Inspection on 10/01/07 for Upalong

This inspection was carried out on 10th January 2007.

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 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

Upalong 09/11/07

Upalong 21/11/05

Upalong 01/10/04

Upalong 20/04/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Upalong Upalong 16 Castle Road Camberley Surrey GU15 2DS Lead Inspector Damian Griffiths Unannounced Inspection 10 January 2007 10:30 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 Upalong DS0000013817.V325407.R01.S.doc Version 5.2 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. Upalong DS0000013817.V325407.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Upalong Address Upalong 16 Castle Road Camberley Surrey GU15 2DS 01276 682132 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) Mrs M McTeggart Mrs M McTeggart Care Home 9 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (9), of places Physical disability over 65 years of age (2) Upalong DS0000013817.V325407.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st November 2005 Brief Description of the Service: The home has been established since 1988 and has benefited from regular modernisation. The home enjoys a location that is close the centre of busy Camberley and yet situated in a peaceful location. The accommodation is arranged over two floors and contains nine mainly single rooms, one double; all rooms are en-suit. Rooms are fitted with individual alarms and the home has recently installed a basic surveillance system for added security. The home is registered for nine residents over the age of sixty-five, three of whom may have dementia and two who may have a physical disability. Upalong DS0000013817.V325407.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of the Commission for Social Care Inspection (CSCI) year April 2006 to 2007 using the new ‘Inspecting for Better Lives’ (IBL) process. The IBL process involved a pre-inspection assessment of service information from a variety of sources initially helping to prioritise the order of inspections and identify areas that may require more attention during the inspection process. A new Inspection record was compiled from details received from a preinspection questionnaire, notifications of significant events known as Regulation 37’s compiled by the home. Any comments and complaints received and previous inspection reports were all considered for inclusion prior to the inspection visit. For more details of ‘IBL’ please visit the Commission for Social Care Website details can be found on the last page of this Inspection report. The Registered Manager Mrs. Moira Mc Teggart representing the establishment assisted Lead Regulation Inspector Damian Griffiths throughout the inspection. The inspector was with residents and staff at Upalong for a period of 7 ½ hrs during which time residents and staff were consulted and samples of; care assessments, care plans, staff recruitment, training and documentation concerning ‘policies and practices’ were inspected. The inspector consulted residents and staff for their views about the home: Residents commenting on their residency stated that; ‘Staff make family welcome’ and ‘staff are very helpful’. Staff said they felt appreciated by the manager and felt happy in their work. The inspector would like to extend thanks to residents and staff at Upalong for their time and hospitality. What the service does well: Useful details about the home were provided to new and prospective residents and their representatives prior to admittance and a comprehensive assessment of the residents care needs was completed if they chose to become a resident. Residents benefited from regularly reviewed care plans that contained relevant details of social and healthcare needs and staff were trained to ensure residents prescribed daily medication was administered correctly. Upalong DS0000013817.V325407.R01.S.doc Version 5.2 Page 6 Residents were satisfied with the level of activities available and considered the staff helpful and considerate. Personal religious preferences were respected and local facilities were accessible. The complaints procedure was accessible to residents, relatives and friends and the home had a copy of the Surrey Multi-Agency Procedures to ensure the safeguarding of Vulnerable Adults and it was recommended that staff attend a refresher-training course in this area. The home was comfortable, airy and clean providing the residents with a relaxing homely environment to enjoy and provided residents with a stair lift and new bathroom appliance that helped to maintain comfort and independence. The manager was supported well by the staff and provided clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities and residents and their representatives were consulted about the quality of care. What has improved since the last inspection? What they could do better: The home received just one requirement: That the registered manager ensures that staff have a full employment history, together with a satisfactory written explanation of any gaps in employment. Five recommendations were made: It was recommended that residents receive periodic dietary assessments and that each Medicine Administration Record is identified with the appropriate photo image of the resident involved and that the ‘drugs-return book’ be updated with the pharmacists signature at the next collection. That the home’s copy of the Surrey Multi-Agency Procedures to safeguard vulnerable adults be updated and that a senior staff member attend a Surrey Multi-Agency Procedures course. That Upalong include others not directly linked to the home when next conducting a quality assurance monitoring exercise and that the home inform all parties involved of the outcome including CSCI. The home conduct a health and safety audit of the kitchen area and the chef consider a health and safety refresher course. Upalong DS0000013817.V325407.R01.S.doc Version 5.2 Page 7 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 summary of this inspection report can be made available in other formats on request. Upalong DS0000013817.V325407.R01.S.doc Version 5.2 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 Upalong DS0000013817.V325407.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Useful details about the home were provided to new and prospective residents prior to admittance and a comprehensive assessment of the residents care needs was completed. The home does not provide Intermediate care. EVIDENCE: There had been one new resident to join the home since the last inspection and a full assessment of their care needs was available for inspection. The resident had also received assessments from various local healthcare providers and staff had received additional training to meet the residents assessed care needs. The family had received full details of the homes service user guide for consideration and the resident and family were able to visit the home prior to making a decision. Upalong DS0000013817.V325407.R01.S.doc Version 5.2 Page 10 Residents consulted stated that; ‘staff make family welcome’ and ‘Staff are very helpful’. Upalong DS0000013817.V325407.