Inspection on 02/10/06 for Upsall House

This inspection was carried out on 2nd October 2006.

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

Upsall House 07/09/07

Upsall House 28/10/05

Upsall House 02/06/05

Upsall House 08/09/04

Upsall House 14/04/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Upsall House Guisborough Road Middlesbrough TS7 0LD Lead Inspector Neil McKenzie Key Unannounced Inspection 2nd October 2006 12:30 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 Upsall House DS0000000091.V313574.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. Upsall House DS0000000091.V313574.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Upsall House Address Guisborough Road Middlesbrough TS7 0LD 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) 01642 300429 Upsall House Residential Homes Limited Mrs Pamela Parry Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Upsall House DS0000000091.V313574.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th October 2005 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 has a no smoking policy. Upsall House DS0000000091.V313574.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. The inspection lasted for 6 hours. The reason for the inspection was to see how good a job the home does in meeting the National Minimum Standards for Care Homes. During the visits the inspector spoke to 4 residents, 1 relative and 4 staff to find out what their views were about living and working at Upsall house. The inspector also spent time speaking to the manager of the home. The inspector spent some more time watching how staff and residents are with each other. A tour of the home took place and records looked at included staff recruitment, staff levels and staff training records. In addition resident care plans, opportunity for social activity, and how the home handles medication were also looked at. There was also questionnaire sent to the home, this was looked at to help decide how good a job the home does in meeting the National Minimum Standards. At the time of the inspection the minimum cost for a bed was £335.00 per week and the maximum cost for a bed £353.00 per week. There are additional costs for hairdressing, chiropody, taxi service and personal items. What the service does well: The home provides a clean environment that is well maintained and has a large garden with pleasant views for residents. Rooms seen at the time of the inspection were personalised with resident furniture, mini fridges, televisions, photographs and pictures. Resident and relative comments included; ‘Nothing could be better’ ‘I think it is lovely, it is homely, good food, lovely room with a patio and you get well looked after’ ‘This is better than the other one, grub is better, room is better’. ‘Oh I like it, food is good, carers is good’ ‘Staff polite’ Upsall House DS0000000091.V313574.R01.S.doc Version 5.2 Page 6 95 of staff have achieved a National vocational qualification in Care at either level 2 or 3 and experience other regular specialist training in, for example, dementia. 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 DS0000000091.V313574.R01.S.doc Version 5.2 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 Upsall House DS0000000091.V313574.R01.S.doc Version 5.2 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): 1 and 3. The home does not provide intermediate care The quality in this outcome area is good as residents’ benefit from a statement of purpose describing the services of the home and a needs assessment before moving into the home. This judgement has been made using available evidence from resident care records and interviews with staff and residents. EVIDENCE: The statement of purpose gives a description about the persons responsible for the home and describes the care that is offered to people requiring personal care and other services. The home is a no smoking home and this is stated at the front of the statement. A copy of the statement of purpose was observed in resident bedrooms. 4 resident records examined, the 2 residents referred through Care Management arrangements had a copy of their needs assessment completed by a professional in their record. 2 residents who were self funded and without Care Management assessment had a needs assessment covering social, personal and physical wellbeing completed by the manager. This initial assessment is reviewed after 6 weeks to ensure the home can meet the needs of resident. Upsall House DS0000000091.V313574.R01.S.doc Version 5.2 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): 7,8,9 and 10 The quality in this outcome area is adequate. This judgement has been made using available evidence from resident files, the pre-inspection questionnaire, and interview with resident, staff and manager. EVIDENCE: In the 4 resident records sampled by the inspector each resident’s had a personal care plan that included daily records documented in their file. These plans and daily records were up to date in their recording and demonstrated involvement of other health specialists such as district nurses and doctors. The records included a separate file for visiting doctors to pass on information to staff at the home. Care plans included risk assessments on manual handling, nutrition, and falls. These risk assessments involve relatives who have opportunity to sign them if in agreement. New residents have an initial 6-week assessment care plan that is reviewed before the final care plan is agreed. The staff review care plans monthly and amend them as required. Upsall House DS0000000091.V313574.R01.S.doc Version 5.2 Page 10 During the inspection