Inspection on 23/06/05 for The Salisbury

This inspection was carried out on 23rd June 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Salisbury 30/07/07

The Salisbury 14/08/06

The Salisbury 06/10/05

The Salisbury 15/12/04

The Salisbury 26/04/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE The Salisbury 20 Marine Crescent Great Yarmouth Norfolk NR30 3ED Lead Inspector Hilary Shephard Unannounced 23 June 2005 9.00am rd 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. The Salisbury I55 s27419 the salisbury v233742 230605(4).doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Salisbury Address 20 Marine Crescent, Great Yarmouth, Norfolk, NR30 4ET 01493 843414 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) Dr Suman Nagpal, Dr Sunita Nagpal, Dr Surrinder Batra and Mrs Indira Batra Christine Horner Care Home 26 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (26) of places The Salisbury I55 s27419 the salisbury v233742 230605(4).doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Twenty six (26) older people of either sex may be accomodated, to include: One (1) Service User with dementia, who is named on the records held by CSCI, may be accomodated provided care needs have been assessed and these can be met at The Salisbury. No other person with a diagnosis of dementia is to be admitted. To accommodate no more then twenty-six (26) people in total Date of last inspection 15th December 2004 Brief Description of the Service: The Salisbury is a care home providing care and accommodation for up to 26 older people and is situated approximately one mile from the centre of Great Yarmouth. Accommodation is provided on two floors and there are 16 single bedrooms, four with en-suite facilities, and five shared rooms. There are two lounges and a dining room and a pleasant secure garden to the rear of the building. The Salisbury I55 s27419 the salisbury v233742 230605(4).doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine unannounced inspection was carried out between 9am and 1.30 pm, and was undertaken with assistance from residents and staff. A sample of records were examinedand all parts of the accomodation were seen. What the service does well: What has improved since the last inspection? The care plans have been amended and improved since the previous inspection, but still need further work. Assessments of residents’ physical needs have been undertaken, which has enabled certain care needs to be identified. Residents have benefited from their medication being reviewed by a pharmacy support technician linked to the Primary Care Trust. Better recording and safer storage of controlled medication has been implemented. Two bedrooms have been fitted with new carpets, removing their unpleasant odour, and bedrooms have been made safer by the removal of old wall mounted electric heaters and the installation of window restrictors. Some residents also benefit from having proper door closures fitted to their bedrooms doors enabling these doors to be safely kept open. The Salisbury I55 s27419 the salisbury v233742 230605(4).doc Version 1.30 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. The Salisbury I55 s27419 the salisbury v233742 230605(4).doc Version 1.30 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 The Salisbury I55 s27419 the salisbury v233742 230605(4).doc Version 1.30 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) 3 Residents’ needs are assessed prior to admission, ensuring the home is able to meet their needs. EVIDENCE: Care plans of newly admitted residents were viewed which contained preadmission assessments briefly covering all aspects of their required care. One of the Registered Providers confirmed that the home does not admit any residents whose needs cannot be met. The Salisbury I55 s27419 the salisbury v233742 230605(4).doc Version 1.30 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 and 9 Care plans contained evidence that residents’ needs had been assessed although some assessments had not been dated or updated. Care guidelines were too brief, which could cause incorrect care to be given. Medication Administration Records (MAR) were not being completed correctly indicating that medication may not be administered properly. EVIDENCE: All residents had a care plan, and the deputy manager advised that new ones had been introduced recently. Care plans have improved, with the addition of nutritional assessments for each resident; however, these had not been dated leaving it difficult to use as a guide to their initial nutritional status. One resident was very unwell, and her care plan had not been updated to reflect her changing needs. Care guidelines for staff have improved but are still brief, and need to be clearer and more focused on the individual residents capabilities and actual needs. Care plans are also haphazardly organised with information split in two areas, some accessible to staff, and some remaining in the office. Care plans need to be easily accessible, with information about each person all-together in an easily accessed and understood format. They need to be well organised, ensuring staff will use them to identify and meet the needs of the residents. The Salisbury I55 s27419 the salisbury v233742 230605(4).doc Version 1.30 Page 10 Medication was checked which was booked in and stored correctly, however, the MAR sheets contained numerous gaps, with some medicines remaining in the blister packs. All residents medication has been reviewed by a pharmacy support technician linked to the Primary Care Trust. This person has liaised with the GP who has made changes