Inspection on 23/01/06 for Upper Mead

This inspection was carried out on 23rd January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

Upper Mead 04/07/07

Upper Mead 13/09/06

Upper Mead 27/10/05

Upper Mead 23/09/04

Upper Mead 20/05/04

Upper Mead 25/11/02

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Upper Mead Fabians Way Henfield West Sussex BN5 9PX Lead Inspector Mrs S Gawley Unannounced Inspection 23rd January 2006 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 Upper Mead DS0000024232.V278555.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Upper Mead DS0000024232.V278555.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Upper Mead Address Fabians Way Henfield West Sussex BN5 9PX 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) 01273 492870 01273 494946 Dr Shafik Hussien Sachedina Mr Shiraz Boghani Mrs Elizabeth Nellie Kandi Care Home 48 Category(ies) of Dementia - over 65 years of age (11), Old age, registration, with number not falling within any other category (37), of places Physical disability (7) Upper Mead DS0000024232.V278555.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Accommodation is provided in two separate units. A maximum of 48 Service Users may be accommodated. Unit one is for 11 Service Users in the category dementia, over 65 years of age - DE (E). Unit two is for 37 Service Users in the category older persons not falling within any other category (OP). Unit two may include in its number of Service Users up to seven persons in the category physical disability aged 50 years and over (PD) 27th October 2005 Date of last inspection Brief Description of the Service: Upper Mead is a care establishment, that provides nursing, and is registered to accommodate a total of 48 residents. Upper Mead is a large detached property located in the West Sussex village of Henfield, close to housing and shops. it has pleasant accessible grounds. Sussex Health Care privately owns the service, and the responsible person acting on behalf of the company, is Mr S Boghani Upper Mead DS0000024232.V278555.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on 23rd January 2006 and the home was inspected against the National Minimum standards. The manager was available throughout to facilitate the inspection. Residents, visitors and staff were spoken to and all expressed satisfaction with the quality of care in the home. These comments as well as observations from the inspection of the building will be used in compiling this report. What the service does well: What has improved since the last inspection? 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. Upper Mead DS0000024232.V278555.R01.S.doc Version 5.1 Page 6 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 Upper Mead DS0000024232.V278555.R01.S.doc Version 5.1 Page 7 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): 3. No resident moves into the home without having had his/her needs assessed and been assured that these will be met. EVIDENCE: The manager stated that all Residents admitted to Upper Mead have a pre assessment, she does the majority but 2 Registered Nurses can do so when she is on leave. When an emergency admission is requested, it is only accepted if a pre assessment is possible. This ensures that the home can meet residents needs. Upper Mead DS0000024232.V278555.R01.S.doc Version 5.1 Page 8 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): 9. Residents, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. 10. Resident feel they are treated with respect and their right to privacy is upheld. EVIDENCE: Medicine Administration Charts inspected were to date with topical agents now being signed for correctly. The issue of storage of topical creams in the bathroom of a shared room was discussed with the Registered Nurse for the floor and the manager. The items were in general disarray and it could not be guaranteed that each resident had their own items administered. This could pose a risk to the residents. Residents spoken to stated that they are treated with respect at all times. Upper Mead DS0000024232.V278555.R01.S.doc Version 5.1 Page 9 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): 13, Residents maintain contact with family/ friends/ representatives and the local community as they wish. 14, Residents are helped to exercise choice and control over their lives. EVIDENCE: Residents and relatives were spoken to and all stated that there is freedom of movement in the home and relatives are welcome at all times and residents can go out as they wish. One relative stated that the home is very accommodating in organising trips and appointments with his relative who has mobility difficulties. Upper Mead DS0000024232.V278555.R01.S.doc Version 5.1 Page 10 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. will 17. 