the home’s policy and procedures and arrangements for receiving, storing, administering, recording and disposing resident’s medication were observed, examined and discussed in depth with the senior staff member responsible to administer medication that day. At the time of the inspection visit, medication was seen to be correctly stored with accurate records for disposal. Separate records for controlled drugs counter signed when administered by 2 qualified members of staff showed that the stock exceeded by one tablet. Staff interviewed stated that only qualified senior staff handled medication. Staff members who handle medication attend an external training course and receive a certificate on completion. These certificates are displayed in the room where medication is stored. At the time of the inspection the senior member of staff on duty certificate was not available. The manager stated that the staff member had completed the course successfully but the certificate had yet to be obtained from the college. Individual residents’ medication record sheets did not contain photographs of the person to help ensure that residents receive the correct medication. At the time of the inspection there were no residents who were administering their own medication. The residents’ who spoke to the inspector stated that staff treated them with respect and dignity. Comments made by residents included, ‘Oh I like it, food is good, carers is good’ ‘Staff polite’ ‘They help me with undressing and wash me down, she is very good’ ‘Ring the bell, someone comes straight away’. Upsall House DS0000000091.V313574.R01.S.doc Version 5.2 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 the following standard(s): 12,13,14 and 15 The quality in this outcome area is good. This judgement has been made using evidence from a tour of the home, observation, and interview with residents, staff and relative. EVIDENCE: One relative visiting on the day of the inspection stated, ‘made to feel welcome here, nothing could be better’. Residents interviewed confirmed that family members visit them on a regular basis and are involved in their care plans. One resident showed a bird stand and bench on his patio area outside his room provided to him by his visiting relatives. Residents who spoke to the inspector suggested there was enough activity that included trips out. One resident stated that she was soon to go on a planned trip to the theatre. Another resident had a personal activity plan that involved family and friends from outside of the home. This included badminton 3 times a week, walking club 2 times a week and a night out once a week. This activity plan included packed lunches chosen by the resident. Other activity available for residents included games, dance and singing, hairdresser, reading in a small lounge described as a ‘snug’ library and television. At the time of the inspection a group of residents involved themselves in a game of dominoes. Upsall House DS0000000091.V313574.R01.S.doc Version 5.2 Page 12 Another resident enjoyed a beer whilst watching television in his room after lunch. Photographs displayed in the home included a recent garden fete organised by the home for all residents. On the whole residents were observed to receive a wholesome and balanced diet. Choice of sandwiches, home made soup and flan provided as the main course for lunch. Choice of quiche or roast beef with vegetables and home made custard or cherry pie for tea. Cakes also made available for snacks. Residents interviewed stated, ‘grub is better here’, ‘good food’, ‘oh I like it, food is good’. Upsall House DS0000000091.V313574.R01.S.doc Version 5.2 Page 13 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 18 The quality in this outcome area is good. This judgement has been made using evidence from the pre-inspection questionnaire and documentation of complaints and investigations and interview with staff. Residents are protected by a complaints procedure and a policy and procedure on adult protection and prevention of abuse. EVIDENCE: A relative stated at the time of the inspection, ‘no complaints and if I had any I would act on this’. A complaints procedure is displayed in the home for the benefit of residents and visitors. Complaints are logged in a book. There has been one anonymous letter of complaint since the last inspection that required no further action. The residents are protected by an Adult Protection and Prevention of Abuse policy. This was last reviewed in March 2006. Training on the protection of vulnerable adults is regularly organised by the manager and this provides further protection for residents. The manager stated that 19 of the 28 staff have attended this training. Upsall House DS0000000091.V313574.R01.S.doc Version 5.2 Page 14 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): 19,24 and 26 The quality in this outcome area is good. This judgement has been made using evidence from a tour of the premises, the pre-inspection questionnaire and interview with residents. The residents live in a well maintained home. EVIDENCE: On the whole home provides a clean environment that is well maintained. There was evidence of ongoing refurbishment with new corridor and bedroom carpets and new chairs in the lounge. The kitchen had some cracked tiles that need replacing and the deco appeared ‘tired’ Residents also benefit from a large garden that includes a fishpond with pleasant views of the Cleveland hills. Upsall House DS0000000091.V313574.R01.S.doc Version 5.2 Page 15 Rooms seen at the time of the inspection were personalised with resident furniture, mini fridges, televisions, photographs