to some of the prescribed medicines. The deputy manager advised that two senior care staff had recently undergone medication administration training, ensuring that the home now has four staff trained to administer medication. Requirements and recommendations have been made regarding care plans and medication. The Salisbury I55 s27419 the salisbury v233742 230605(4).doc Version 1.30 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, 13, 14 and 15 The lifestyle experienced by the residents was generally positive and enjoyable, family contact is encouraged and maintained, and residents are enabled to make choices about their lifestyle. Meals are well prepared and nicely presented by an experienced chef. EVIDENCE: Residents advised that they were satisfied with the care they received, that there was enough for them to do and that they could manage their day how they wished. Residents were involved in outings to the town, sing-a-longs with the staff, entertainment from “The music man” and activities arranged by staff. Staff were seen to be interacting with the residents, and advised that they are usually able to spend more time with individual residents during the afternoons. Residents receive visits from friends and family, and no restrictions are in place. The home is arranging a summer fete, which will involve residents, visitors and the local community. The home has just employed a new chef who demonstrated a good understanding of the residents needs. Lunch looked appealing, and was enjoyed by the residents. Residents confirmed that the food was generally good, and one advised there was a choice of meals. A list of residents food dislikes was displayed in the kitchen and residents were always provided with an alternative meal. The Salisbury I55 s27419 the salisbury v233742 230605(4).doc Version 1.30 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) Not assessed at this inspection. EVIDENCE: The Salisbury I55 s27419 the salisbury v233742 230605(4).doc Version 1.30 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) 19 and 26 Improvements have been made to the environment, which is now much safer and pleasant smelling. However, the practice of wedging doors open is compromising the safety of residents. EVIDENCE: The home was clean and free from unpleasant odour. Two bedrooms have new carpets; one has been redecorated and both are much improved. The Registered Provider advised that some bedroom doors have been fitted with special closures enabling the residents to have them open as they wish, although some doors were wedged open with chairs. Old wall mounted electric heaters have been removed, and windows have been fitted with restrictors to ensure residents safety. A requirement has been made regarding wedging doors. The Salisbury I55 s27419 the salisbury v233742 230605(4).doc Version 1.30 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) 27 Staffing levels provided are at the minimum required and are at present, meeting the needs of the current residents. EVIDENCE: Currently the home has 15 residents and 11 vacancies, and staffing has been reduced as a result of this. The home is providing three care staff in the morning, two in the afternoon, three in the evening and two at night. The manager also undertakes care duties for a few hours every morning. Quite a few residents are able to look after themselves with help from the care staff. Some residents are more dependent, needing help from two care staff, and one resident is very dependent needing regular input and care. A chef and two cleaners are also employed, who work during the day. Care staff serve the evening meal, which has been prepared by the chef. The Salisbury I55 s27419 the salisbury v233742 230605(4).doc Version 1.30 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) Not assessed on this occasion. EVIDENCE: The Salisbury I55 s27419 the salisbury v233742 230605(4).doc Version 1.30 Page 16 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 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x x x x x The Salisbury I55 s27419 the salisbury v233742 230605(4).doc Version 1.30 Page 17 Are there any outstanding requirements from the last inspection? Two Requirements are repeated 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 7 Regulation 13, 15 Requirement The Registered person must ensure that the care plans contain more detailed and specific guidelines for staff to follow to enable service users needs to be met. Timescale of 28th February 2005 not met. The Registered person must ensure that the assessments of residents needs are reviewed and updated when changes occur. The Registered person must ensure that the correct codes are used on the MAR sheets and that gaps do not occur. The Registered person should ensure that doors are not wedged open, or should fit a suitable type of door closure. Timescale for action 31st July 2005 2. 8 14 Immediate and ongoing Immediate and ongoing 31st July 2005 3. 9 13 4. 19 12, 13 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 8 Good Practice Recommendations The Registered person should ensure that all nutritional I55 s27419 the salisbury v233742 230605(4).doc Version 1.30 Page 18 The Salisbury 2. 9 assessments are dated. The Registered person is recommended to to undertake regular audits of the medication administration records. The Salisbury I55 s27419 the salisbury v233742 230605(4).doc Version 1.30 Page 19 Commission for Social Care Inspection 3rd Floor, Cavell House St Crispins Road Norwich NR3 1YF 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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