18. Residents and their relatives and friends are confident that their complaints be listened to, taken seriously and acted upon. Residents legal rights are protected Residents are protected from abuse EVIDENCE: There is a written complaints procedure, which is provided to service users in the Statement of purpose and Service Users Guide, and it was displayed on the entrance wall. Residents spoken to stated that they would know how to make a complaint and were confident that it would be dealt with. They are enabled to vote if they wish to do so. Systems and procedures and training are in place to protect residents from harm. Upper Mead DS0000024232.V278555.R01.S.doc Version 5.1 Page 11 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. Residents live in a mostly safe and well-maintained environment. 22. Residents have the specialist equipment they require to maximise their independence. 23. Service users’ own rooms suit their needs 26. The home is clean, pleasant and hygienic EVIDENCE: The home is clean and well maintained. It is mostly safe environment for residents but automatic door closures are not in place on all doors as yet and some doors were wedged open. There are sufficient hoists, wheelchairs and specialist equipment to meet resident’s needs. The home was clean and free from offensive odours today. Residents rooms are comfortable and personalised where possible. They are well maintained with the exception of one room, which had a worn table edge. This was discussed with the manager. There are suitable laundry facilities and the issue of correct mop Upper Mead DS0000024232.V278555.R01.S.doc Version 5.1 Page 12 storage and the practice of soaking clothing in the laundry sink, which was a recommendation of the last inspection, have been addressed. Upper Mead DS0000024232.V278555.R01.S.doc Version 5.1 Page 13 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. The numbers and skill mix of staff do not meets residents needs at all times 29. The home’s recruitment policy and practices mostly support and protect residents. EVIDENCE: One member of staff and one resident stated that the numbers of staff at weekends is not sufficient. Two days were cited when there were only four carers instead of the usual six with two Registered Nurses on duty. The Resident stated that she had not been given her bath due to staff shortages. The need to maintain adequate numbers of staff based on resident need, to ensure their health, safety and wellbeing was discussed with the manager. The manager stated that problems usually occur due to sickness and that there are financial constraints on the use of agencies. Travel difficulties are also, she stated a problem. Policies and procedures are in place on recruitment to ensure the Residents are protected. Staff files inspected were up to date with all of the necessary documentation with the exception of one Registered Nurse whose Personal Identification Number which evidences registration with the Nursing and Midwifery Council was not recorded. These shortfalls could put resident’s health and safety at risk. Upper Mead DS0000024232.V278555.R01.S.doc Version 5.1 Page 14 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. The home is run in the best interests of service users. 35. Residents’ financial interests are safeguarded. 38. The health, safety and welfare of service users and staff are promoted and protected. EVIDENCE: Resident’s positive comments on the home far outweighed any negative comments made. The home has a caring, homely atmosphere and staff feel mostly well supported with the only problem mentioned that of staff shortages at times. The home does not hold any monies or bank accounts for Residents. The health, safety and welfare of service users and staff are promoted and protected by the training, which is in place, the need for ongoing update was discussed in reference to cleaning staff. The home complies with requirements of statutory bodies which is ongoing work in relation to the installation of automatic door closures. Upper Mead DS0000024232.V278555.R01.S.doc Version 5.1 Page 15 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 X X 3 3 X X 3 STAFFING Standard No Score 27 2 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 3 Upper Mead DS0000024232.V278555.R01.S.doc Version 5.1 Page 16 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 OP27 Regulation 13,18 Requirement Timescale for action 31/03/06 2 OP29 19 Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health The registered person to obtain 31/03/06 in respect of all staff the information and documents specified in (i) paragraphs 1-7 in schedule 2 Upper Mead DS0000024232.V278555.R01.S.doc Version 5.1 Page 17 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 OP9 OP19 Good Practice Recommendations The storage of topical agents to particularly in shared rooms to be reviewed. The programme of maintenance to complete the installation of automatic door closures and the renewal of furnishings. Upper Mead DS0000024232.V278555.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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 Upper Mead DS0000024232.V278555.R01.S.doc Version 5.1 Page 19 - 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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