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Inspection on 02/06/05 for Upsall House

Also see our care home review for Upsall House for more information

This inspection was carried out on 2nd June 2005.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provides a very good service to residents who confirmed this at interview. I spoke with six residents who all expressed their care was very good. Assessments of residents needs are detailed and include specific risk assessments for people who are at risk of injury if they fall. A positive outcome is there is less falls occurring causing bone injuries.

What has improved since the last inspection?

The care records have improved since the last inspection though further development is required. A deputy manager has been appointed to give continuous support to the staff and her role is also to audit care plans. A training officer ensures all staff have training in keeping with TOPPS.

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE Upsall House Guisborough Road Middlesbrough TS7 0LD Lead Inspector Lyn Burrell Unannounced 2 June 2005 10:00 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. Upsall House B51-B01 S91 Upsall House V230742 020605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Upsall House Address Guisborough Road Middlesbrough TS7 0LD 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) 01642 300429 Upsall House Residential Homes Limited Mrs Pamela Parry Care Home 30 Category(ies) of OP Old age (30) registration, with number of places Upsall House B51-B01 S91 Upsall House V230742 020605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 08/09/04 Brief Description of the Service: Upsall House is a two storey converted private dwelling set in spacious and attractive grounds with extensive views across to the Cleveland Hills. The home is well appointed with three lounges and a dining room. Accommodation is provided in 30 single bedrooms, 24 of which have an en-suite facility.The home is registered to provide care for thirty older persons. Upsall House B51-B01 S91 Upsall House V230742 020605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A tour of the home showed that it was clean, tidy and fairly well decorated in most parts of the home. However the proprietor must consider replacing carpets and chairs throughout the home as they are worn. Six of the residents interviewed were very satisfied with the care they received. They and felt happy and well cared for. Two relatives who were visiting the home also confirmed the care delivered to the residents was very good. 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. Upsall House B51-B01 S91 Upsall House V230742 020605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Upsall House B51-B01 S91 Upsall House V230742 020605 Stage 4.doc Version 1.30 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 standard(s) 3 All residents have their needs assessed prior to admission. This ensures the home can provide the appropriate care the resident needs. EVIDENCE: Prior to admission the manager views the care managers assessment and also reassesses the person using a detailed questionnaire. Within the assessment a whole picture is formed that includes risk elements particularly if the person is at risk of falling. It is also interesting to see there is a pen portrait of the person’s life and what kind of work the person did. This information includes family, hobbies and historic events in their life. Upsall House B51-B01 S91 Upsall House V230742 020605 Stage 4.doc Version 1.30 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 standard(s) 7,8 Progress has been made to improve care planning, however there is still some areas that require improvement. Health related issues are dealt with by the Primary Health Care team which includes the GP, District Nurse, Optician, chiropodist & dentist. EVIDENCE: Although the care records are detailed and care plans and risk assessments follow from the initial assessment of need. Evaluation of the care given is not complete. Therefore this does not give a clear picture of improvement or deterioration of the person’s well-being. Health related issues are dealt with by the appropriate health care professional. GP’s will visit on request and the home has 24-hour contact with NHS Direct if necessary. The District Nursing service frequently visits the home to deliver any nursing interventions or therapies. Upsall House B51-B01 S91 Upsall House V230742 020605 Stage 4.doc Version 1.30 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 standard(s) 13,15 Residents’ families and friends are welcome to visit at any reasonable time and residents go out in the community as they choose. The residents said that they are suitably catered for with a well-balanced menu that meets their tastes however there was not an alternative menu available. EVIDENCE: During the inspection several visitors came in and out of the home and spent time with their relative. It was also noted that one resident went out for the day to enjoy the local shops and local facilities. The menus lack choice though the residents said they enjoyed the homemade foods. The cook is aware of the residents’ likes and dislikes and asks for their preferences prior to each meal. There is a well-stocked pantry and fresh produce is delivered daily to the home from local suppliers. A menu should be available to the residents at each mealtime to allow them to choose their meals. The menus do not show that there is fresh fruit available that is in keeping with the government guidelines for healthy eating. Upsall House B51-B01 S91 Upsall House V230742 020605 Stage 4.doc Version 1.30 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 standard(s) 16,18 Complaints are handled appropriately and objectively. They are all treated seriously and investigated fully by the management team. All staff have had training in Adult Protection. EVIDENCE: The home has a detailed complaints procedure and supporting records. In the last year there have been 3 complaints made to the home all of which were managed appropriately. Residents said they felt confident and able to approach the manager or the owners if it was necessary. Records show that all staff have received training in adult protection and are aware of the “NO Secrets” guidance and protocols to follow. Upsall House B51-B01 S91 Upsall House V230742 020605 Stage 4.doc Version 1.30 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 standard(s) 19,25,26 The standard of the environment within the home is poor with little evidence of improvement through furniture replacement and future planning. The does not present as a homely and comfortable environment for the residents. The home is clean and tidy throughout. EVIDENCE: Whilst touring the home it was noted that there were chairs and carpets that were well worn and improve the environment if they were replaced. Chairs were noted to have “bottomed out” and were not comfortable to sit in. residents confirmed they did not like some of the chairs because of this. Many of the chairs and soft furnishings have been in the home since it was built and a plan of refurbishment must be implemented. There were no physical hazards identified and the home was clean and tidy throughout. Upsall House B51-B01 S91 Upsall House V230742 020605 Stage 4.doc Version 1.30 Page 12 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) 29,30 The recruitment policy is detailed and ensures all checks are undertaken on each applicant to protect the residents. Staff receive appropriate training to undertake their roles. EVIDENCE: Staff records showed that each employee provided the home with references, from a previous employer and a criminal records bureau check. Records are retained under DATA protection compliance. 75 of the care staff have achieved NVQ2 & 3 in care. There is a training officer employed and there is a annual training plan in place that covers all Health & Safety issues and care practises Upsall House B51-B01 S91 Upsall House V230742 020605 Stage 4.doc Version 1.30 Page 13 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 The health and safety of residents and staff are recognised and the home meets the legislative requirements. EVIDENCE: The maintenance certificates were up to date and showed appliances were regularly serviced. Staff received training in health and safety and also had fire training twice a year. Upsall House B51-B01 S91 Upsall House V230742 020605 Stage 4.doc Version 1.30 Page 14 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 2 x x x x x 2 3 STAFFING Standard No Score 27 x 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x x 3 Upsall House B51-B01 S91 Upsall House V230742 020605 Stage 4.doc Version 1.30 Page 15 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. Standard 7 15 19 Regulation 13,15,17 Requirement Timescale for action 3 July 2005 3 July 2005 31 October 2005 All care plans must evaluated monthly 4,13,14,1, An availalternative menu must 5,16,18 be available for residents to choose from a wholesome diet. 4,23 Corridor carpets and worn chairs must be replace and a refurbishing programme be in place. 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 Good Practice Recommendations Upsall House B51-B01 S91 Upsall House V230742 020605 Stage 4.doc Version 1.30 Page 16 Commission for Social Care Inspection Unit B, Advance St Marks Court Teesdale, Stockton-on-Tees TS17 6QX 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 Upsall House B51-B01 S91 Upsall House V230742 020605 Stage 4.doc Version 1.30 Page 17 - 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. 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