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefited from regularly reviewed care plans that containing details of their social and health care needs and staff were trained to ensure that the residents prescribed medication was administered correctly. EVIDENCE: A Sample of four care plans were inspected and they each contained details full details of the residents social and healthcare needs and background details. New care plan folders were being introduced to ensure that lose pages were secured and different sections of the care plan were easier for staff to access. The residents were seen regularly by the local GP who was visiting on the day of the inspection. He confirmed that residents benefited from caring staff and a pleasant environment. Care plans contained all the care details required including information about residents: medication, weight and risks such as: falls and diabetes care and it Upalong DS0000013817.V325407.R01.S.doc Version 5.2 Page 12 was recommended that residents also receive periodic dietary assessment to ensure the appropriate nutrition was being provided. Records of recent appointments were in evidence such as: Chiropody and regular eye and hearing tests. One resident commented on the quality of care and attention she had had received from staff when she was required to visit the hospital. Medication Administration Records (MAR) of all the residents were inspected and found to be in order. The inspector was informed that the local pharmacy had recently audited the homes. The pharmacy regularly collected unused medication and a record of this was maintained however the most recent collection remained unsigned. Staff had received the appropriate training in the administration of medicines and additional instruction to meet the additional needs of the new resident. It was recommended that residents receive periodic dietary assessments and that each Medicine Administration Record is identified with the appropriate photo image of the resident involved and that the drugs return book be updated at the next collection. Residents consulted during the inspection said that they felt the personal care they received was good and that staff were considerate and respected their needs. One resident said, “Staff were doing very well”. Please see the recommendation section of this report. Upalong DS0000013817.V325407.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents satisfied with level of activities available and considered the staff helpful and considerate. Personal religious preferences were respected and local facilities were accessible. EVIDENCE: During the in section the residents were observed reading newspapers/books, knitting, watching TV and enjoying an exercise session in the afternoon. An activities programme was observed on the resident’s notice board with a variety of activities available and a staff member was working with residents to produce a brief ‘pen-picture’ of residents’ background, interests and favoured activities. Entertainers were commissioned to visit the home, and residents were happy with the current arrangements for trips out. A resident stated that the home was: ‘Quite pleasant’ and ‘you can do what you want’. Resident’s were able to practice their religious preferences and regularly visited the areas local church and enjoyed luncheons. During the Christmas period Upalong DS0000013817.V325407.R01.S.doc Version 5.2 Page 14 Carol singers had visited the home and a resident consulted confirmed that: the ‘staff make family welcome’. Residents chose what food they ate, clothes to wear and level of activity and involvement they wished. Family and friends generally managed resident’s finances. There was information about how to contact an advocacy services and the CSCI was available on the notice board and in the service users guide and there was a folder for visitors to comment available in the reception area and a visitor’s book. Residents were very pleased with the choice and quality of food and the Inspector was invited to stay for lunch. Staff were observed asking residents what meals they preferred from a choice of two menus available and the chef would cook any other preference. Residents requiring help received sensitive support fro staff assigned to the table. The meal was nutritious and hot when served with a hot pudding that was enjoyed by the residents. Fresh fruit was available on a daily basis. Upalong DS0000013817.V325407.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure was accessible to residents, relatives and friends and the home had a copy of the Surrey Multi-Agency Procedures to ensure the safeguarding of Vulnerable Adults and it was recommended that staff attend refresher-training course in this area. EVIDENCE: The homes complaints policy and procedure was in place details about how to contact CSCI were visible in the reception area and also to be found in the service users guide. The complaints log was in place and there were no complaints on record or reported during the inspection visit. There had been no reported instances of concern regarding the safeguarding of vulnerable adults. Policies and practices were available and staff had signed policy documentation to state that they had read this and in the event of poor practice being observed within the organisation the ‘Whistle-blowing guide’ also showed evidence of staff awareness. The Surrey Multi-Agency Procedures to safeguard of Vulnerable adults was in place but not up-to-date. Staff had received training in this area of importance however when staff were questioned it was apparent that some of the procedures were not understood therefore it was recommended that a Surrey Multi-Agency Procedures training course or be sought and the written procedures be updated. Upalong DS0000013817.V325407.R01.S.doc Version 5.2 Page 16 Home security has been improved by the installation of a visual display unit combined with the doorbell that ensuring staff ability to check the identity of visitors to the home. Residents consulted agreed that they felt safe and cared for at the home. Please see the recommendations section of this report. Upalong DS0000013817.V325407.