Care Home: Culworth House Nursing Home

Annual service review Name of Service: Culworth House Nursing Home The quality rating for this care home is: The rating was made on: two star good service 0 9 1 0 2 0 0 8 A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection We do an annual service review when there has been no key inspection of the service in the last 12 months. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection or annual service review.   Has this annual service review changed our opinion of the service?   No You should read the last key inspection report for this service to get a full picture of how well outcomes for the people using the service are being met. The date by which we will do a key inspection: Name of inspector: Ansuya Chudasama Date of this annual service review: 0 2 1 0 2 0 0 9 Annual Service Review Page 1 of 10 Information about the service Address of service: Queens Street Culworth Banbury Oxfordshire OX17 2AT 08453455744 01295768201 martha.cromhout@blanchworth.net Telephone number: Fax number: Email address: Provider web address:   Name of registered provider(s): Conditions of registration: Category(ies) : old age, not falling within any other category physical disability Conditions of registration: Culworth House Partnership Number of places (if applicable): Under 65 Over 65 0 0 35 35 A maximum of 35 residents may be accommodated in the home at any one time. No more residents in the category of OP may be admitted to the home when there are already 35 residents in this category accommodated. No more residents in the category of PD(E) may be admitted to the home when there are already 35 residents in this category accommodated. Have there been any changes in the ownership, management or the Yes service’s registration details in the last 12 months? If yes, what have they been: Date of last key inspection: Date of last annual service review (if applicable): Brief description of the service The Home is situated in 4 acres of secluded gardens in the centre of a rural village. It provides accommodation for up to 35 elderly residents. The accommodation is provided in mainly single rooms with two companion rooms available for those who wish to share. The large surrounding gardens are beautifully kept. They are mainly laid Annual Service Review Page 2 of 10 None 0 9 1 0 2 0 0 8 to lawn with mature trees and shrubs dividing the garden into smaller secluded areas where the people can relax with visitors more privately. It provides 24 hour nursing and personal care. Fees in this home range from £427.74 - £700.00 per week, depending on the facilities and service required by the individual. Annual Service Review Page 3 of 10 Service update since the last key inspection or annual service review: What did we do for this annual service review? We looked at all the information that we have received, or asked for, since the last key inspection or annual service review. This included: The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. Surveys returned to us by people using the service and from other people with an interest in the service. Information we have about how the service has managed any complaints. What the service has told us about things that have happened in the service, these are called notifications and are a legal requirement. The previous key inspection and the results of any other visits that we have made to the service in the last 12 months. Relevant information from other organisations. What other people have told us about the service. What has this told us about the service? The home sent us their annual quality assurance assessment (AQAA) when we asked for it. It was clear and gave us all the information we asked for. We looked at the information in the AQAA and our judgment is that the home is still providing a good service and that they know what further improvements they need to make. We received 10 survey questionnaires that were completed by the people with help from their relatives. The feed back was very positive. Some of the feedback include: All the people said that they received enough information to help them decide if this was the right home for them. All the people said that they had the terms of conditions. 6 people said that they always receive the care that they need and 4 people said usually receive the care and support they need. 4 people said that the staff were always available when they need them, 5 people said usually and I person said sometimes. 5 people said that the staff listen to them and act on what they say and 4 said usually and 1 said sometimes. 7 people said that they get the medical that they need and 3 people said usually. 8 people said that the home arranges activities that they are able to take part in and 2 said some times. 5 people said that they always like the meals and 5 people said that they usually like the meals. Annual Service Review Page 4 of 10 All the people said that they knew who to speak to if they were not happy. 