000003989.V277488.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Summerhayes Address 1700 Wimborne Road Bear Cross Bournemouth Dorset BH11 9AN 01202 574330 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) Dr John Hutchings Mrs Jane Hutchings Mrs Tracy Anne Fitzpatrick Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places DS0000003989.V277488.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th October 2005 Brief Description of the Service: Summerhayes is owned by Dr & Mrs Hutchings, the registered manager is Tracey Fitzpatrick. The home is registered to accommodate a maximum of twenty-one older persons requiring personal care. Located in Bear Cross, a suburb of Bournemouth, Summerhayes is close to local shops, pubs and post office and has main road access to both Poole and Bournemouth town centres. Resident accommodation is provided over two floors with a central stairway with a chair lift providing access between floors, there are nineteen single bedrooms and one shared room, three rooms have en-suite facilities, the remainder have use of conveniently sited bathrooms and toilets around the home. Communal space is provided on the ground floor, a lounge and dining area and a smaller sun lounge area are available. Pleasant gardens are accessible to residents and off road parking is provided for a limited number of cars. Summerhayes provides twenty-four hour care and domestic services including laundry and catering. DS0000003989.V277488.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection on 18th January 2006 lasted for three hours. Tracey Fitzpatrick, registered manager assisted throughout the inspection and provided necessary information and access to some records. This was a brief inspection the purpose of which was to monitor progress in addressing requirements and recommendations of the last inspection and to review practices in relation to some of the National Minimum Standards. Not all standards were assessed and the reader is referred to the report of the last inspection dated 17th October 2005, which can be obtained either from the home or can be viewed on www.csci.org.uk The inspector spoke with five residents, two members of staff and the manager, took a tour of the premises and examined relevant records. What the service does well: Residents are provided with sufficient information about the service provided at Summerhayes in the form of a Service User Guide and Statement of Purpose. Resident’s needs are assessed and care plans developed detailing for staff how those needs are to be met in respect of each residents health and welfare. The home has good systems of resident consultation with regards their care and there was evidence of regular reviews and evaluations where care plans are changed as resident’s needs change. Care records evidence that residents maintain contact with community health care services and are enabled to attend appointments with their GP etc. as required. Medication management is, in the main satisfactory although a few anomalies have resulted in a requirement being made. Residents spoken with were full of praise for staff and services at the home, all residents spoken with who were able to comment, confirmed that staff treat them kindly and respectfully and are dependable. Social care programmes in the home are dependent on individual residents preferences and abilities, group activities are organised and some of the residents spoken with confirmed that they were able to do their ‘own thing’ including going out, receiving visitors, reading, watching television, going to church etc. Residents stated that they are able to make choices about their lives in the home and with regard to their daily routines. DS0000003989.V277488.R01.S.doc Version 5.1 Page 6 Residents confirmed that they had no complaints or grumbles although if they ever did, they would know who to speak to, a complaints procedure is available assuring residents and visitors that their concerns, if any, will be managed appropriately. The home is clean and well maintained and there was evidence of some redecoration and refurbishment. Room sizes vary considerably although residents spoken with confirmed that their rooms met their needs in terms of space. Staff recruitment practices now protect residents by ensuring that staff vetting procedures are robust before the person starts work at the home. For those residents who request assistance in managing their personal allowances, a well organised system of recording and safe storage of any money held demonstrates that residents rights and interests are protected in relation to their personal funds. What has improved since the last inspection? What they could do better: This inspection has resulted in four requirements and three recommendations where improvements are needed. • Management of medication systems need to be reviewed in order that all medicines are held securely and that if staff are to remove medicines from their original containers, they must be accurately labelled. It has been recommended that this form of double dispensing does not take place. A requirement has been repeated from the previous inspection that the screening provided in a shared room is adequate and that it protects DS0000003989.V277488.R01.S.doc Version 5.1 Page 7 • • • resident’s privacy and dignity. It has been recommended that the use of this room is reviewed and that consideration is given to moving the linen store from this room. A record must be held on staff files detailing the position held, the date employment commenced, the work performed and the hours they are employed each week. It is recommended that an employment contract be issued. A system must be established for reviewing and improving the quality of care in the home. In view of impending changes to the regulations, it would be prudent for the registered persons to develop a selfassessment and review programme to measure the home’s success in meeting its aims and objectives and developing and improving care and services provided. 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. DS0000003989.V277488.R01.S.doc Version 5.1 Page 8 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 DS0000003989.V277488.R01.S.doc Version 5.1 Page 9 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. Standard 6 is not applicable. Up to date information is available to prospective residents to inform them of the care and services provided by the home. EVIDENCE: Following the last inspection, the Statement of Purpose and Service User Guide have been updated to include the current information about the Commission and availability of inspection reports. Standards three and four were assessed as met at the last inspection. DS0000003989.V277488.