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was fit for purpose, comfortable, airy and clean providing the residents with a relaxing homely environment to enjoy with good facilities provided to meet their care needs. EVIDENCE: A tour of premises was conducted and they were clean, airy and a homely atmosphere prevailed throughout. Residents enjoyed the quality of the furniture and decorative quality to be found in this comfortable environment. The condition of the carpets however was disappointing and detracted from the overall quality of the home. Despite the carpets being relatively new and regularly cleaned they looked worn and dirty throughout the home. The home was addressing this matter with the carpet suppliers. The lounge is of generous proportions and has good access to the dining area. Upalong DS0000013817.V325407.R01.S.doc Version 5.2 Page 18 The bedrooms were of various sizes some bigger than others and the residents’ were encouraged to personalise their own rooms by use of their own furniture and fittings. A bathroom available to residents had recently been renovated and provided a sit-in bath that all residents could enjoy. Residents had full access to the grounds, which had an aviary, benches, and a space at the rear to relax or stroll. The laundry room was in good order and the home was without any bad smells or odours. The laundry area was clean and tidy with hand washing facilities available. The clothes laundering system worked well and there had been no complaints made from residents or their families. Upalong DS0000013817.V325407.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were well served by experienced and committed staff that had undergone regular training to ensure their knowledge of the residents care requirements were properly understood however recruitment documentation was incomplete and this standard was not completely met. EVIDENCE: Staff members were consulted and staff files were examined. Staff were knowledgeable and experienced and a good raft of training had been experienced in the last twelve months including a lengthy dementia care course. There were no concerns regarding the skill mix and experience of the staff on duty. 55 of staff were at least NVQ level 2 trained and the manager, Mrs Tegggart and other senior staff had attained NVQ level 4 in management. There had been one new staff member joining the home since the last inspection. Employment documentation was examined to establish whether the correct recruitment procedures had been implemented. All documentation was in place except for a full employment history however this did include the staff member’s employment history as a care worker. Upalong DS0000013817.V325407.R01.S.doc Version 5.2 Page 20 Staff training programme in place for new staff induction, GSCC approved course covering core skills including protection of vulnerable adults. Staff training over the last twelve months included: first aid, fire safety, manual handling, dementia awareness and the application of insulin. Please see the requirement and recommendation section of this report Upalong DS0000013817.V325407.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager was supported well by the staff and provided clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. Residents and their representatives were consulted about the quality of care. Staff promoted the health and safety of the residents however there were some minor issues that were recommended for action. EVIDENCE: Staff and residents consulted where pleased with the management approach and style and it was established that the manager was well respected and staff were seen to support her in applying a consistent approach. Upalong DS0000013817.V325407.R01.S.doc Version 5.2 Page 22 A quality assurance exercise had been conducted earlier in the year by providing the residents and their families and friends with a questionnaire to complete. The residents confirmed that they were regularly consulted about their preferences by staff. One residents confirmed this by stating that staff ‘will. The manager had informed residents and their families ‘in-person’ about the outcome of the quality assurance exercise therefore it was recommended that this should be followed up in writing and a copy be sent to all parties involved, including CSCI. The service users guide that was available in the reception area contained details of the homes new policy on ‘handling resident’s money’. It stated that it did not take any active part in this area of support. Relatives and residents manage their own financial affairs at the home. Health and safety training had been received by staff and promoted by the home. Fire drills were regularly completed and alarms and extinguishers had been regularly checked. All areas of the home had been risk assessed however the kitchen’s extraction hood was reported to have a minor ‘condensation’ problem only occurring during cold weather. On inspection of foodstuffs stored in the refrigerator a large jar, bearing an appropriately labelled opening date, was beyond the manufactures recommended storage date. It was recommended that the home conduct a health and safety audit of the kitchen area and the chef consider a health and safety refresher course. Upalong DS0000013817.V325407.R01.S.doc Version 5.2 Page 23 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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 3 X X 2 Upalong DS0000013817.V325407.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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 OP29 Regulation 19(1)(b) Requirement The registered manager must ensure that staff are fit to work at the home and obtained in respect of that person the information and documents specified in paragraphs 1 to 9 of schedule 2 of the Care Homes Regulations (2001) that states, ‘a full employment history, together with a satisfactory written explanation of any gaps in employment’. Timescale for action 10/02/07 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 OP8 OP9 Good Practice Recommendations It was recommended that resident receive periodic dietary assessment. It was recommended that each Medicine Administration Record is identified with the appropriate photo image of the resident involved and that the ‘drugs-return book’ be updated with the pharmacists signature at the next DS0000013817.V325407.R01.S.doc Version 5.2 Page 25 Upalong 3 OP18 4. 5. OP33 OP38 collection. It was recommended that the Surrey Multi-Agency Procedures to safeguard vulnerable adults be updated and that a senior staff member attend the Surrey Multi-Agency Procedures course. It was recommended that the home ensure that it informers all parties involved with the quality assurance exercise including CSCI of the outcome. It was recommended that the home conduct a health and safety audit of the kitchen area and the chef consider a health and safety refresher course. Upalong DS0000013817.V325407.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Upalong DS0000013817.V325407.R01.S.doc Version 5.2 Page 27 - 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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