Inspection on 28/10/05 for Upsall House

This inspection was carried out on 28th October 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Upsall House 07/09/07

Upsall House 02/10/06

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 OLD Lead Inspector Lyn Burrell Unannounced Inspection 28th October 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 Upsall House DS0000000091.V258292.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. Upsall House DS0000000091.V258292.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Upsall House Address Guisborough Road Middlesbrough TS7 OLD 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.V258292.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd June 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 spacious dining room. Accommodation is provided in 30 single bedrooms, 24 of which have an ensuite facility that comprises of a WC and hand basin. A lift is available for the residents to take them to the first floor rooms. The home is registered to provide personal care for thirty older people. The home is close to Guisborough, Nunthorpe and Ormesby and buses are accessible to the local areas. A train station is also within walking distance of the home. Upsall House DS0000000091.V258292.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A positive inspection, whereby nearly all of the National Minimum Standards looked at was met. The inspection lasted three and a half hours with one inspector; three residents were interviewed. During this inspection discussion with residents took place, the inspector walked around the home, read the Statement of Purpose, medication records, social activity within the home, staffing levels, staff training records, staff supervision records and quality assurance information. A tour of the home showed that it was clean, tidy and well decorated throughout. What the service does well: What has improved since the last inspection? The home has continued to offer an excellent care service to the residents but it has not improved the living environment as the chairs and carpets have not yet been replaced. The action plan from the last inspection states that chairs and carpets will be replaced on a rolling programme. Upsall House DS0000000091.V258292.R01.S.doc Version 5.0 Page 6 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.V258292.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 Upsall House DS0000000091.V258292.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): 1,6 Full information is available to prospective residents to allow the person to make an informed decision as to whether or not to move into the home. Intermediate care is not provided at Upsall House. EVIDENCE: The Statement of Purpose gives a description about the persons responsible for the home and the registered manager. A description of the staff that works at the home and the qualifications they have achieved. It also describes the care that is offered to people requiring personal care and also the services that are available including access to the emergency services. A copy of the Statement of Purpose in a summarised information leaflet is in every bedroom and on the notice board. This is available for anyone to read or take away with them. Upsall House DS0000000091.V258292.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): 9,10 Medication arrangements are safe, and the administration; recording and handling systems are appropriately managed, which will ensure that service users receive their medication as prescribed by their GP. Arrangements are in place to help preserve service users’ privacy and dignity. EVIDENCE: An arrangement has been agreed with the local pharmacist and the monthly prescriptions are collected from the residents GP surgery and the chemist delivers the medication to the home. The records for handling and returning medication is detailed and there are signatures from the senior carer on duty and the person who collects unused medicines. The records are up to date and accurate. Upsall House DS0000000091.V258292.R01.S.doc Version 5.0 Page 10 During discussion with some of the residents they confirmed that the staff were kind and respectful towards them. The home was a happy place where the staff spent time with the residents. The staff assisted residents at mealtimes and also whilst they were carrying out there day to day work. The residents said “ staff always knock on the door before coming in” and their privacy was maintained in bathrooms and bedrooms. A gentleman said he always received his mail unopened but if he needed the staff to open his letters they will. Upsall House DS0000000091.V258292.R01.S.doc Version 5.0 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): 12,15 Residents are offered the opportunity of participating in a wide range of leisure and social activities enabling them to lead active and fulfilled lives. Information is given to residents to allow them control over their lives. EVIDENCE: A daily record of activities that have been available is kept, the record shows which residents that have participated. Activities include going out with families, reading and discussing newspaper headlines, television and sport. Each person living in the home discusses their hobbies, likes and dislikes with the key carer to ensure that the activities are arranged to suit as many people as possible. Some residents said, “Although there was various things to do they didn’t want to join in”. Group activities include singers and