Inspection on 08/08/05 for Tegfield House

This inspection was carried out on 8th August 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

Tegfield House 20/04/06

Tegfield House 24/01/06

Tegfield House 07/12/04

Tegfield House 01/07/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Tegfield House 24 Chilbolton Avenue Winchester SO22 5HD Lead Inspector Tracey Box Unannounced 08.08.05 9:30am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Tegfield House H54 S60876 Tegfield Hse V241263 090805.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Tegfield House Address 24 Chilbolton Avenue, Winchester, SO22 5HD Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01962 854600 Hartford Care Ltd CRH 24 Category(ies) of OP - 24 registration, with number of places Tegfield House H54 S60876 Tegfield Hse V241263 090805.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: N/A Date of last inspection 07.12.04 Brief Description of the Service: Tegfield House is a care home registered to provide accommodation and support for up to twenty four older people. Hartford Care Limited own the home. Mr Terry Whayman has been managing Tegfield House and has applied to the Commission for Social Care Inspection to become the homes registered manager. Tegfield house is situated in a quiet residential area of Winchester, within easy reach of local ameneties. The home comprises of twenty four single bedrooms, most of which are en-suite, a large lounge, dining room and a room which is used for the haridresser when she visits. The accommodation is located over two floors, access can be gained by two staircases and a pasinger lift. The home has a large, secluded well maintained garden. Tegfield House H54 S60876 Tegfield Hse V241263 090805.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over five hours, the inspector was assisted during this inspection by one senior staff member and an administrator who were working at the home. The manager arrived later in the morning, he assisted with the rest of the inspection. The people living at Tegfield house prefer to be referred to as residents, therefore will be referred to as this throughout the report. The inspector had the opportunity to speak with one relative and the hairdresser, both commented on the high level of care the residents appear to receive. The inspector spent time with three residents as they looked at their care plans and witnessed good interacting between residents and staff. The inspector looked at records and asked staff, residents and visitors for their views and experiences. The manager showed the inspector the layout within and surrounding the home, which appeared very clean and comfortable, providing the residents with an attractive ‘homely’ environment. The inspector was impressed by the quality of the food that was served for lunch. Residents received their choice of meal and vegetables were placed in a dish in the middle of the table allowing the residents to have more if they wished, the residents confirmed this practice occurs daily. One resident said, “The food is out of this world”. What the service does well: What has improved since the last inspection? Tegfield has benefited from building work to install a new boiler system, passenger lift, bathroom with a new bath which meets the residents’ needs, a wheelchair access ramp to the front door and outside lighting to aid the fire escape route at night. Two additional bedrooms have been built. Internal refurbishment has improved the entrance hall and dining room. The medication system has been reviewed. Tegfield House H54 S60876 Tegfield Hse V241263 090805.doc Version 1.40 Page 6 The home has a ‘Whistle blowing’ policy, to which residents and staff are aware of. Fire doors were not wedged open. Cleaning products are not left unattended when cleaning is in progress. First aid boxes have been installed and are maintained. 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. Tegfield House H54 S60876 Tegfield Hse V241263 090805.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Tegfield House H54 S60876 Tegfield Hse V241263 090805.doc Version 1.40 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 standard(s) These standards were not assessed on this occasion. EVIDENCE: These standards were not assessed on this occasion. Tegfield House H54 S60876 Tegfield Hse V241263 090805.doc Version 1.40 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 standard(s) 7,8,9 Residents health, personal and social needs are not set out in individual’s care plans, recording of the care plan review has yet to be established. It was demonstrated within health care records that resident’s health care needs were met. Residents are protected by appropriately trained staff, who follow the homes policies and procedures for dealing with medicines. EVIDENCE: The information held in the individuals care plans was limited, more specific detail is required to enable residents to be cared for appropriately. There were limited risk assessments in place to ensure the safety of residents and staff. The home is required to review its recording system and ensure risk assessments are in place. There was no evidence to show that care plans had been updated at all, with or without the resident’s involvement, the home must review care plans each month or sooner if necessary. Three residents explored their care plan with the inspector, the residents said they had not seen the plans before, however, did agreed with the contents and confirmed the staff care for them in the way they wish. Tegfield House H54 S60876 Tegfield Hse V241263 090805.doc Version 1.40 Page 10 The manager said all residents have a concise care plan in their bedrooms, however, the inspector was unable to find these in the rooms of the three residents spoken with, although the residents did confirm having had one in the past. The manager said he would investigate where they had gone as he was not aware they were missing. Care plans seen did included information following visits to Doctors and chiropodist. The manager explained other visits to health care professionals would also be included in the care plan. It is of serious concern that care plans and risk assessments are not being updated or have in depth information within them to enable staff to competently attend to residents needs effectively. This has been required on three consecutive occasions, 01/10/04, 07/01/05 and 09/08/05. This matter will now be addressed by way of a serious concern letter outside of this inspection report. At the time of the inspection, staff