CARE HOMES FOR OLDER PEOPLE
Upalong Upalong 16 Castle Road Camberley Surrey GU15 2DS Lead Inspector
Damian Griffiths Announced Inspection 21st November 2005 10:00 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.V269153.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Upalong DS0000013817.V269153.R01.S.doc Version 5.0 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.V269153.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 18th April 2005 Brief Description of the Service: Upalong is a private care home situated in a quiet residential road easily accessible from the M3 motorway. It offers permanent and short stay provision for nine residents age 65 years and over. It is close to Camberley town centre and local amenities. The owners have been able to retain many of the original features of the home while providing modern care facilities. All but one room, situated on the ground floor, are en-suite and they can be assessed by a chair lift situated on a broad staircase. The lounge and dining area offer a comfortable and roomy place for residents to relax. Set in its own grounds Upalong has a convenient car parking area recently resurfaced for ease of use and there is an aviary for the interests of residents and visitors. Upalong DS0000013817.V269153.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the second inspection to be undertaken in the Commission for Social Care Inspection Year April 2005 to March 2006. It was an announced inspection and took place over a period of 7 hours. Lead Regulation Inspector Damian Griffiths was assisted throughout the inspection by Mrs Mc Teggart the registered manager representing the establishment. Three care plans, six staff files were inspected and a pre-inspection report was received from Upalong before the inspection. Residents and staff members were consulted and carers and relatives returned a total of seven comment cards including one from the GP. The inspector would like to extend thanks to the staff and management at Upalong for their assistance and hospitality. What the service does well: What has improved since the last inspection?
Upalong have not had reason to employ any new staff since the last inspection and recruitment requirements had been met. Induction training for staff was adequately covered important areas of risk including: Fire safety, First aid, and Safe manual handling.
Upalong DS0000013817.V269153.R01.S.doc Version 5.0 Page 6 Residents and relatives were happy with the complaints system and the information available to them. The home was bright and had been nicely decorated and radiator covers had received a tasteful wood colouring. 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. Upalong DS0000013817.V269153.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Upalong DS0000013817.V269153.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): This standard was not inspected: EVIDENCE: This standard was not inspected: Upalong DS0000013817.V269153.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 8. Residents’ benefit from detailed care plans that contained health care information that was up-to-date and informative. EVIDENCE: The three care plans inspected contained information that had been obtained from a comprehensive assessment of daily care needs. They were clear and well detailed. The health and safety of the residents was evidenced and relevant risk assessments had been completed, such as, safe management of the homes stairs. The inspector discussed the care plans with the manager and staff who were aware of the individual needs of the residents as recorded. Residents seen required the minimum of specialist equipment being able to manage adequately with: walking frames and walking sticks. There were full details of regular health practitioner involvement and appointments were well documented including input from community health practitioners such as the GP, district nurses and chiropodists.
Upalong DS0000013817.V269153.R01.S.doc Version 5.0 Page 10 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 and 15. Residents’ preferences and choices were respected and activities suited the residents’ needs. The home ensured that relatives’ and friends were always welcomed and meals at Upalong were good offering both choice, variety and catering for special dietary needs. EVIDENCE: Residents’ were benefiting from the attention of the hairdresser at the time of the inspection. Residents consulted spoke of their favourite activities, these included: the daily pleasure of reading the newspapers, planned activities such as quizzes, ball games, board games and bridge. Trips to the local shops, theatre and places of interests were regularly available to residents. The local church hall offered activities and the Vicar was a regular visitor. Staff were reviewing the activities offered to the residents and were preparing to use a new format for recording their choices. It is recommended that the individual residents activity programmes include a pen-picture of the resident’s background in order to ascertain their needs more fully. Upalong DS0000013817.V269153.R01.S.doc Version 5.0 Page 11 One resident consulted said that they were getting older and didn’t require the level of activity demanded by somebody younger, referring to the inspector. Relatives and friends were able to visit at times convenient to them and without prior appointment. Comments received from relatives stated that the ‘nothing is too much trouble’ and that the residents received care with dignity and respect’. The inspector was able to share a meal with the residents and was served a vegetarian meal without notice being given to the chef. The Residents were pleased with the quality of the food and the choice on offer. Please see the recommendations section of this report. Upalong DS0000013817.V269153.R01.S.doc Version 5.0 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 the following standard(s): 16 and 17. The complaints procedure was accessible to residents, relatives and