choirs coming in to the home for evening and afternoon entertainment. The residents said they have recently enjoyed a trip to the theatre and in the summer there was a garden fete. Nearer to Christmas a family night is planned whereby relatives and children are invited to enjoy the entertainment. Upsall House DS0000000091.V258292.R01.S.doc Version 5.0 Page 12 Residents are promoted in maintaining their independence for as long as they are able or choose. Many residents are happy for there family to see to their financial matters. A notice board is in the main entrance that shows telephone numbers of Citizens Advice Bureau and other agency’s the residents’ may wish to contact. The resident’s bedrooms show they are personalised with their belongings and they said, “It makes a difference to them having their memories around them”. Upsall House DS0000000091.V258292.R01.S.doc Version 5.0 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): This standard was not assessed on this occasion. EVIDENCE: Upsall House DS0000000091.V258292.R01.S.doc Version 5.0 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 The home is clean, fairy well decorated in parts and satisfactorily maintained. This can help promote a positive image for service users, and ensure they remain safe. The standard of the environment within the home is poor with little evidence of improvement through furniture replacement and future planning. The home does not present as a homely and comfortable environment for the residents. 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. Upsall House DS0000000091.V258292.R01.S.doc Version 5.0 Page 15 There were no physical hazards identified and the home was clean and tidy throughout. There have been no improvements since the last inspection. Upsall House DS0000000091.V258292.R01.S.doc Version 5.0 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 Staffing levels are sufficient to effectively meet the needs of service users living in the home. The staff have had training in relation to the care needs of service users, to ensure they have a good understanding of these needs and how they can be met. EVIDENCE: There are 30 residents living in the home and there are six carers on duty from the morning to afternoon, followed by four carers in the evening and two carers on night duty. A senior carer is on duty at all times and the manager or deputy manager is available via the on call process. 86 of the staff have achieved a National Vocational Qualification in care some at level 2 and others at level 3. All staff have had training in Adult Protection and are aware of the “No Secrets” policy and procedure that they must follow should they suspect abuse of a person may have happened. Upsall House DS0000000091.V258292.R01.S.doc Version 5.0 Page 17 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): 33,36 Views of the residents are sought in order that they can contribute to the development of the service. Staff are appropriately supervised which assists in promoting and safeguarding the best interests of the resident’s. EVIDENCE: The management team view the quality of their service as being paramount as all services in the home are monitored periodically. As part of the monitoring process the incidence of resident falls are counted. An action plan would be put into place if the same person is having multiple falls or other trends or patterns were seen. As part of this plan the health care team is involved to ensure the well being of the resident. Care records and policies are audited annually as is the environment; this is to ensure high standards are maintained in the home. Upsall House DS0000000091.V258292.R01.S.doc Version 5.0 Page 18 This audit also includes the effectiveness of suppliers to the home. The staff review care plans monthly and amend them as required. The last residents meeting was held in August 2005 and as a result of this a new TV Ariel was purchased for the snug lounge. The residents said they enjoyed going to the theatre and would like to go again. A notice board is now displayed in the entrance area to display relevant information and forthcoming social events. The residents survey was positive, the survey asked about the quality of the accommodation, standards of care, facilities available to them, meals and suggestions to improve the service. The survey also included family members and it was anonymised to promote people to speak freely about the home. The relative’s response to the survey was also positive. Each member of staff receives a formal supervision every two months this includes observed care practises and detailed records are kept. To go hand in hand with the supervision all staff have an annual appraisal that covers personal development and training. Upsall House DS0000000091.V258292.R01.S.doc Version 5.0 Page 19 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 X X X X X X X STAFFING Standard No Score 27 3 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X 3 X X Upsall House DS0000000091.V258292.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 4,23 Requirement Corridor carpets and worn chairs must be replaced and a refurbishing programme is in place. Timescale for action 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Upsall House DS0000000091.V258292.R01.S.doc Version 5.0 Page 21 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.V258292.R01.S.doc Version 5.0 Page 22 - 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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