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Care plans provide sufficient detail for staff to be aware of resident’s health and welfare needs and how to meet them and are reviewed appropriately. Effective systems of consultation are in place in order that residents can review their care plans to agree with the identified care outcomes. There are satisfactory arrangements for managing medication in the interests of residents who live at the home although to protect those residents who stay at Summerhayes for short periods of respite, further attention is required. Resident’s rights are respected and their right to privacy is supported through care delivery and relationships with staff. EVIDENCE: Examination of residents care files demonstrated that personal care, health and welfare needs are identified through assessment, are reviewed and a plan of care is established and up dated in order to inform staff of the action necessary to meet needs. Care plans are well written and informative and consideration has been given to ensuring the resident’s independence is maintained and that choices are enabled with regard to self-care and social life. DS0000003989.V277488.R01.S.doc Version 5.1 Page 11 Records demonstrate that residents maintain contact with their GP and other health care staff as required. Residents spoken with confirmed that their needs are met in the home by a hard working, caring staff group who treat them respectfully and that they have access to GPs, opticians, dentists as required. Some residents spoke of the support they had from the home in arranging transport for outside appointments to hospital. Medication systems in the home were examined including receipt of medicines, storage, administration and disposal. The chemist that supplies the home assists in the management by providing medicines in 28 day blister packs and with a good recording system. However, where a resident is admitted to the home for a short period of respite, is newly admitted, or returns from hospital with medicines provided in bottles or boxes, these are not managed so well. Ms Fitzpatrick will dispense medicines from their original bottled or boxed, labelled containers, into a dossette dispensing box for one week at a time. Staff then administers the medicine to the resident from this dossette box at the correct time. The dossette boxes are marked with the resident’s name. The balances of stock of bottled or boxed medicines are held in the office of the home. Royal Pharmaceutical Guidelines state: Section 4.2 For a care home member of staff to administer a medicine it must have a printed label containing the following information: •Service users name. •Date of dispensing. •Name and strength of medicine. •Dose and frequency of medicine. Section 6.2.3 Medication should never be removed from the original container in which a pharmacist or dispensing doctor supplied it until the time of administration. The best way of administering medicines to a service user is directly from the dispensed container, medication can be placed in a small pot after removing it from the dispensed container as a way of hygienically handing it to the service user. Medication should never be secondary dispensed for someone else to administer to the service user at a later time or date. Medicines are disposed of appropriately by the supplying pharmacies except where residents have come to the home with their own supplies. In these instances, the chemist will not take the medicines for disposal. The inspector has asked the Commission’s pharmacy inspector to contact the home to discuss this. Medication storage is appropriate in the main although some medicines were noted to be held in an unlocked cupboard in the home. DS0000003989.V277488.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 & 14 Social, cultural, and recreational activities are dependent on individual preferences and the resident’s capacity for involvement. Residents are supported in maintaining contact with their friends, family and the local community and in making decisions about their lives in the home. EVIDENCE: The last inspection report made the recommendation that records of care for residents detailed their social care as well as their personal care, this inspection evidenced that this is now being done. Care records examined evidenced resident’s lives in the home including any social engagements, visits from friends and family, visits to church etc. Care plans for residents identify their personal preferences regarding social arrangements and whether they are able to arrange their own leisure time or need any assistance from the home. Care plans also address residents spiritual and emotional needs identifying any cultural or religious needs. Resident consultation in the assessment and care planning process was evident indicating that residents were involved in decision making, were able to make choices and agreed with care outcomes. Residents spoken with confirmed that they were able to arrange their own daily routines including making decisions about what time to get up, go to bed and how to spend their day. Some residents are more constrained by physical frailty and some degrees of confusion although it was evident that the home provides a programme of entertainment including games and musical events. DS0000003989.V277488.R01.S.doc Version 5.1 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 A written complaints procedure is available giving residents confidence that steps will be taken to deal with any complaint or concern they may have. EVIDENCE: The last inspection reported that the home’s complaints procedure needed updating to inform complainants that they can approach the Commission at any time. This inspection evidenced that this has been done. The complaints procedure is available in the Service User Guide and residents spoken with confirmed that they would know who to talk to if they had any concerns. No complaints have been received. The last inspection reported that standard 18 was met, this was not assessed on this occasion. DS0000003989.V277488.R01.S.doc Version 5.1 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, 23 & 24 Summerhayes is clean and well maintained and routine maintenance schedules ensure residents health and welfare through regular checking and servicing of equipment. Bedrooms do not all meet the standard of expected spatial requirements although as a home registered before the National Minimum Standards were implemented, the standards do not apply to current accommodation at Summerhayes; bedrooms meet resident’s needs in respect of the personal space they require. A