friends and the home had a copy of the Surrey Multi-Agency Procedures. Staff have attended Protection of Vulnerable Adult training. EVIDENCE: The home has not received any complaints since the last inspection. Relatives consulted had been informed of the inspection and confirmed that they were aware of the complaints system and were kept well informed. The residents were satisfied with the amount of information made available to them about the home and were very happy with the care and attention they received. The Surrey Multi-Agency Procedures were in evidence and up to date. Staff had received Protection of Vulnerable Adults training. There had been no recorded instances of concern at the home and the residents were all well and happy. Upalong DS0000013817.V269153.R01.S.doc Version 5.0 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 the following standard(s): 19. The residents benefited from a recent redecoration of the premises and there was some additional repairs being completed. Overall the premises and grounds were in good order. EVIDENCE: The home had been redecorated and radiators, skirting boards and coving had been highlighted in contrasting colours that helped to add to the welcoming atmosphere of the home. The premises were clean and airy and a homely atmosphere prevailed throughout the inspection. Repairs were being carried out to the rear of the premises and this area was not accessible to residents in respect of health and safety. The front gardens were in good condition as the season allowed. Upalong DS0000013817.V269153.R01.S.doc Version 5.0 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29 and 30. Staff rotas were adequate and there was sufficient staff available for each shift. Staff training was comprehensive, providing residents with staff that had a good command of the core skills required. There was however a recommendation for further training. There were no recruitment issues at the home due to the retention of staff. EVIDENCE: Six staff files were inspected and particular attention was paid to the night shift rota to ensure staff had the sufficient mix of skills to ensure the safety and welfare of the residents. The night-staff had received mandatory training that included: health and safety, fire Safety, safe manual handling, first aid and basic food hygiene and were adequately trained to ensure the health and welfare of the residents. Evidence of any basic ‘safe medication administration’ training was not available. The local pharmacy visits every three months and there were no reported concerns. There were no outstanding recruitment issues and files showed that the relevant requirements from the last inspection had been met. Upalong DS0000013817.V269153.R01.S.doc Version 5.0 Page 15 Most staff had received NVQ levels 2-4 and or was engaged in the pursuit of continuous professional development supported by the manager who is also pursuing her NVQ Management awards. Please see requirements section of this report. Upalong DS0000013817.V269153.R01.S.doc Version 5.0 Page 16 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,35 and 38. The residents and their relatives had received a Quality Assurance questionnaire from Upalong that would of benefited by including feedback from other health and social care professionals and visitors to the home. Upalong’s policy for handling resident’s money was not in evidence however staff were not involved with handling residents money. The relevant health and safety procedures and training promotes the safety and well being of staff and residents. EVIDENCE: Upalong had completed a quality assurance monitoring process with residents and their relatives but it would have benefited from the inclusion of feedback from others not directly linked to the home such as the community health and social care practitioners, visitors and the vicar. It was recommended that their views be sought at the next opportunity. Upalong DS0000013817.V269153.R01.S.doc Version 5.0 Page 17 The replies received from the relatives and residents were positive and praiseworthy and in keeping to the comments received by the inspector. Upalong’s policy relating to the handling of residents money was not in evidence but the home doesn’t take any active part in this area of care. Relatives and residents themselves manage their own financial affairs. There were no health and safety matters of concern observed or reported to the inspector. The fire brigade had recently attended the home due to a faulty alarm going off. The alarm system is relayed directly to the local fire station. Please see the recommendations and requirements section of this report. Upalong DS0000013817.V269153.R01.S.doc Version 5.0 Page 18 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 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 4 X X X X X X X STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 2 X X 3 Upalong DS0000013817.V269153.R01.S.doc Version 5.0 Page 19 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 OP30 Regulation 18. (1)(a)(c) Requirement The registered person must ensure that staff receive a full and appropriate training to include safe medication administration. The registered person must ensure that the care home provides information to residents regarding the homes policies and practices relating to the handling of residents money. Timescale for action 21/01/06 2. OP35 20. 21/01/06 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 OP12 Good Practice Recommendations It was recommended that a pen-picture regarding residents background and previous activities should be discussed and if appropriate included within the new activity recording format. It was recommended that Upalong include others not directly linked to the home when next conducting a quality assurance monitoring exercise.
DS0000013817.V269153.R01.S.doc Version 5.0 Page 20 2. OP33 Upalong Upalong DS0000013817.V269153.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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