administer the majority of residents medication using a monitoring dosage system, staff told the inspector that most residents prefer them to store and administer residents medication for them. The inspector saw medication being correctly administered, staff followed the homes medication policy and procedure. Records of all staff trained to administer medication were found to be in order. Risk assessments must be completed for the two residents who self medicate. Tegfield House H54 S60876 Tegfield Hse V241263 090805.doc Version 1.40 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 standard(s) 12 Residents social, cultural, religious and recreational needs are met. EVIDENCE: The inspector spoke with residents and a relative, all stated the home is better than they’d imagined, especially the food, one resident said “It’s a lot better than I could do.” The home employs an activities coordinator to arrange daily activities, these range from card games, reading a library and guests to entertain. The inspector saw a lot of residents sitting in the garden enjoying the sunshine talking to one another, this often occurs as the residents enjoy the well presented gardens. One relative said he cannot fault the care his mother receives, staff encourage residents to participate in activities if they want to. Tegfield House H54 S60876 Tegfield Hse V241263 090805.doc Version 1.40 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 The home has a comprehensive complaints procedure, however, the procedure for logging complaints requires revising. The home has a policy on abuse, however, the document requires reviewing. EVIDENCE: The inspector witnessed the homes complaints procedure, which gives clear guidelines of process, a copy of this procedure is held in the homes policy file and in each “residents” welcome pack. The inspector saw the complaints log, and recommended that the log be reviewed to include more detail of the complaint, timescales, action taken and outcome, thus enabling the home to monitor its complaints more effectively. The residents, visitor and hairdresser were aware of the procedure, but have not felt the need to do so, they were confident the home would take appropriate action should a complaint be made. The inspector read the policy on abuse, which was basic, it was recommended the home obtain a copy of the Department Of Health No Secrets Document to correspend with the homes abuse policy and Hampshire County Council procedure for the Protaction Of Vulnerable Adults, these documents together would provide a comprehensive abuse policy and procedure for staff to follow. Staff said they receive training on abuse, and are aware of the homes policy. Tegfield House H54 S60876 Tegfield Hse V241263 090805.doc Version 1.40 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed on this occasion. EVIDENCE: These standards were not assessed on this occasion. Tegfield House H54 S60876 Tegfield Hse V241263 090805.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 30 Staff appear to be trained and competent to do their jobs, however records do not show this. EVIDENCE: Staff said they receive adequate training to carry out their jobs and the manager confirmed this. The inspector saw some training certificates, not all were in place. The staff training records indicated staff were overdue some training, therefore the manager must ensure all staff receive the appropriate mandatory training. Individual staff training plan must also be revised to enable the manager to track training needs. Tegfield House H54 S60876 Tegfield Hse V241263 090805.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 Residents health, safety and welfare are not fully protected. EVIDENCE: Staff said they follow policies regarding health and safety, however, Staff training files were looked at and showed that all staff were overdue moving and handling training and first aid. The home has adequate risk assessments for the building. The inspector witnessed good food hygiene techniques in the serving of the lunch. Radiators were covered and had thermostatic controls. The inspector was unable to view certificates for the servicing of systems as they were not available, the manager assured the inspector all were up to date, they were being sent from head office. Staffs confirmed their awareness of health and safety procedures, and were to find them. Tegfield House H54 S60876 Tegfield Hse V241263 090805.doc Version 1.40 Page 16 Tegfield House H54 S60876 Tegfield Hse V241263 090805.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 x COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 x 28 x 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 x x x x x x x 2 Tegfield House H54 S60876 Tegfield Hse V241263 090805.doc Version 1.40 Page 18 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP 7 Regulation 15, schedule 3 (1)(b) Requirement Care plans must be specific in detail to enable residents to be cared for appropriately. THIS IS A REPEAT REQUIREMENT FROM 01/10/04 AND 07/01/05 Care plans must be reviewed on a one month basis or before if necessary. THIS IS A REPEAT REQUIREMENT FROM 01/10/04 AND 07/01/05 Risk assessments must be completed on all areas that are necessary to protect residents. THIS IS A REPEAT REQUIREMENT FROM 01/10/04 AND 07/01/05 The home must review its complaints log to include more detail of the complaint, timescales, action taken and outcome, and number the pages consecutively, thus enabling the home to monitor its complaints more effectively. The manager must ensure staff are trainind and competent to do their jobs and maintain training plans for each staff. Timescale for action 20/09/05 2. OP 7 15, schedule 3 (1)(b) 20/09/05 3. OP 7 13 (4) 20/09/05 4. OP 16 Schedule 4 (11) 20/09/05 5. OP 30, OP 38 schedule 2 (4) 9/09/05 Tegfield House H54 S60876 Tegfield Hse V241263 090805.doc Version 1.40 Page 19 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. Refer to Standard 18 Good Practice Recommendations The home is strongly advised to obtain a copy of the Department Of Health No Secrets Document to correspend with the homes abuse` policy and Hampshire County Council procedure for the Protaction Of Vulnerable Adults. 2. Tegfield House H54 S60876 Tegfield Hse V241263 090805.doc Version 1.40 Page 20 Commission for Social Care Inspection 4th Floor, Overline House Blechynden Terrace Southampton SO15 1GW 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 Tegfield House H54 S60876 Tegfield Hse V241263 090805.doc Version 1.40 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!