and pictures. One resident had his own bird stand and bench outside his room on the patio area. Resident and relative comments included; ‘Nothing could be better’ ‘I think it is lovely, it is homely, good food, lovely room with a patio and you get well looked after’ ‘This is better than the other one, grub is better, room is better’. Upsall House DS0000000091.V313574.R01.S.doc Version 5.2 Page 16 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): 27,28,29 and 30 The quality in this outcome area is good. This judgement has been made using evidence from, the pre-inspection questionnaire, rota, staff files and interviews. EVIDENCE: An audit of the duty rota was carried out. At the time of the inspection there were 29 residents living at the home. There was 1 senior carer and 4 care assistants during the morning shift. There was 1 senior carer and 3 care assistants during the afternoon and evening shift. Included in the day shift and supporting all the residents in the home a chef and 1 kitchen assistant, 2 domestics to clean the home, a secretary and the manager. There were 2 care assistants on the rota for the night shift. Day and night staff additional responsibility for laundry on behalf of residents. At times of staff sickness the home draws on existing staff to do a double shift. Staff interviewed stated that doing a double shift happened occasionally. The manager has promoted National Vocational Qualification (NVQ) Level 2 and 3 in Care training to staff to offer residents’ safe and competent staff. At the time of the inspection 95 of care staff had an NVQ level 2 or 3 in Care. In addition there was evidence of staff completing training specific to resident needs. For example, training in Dementia and diabetes. Each staff member has a portfolio with records kept on training and induction. Upsall House DS0000000091.V313574.R01.S.doc Version 5.2 Page 17 At the time of the inspection there was ‘in-house’ trainer completing an induction programme for a new member of staff. This person visits the home twice weekly to coordinate training requirements of staff. The recruitment files of 4 staff were looked at. All files contained application forms and were backed up by two written references. Evidence was in place to show that Criminal Records Bureau disclosures at Enhanced level had been received for staff members working in the home. Upsall House DS0000000091.V313574.R01.S.doc Version 5.2 Page 18 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): 31, 33, 35, 36 and 38 The quality in this outcome area is good. This judgement has been made using evidence from the pre-inspection questionnaire, interview with the manager, staff files, and records. The home is run and managed by a person who is fit to be in charge. EVIDENCE: The manager has been in post for 1 year having been a senior carer in the same home. The manager is currently completing National Vocational Qualification level 4 in management. The 4 staff files examined demonstrated that supervision was happening on a regular basis but tended to focus on policy and procedures practiced by the home. Supervision of staff should include all aspects of each employee’s individual practice in the home. Upsall House DS0000000091.V313574.R01.S.doc Version 5.2 Page 19 Staff training portfolio demonstrated regular training on health and safety, fire awareness and other mandatory requirements. The home has regular meetings with residents to discuss matters important to residents. These meetings are recorded in a book. At the last meeting time was spent discussing the menu with residents. The home has annual resident and relative surveys to ensure the home is run in the best interests of residents. The results of resident surveys should be published and made available to current and prospective residents and other interested parties. The home has financial procedures for handling resident money. These were reviewed in June 2005. At the time of the inspection it was stated by the manager that the home handles no money on behalf of residents. Details of health and safety were made available through the pre-inspection questionnaire and tour of the premises. These records were recorded as up to date with relevant certificates available on request. Upsall House DS0000000091.V313574.R01.S.doc Version 5.2 Page 20 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 X X X X 3 X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Upsall House DS0000000091.V313574.R01.S.doc Version 5.2 Page 21 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 OP19 Regulation 23 (2) Requirement The registered manager must ensure broken kitchen tiles are made good. Timescale for action 30/11/06 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 OP9 Good Practice Recommendations The registered manager should ensure individual residents’ medication record sheets contain photographs of the person to help ensure that residents receive the correct medication. Supervision of staff should include all aspects of each employee’s individual practice in the home. The registered manager should ensure any medication discrepancies are investigated and noted. The results of resident surveys should be published and made available to current and prospective residents and other interested parties. 2. 3. 3. OP36 OP19 OP33 Upsall House DS0000000091.V313574.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Tees Valley Area Office 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 DS0000000091.V313574.R01.S.doc Version 5.2 Page 23 - 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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