shared room does not afford residents the privacy they deserve. EVIDENCE: There was evidence of routine and ongoing maintenance during inspection, several bedrooms have been redecorated and work was being carried out on a hall, the office and the staff room/utility room. Residents bedrooms visited were personalised to varying degrees, it being evident that residents are able to bring in items of their own to make their rooms more homely. Residents spoken with all stated that their rooms were comfortable, kept clean, and met their needs. A requirement of the last DS0000003989.V277488.R01.S.doc Version 5.1 Page 15 inspection is repeated as one shared room still has inadequate screening between beds that does not provide satisfactory privacy for the two residents sharing. A recommendation has also been repeated that the use of this room is reconsidered as it is small and it houses the home’s linen cupboard to which staff require constant access. DS0000003989.V277488.R01.S.doc Version 5.1 Page 16 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): 29 Recruitment procedures ensure all staff are vetted before taking up employment although the system is let down by the home’s failure to explore gaps in employment history and issue contracts of employment. EVIDENCE: The last inspection resulted in a requirement being repeated concerning staff recruitment procedures with particular regard to the registered persons ensuring that the applicant has a satisfactory CRB* and POVA* check prior to starting work at the home. Ms Fitzpatrick confirmed that one member of staff had started employment since the last inspection; the recruitment file was examined. Records held demonstrated that a satisfactory CRB and POVA check had been made, references had been received and the applicant had detailed her qualifications and work history in the application form. Copies of relevant identification were also held. However, there was no record of the date employment commenced and no contract or job description. Ms Fitzpatrick confirmed that staff are issued with a contract after 3 months of employment during which time the person is employed on a trial basis. The registered persons are reminded that the Care Homes Regulations state that among the records to be held on staff are detail of the position held, the work to be performed and the number of hours employed each week (Regulation 17 (2) Schedule 4). The registered persons need also to consider that: DS0000003989.V277488.R01.S.doc Version 5.1 Page 17 ‘A contract of employment is a legal agreement between an employer and an employee. It comes into force when an employee agrees to work for an employer in return for pay. An employer is legally required to put some of the main details of an employees work in writing - including hours, pay and leave’ ACAS. Further information for the registered persons is available from ACAS whose registered office in the South West can be contacted on 0117 9065 200 or information available at www.acas.org.uk DS0000003989.V277488.R01.S.doc Version 5.1 Page 18 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 The use of questionnaires to obtain views of residents and relatives has been good although the value of these in setting targets for improvement and reviewing performance is compromised as results have not been evaluated and there is no clear development plan for the home. Resident’s financial interests are safeguarded by efficient record keeping ensuring that resident’s rights and best interests are protected. EVIDENCE: Standard 38 was not assessed except for examination of certificates of maintenance and servicing of emergency lighting and fire alarm systems as a requirement was made at the last inspection, this has been met. Questionnaires are available for residents and visitors in the entrance hall of the home. These have been used to obtain the views of interested parties on the care and services provided by the home. Returned questionnaires were DS0000003989.V277488.R01.S.doc Version 5.1 Page 19 seen to contain mainly positive comments and Ms Fitzpatrick confirmed that where any less favourable comments had been received, these had been dealt with and concerns rectified at the time. Results of questionnaires have not been audited and other aspects of service provision have not been measured to ensure the home is meeting its stated aims and objectives. DS0000003989.V277488.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X 3 1 X X STAFFING Standard No Score 27 X 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 1 X 3 X X X DS0000003989.V277488.R01.S.doc Version 5.1 Page 21 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. Standard Regulation Requirement The safety of the procedure for the administration of medication must be reviewed and risk assessed. For care staff to give a medicine it must be labelled with the residents name, form, strength, dose and frequency of the medicine. All medicines must be stored securely. To protect residents privacy and dignity, adequate screening must be provided in shared accommodation. Previous time-scale 31/12/05 not met, this requirement is repeated for the second time. The registered persons must ensure that a record is held for each staff member detailing the date they commenced (and left) employment, the position held, the work performed and the number of hours for which they are employed each week. The registered persons must establish and maintain a system for reviewing and improving the quality of care in the home, a report of any such review must be provided to the Commission and be available to service users. DS0000003989.V277488.R01.S.doc Timescale for action 1 OP9 13 31/03/06 2 OP24 12 31/03/06 3 OP29 17 31/03/06 4 OP33 24 31/03/06 Version 5.1 Page 22 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 OP9 Good Practice Recommendations Medicines should never be removed from the original container in which the pharmacist or doctor supplied it until the time of administration and should never be secondary dispensed for someone else to administer at a later time. It is recommended that the registered persons consider ways of making better use of the shared room for residents and reconsider the linen storage in the room. It is recommended that the registered persons give employees their written statement of terms and conditions ideally on their first day but no later than within two months of the start of their employment. 1 2. OP24 3 OP29 DS0000003989.V277488.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 DS0000003989.V277488.R01.S.doc Version 5.1 Page 24 - 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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