3 people did not know how to make a complaint but 7 people did know this. 6 people said that the home is always clean and fresh and 4 people said usually. We also received comments about what the home does well and these include: friendly staff provides a comfortable surroundings and is a happy place always have time to talk good food safe kind care welcome and terrific friendliness of staff they take good care of the residents. The comments received for what the home could do better is as follows: More staff at night time more entertaining and not just let them sit there and sleep arrange help for me to get to hospital appointments, there isnt always some one to take me. Sometimes short staffed which may have knock on effect in fewer activities. We also received 3 survey questionnaires. Two were from GPs and one was from social services care manager. These were very positive about the home. One comment said that their contact with the staff and manager have always been helpful; residents seem to be well cared for and happy. Another comment said the home provides excellent services to elderly people in the home for their needs, staff is generally extremely helpful and responds nicely and effectively to any real issues. Comments about what the service could do better was said to have less bank staff. The AQAA says we do the following to ensure that the views of people who use our services are promoted and incorporated into what we do and this includes: Suggestion/comment forms are on display by the signing in book in the entrance hall. If any visitor wishes to complete this and leave at the home, they are able to. Regulation 26 visits incorporate one to one conversations with the residents and or relatives within the Home. They are asked to speak freely regarding any issues they may have. These are recorded appropriately and actioned as necessary. Quality assurance questionnaires are sent annually to all residents, relatives and visiting professionals for completion. Questionnaires returns are audited and any necessary action is taken and if required with a written response sent to the individual. The statistics are feedback to the staff in the Home who provides an action plan of how to improve in the areas where low scores were received. Any respite resident and family receive a Quality Assurance Questionnaire for each stay. Meetings are held at regular intervals for residents/relatives. Staff are taught the importance of equality and diversity as part of the induction programme. The AQAA says We have made the following changes as a result of listening to people who use our services and some of these are: Annual Service Review Page 5 of 10 Activities are provided for residents who, wish to participate. One to one sessions are also conducted. Admission procedures are now more person centred and prospected residents are invited to come and spend time at the home either mornings or afternoons. During this time assessments are carried out by the manager. This ensures residents care needs can be met if they decide to move into the home. On admission. Time is spent with each resident and relative, completing care plans and assessments for each individual assessed need. This ensures the residents are involved in planning their care. There has been more involvement from residents in care plan process, with regular reviews to ensure the care provided is more person centred. The care plan booklet has been updated and improved to make it more user friendly with some additions and improvements to some of the records. All care plans for residents have been transferred to the new documentation and are more person centered. Risk assessments such as self administering medications have been improved. However, there is no one currently self administering medications at the home. There is a new mobility report giving good up to date information regarding the mobility status of residents which is important from a health and safety point of view. Choice and capacity forms are in place with regards to how each individual resident chooses, or chose to take their medication. This has provided medication provision in a more person centred manner. Increased the number of hours provided by maintenance staff Improved the quality of our maintenance staff Maintenance of the Home continues on a rolling scheduled Replaced some flooring and some furnishings at the home that were identified by the home manager and during regulation 26 visits. A significant recruitment campaign was undertaken to try to reduce our reliance on agency staff. Staff vacancies have been reduced. Greater emphasis has been placed on recruiting the right caliber of staff to ensure good quality staff appropriate for the home. There is better communication between the Manager and the Registered Provider to ensure that staffing levels and competency are appropriate for the home. Annual Service Review Page 6 of 10 There has been increased emphasis placed on staff and training provided to ensure the provision of care to be more focused and person centred. There has been greater use made of external accredited training. Regulation 26 visits are more in depth to ensure that there is a more proactive approach to problem solving following the regulation 26 visits. Focus on improved health and safety. For example an improved fire risk assessment and the introduction of a bedrail policy and procedure with checklists. Manager and Maintenance staff at the home have currently undertaken an external Health and Safety course. The AQAA says we know that we give a service that provides value for money because: 37 questionnaires were sent out in June 2008 and there were 19 responses. 55 reported that they felt the accommodation was good. 94 reported that care was good. 100 reported that admission and discharge procedures were good. 83 reported food and cleaning were good. 69 reported activities in the home were good. 68 reported chiropody was good. 5 respite residents that responded said that they would return. We have had good responses from residents when visiting the home during regulation 26 visits. Comments throughout the year include: Settled in really well. Lovely place and staff are so good. No concerns to raise. Food very nice Staff are very helpful and understanding. Given choices of meals and drink though out the day and I know who to complain to. The AQAA says that our plans for improvement in the next 12 months is to provide: Further training for staff in 2009 and increase awareness of our new policy on Equality and Diversity The Equality and Diversity handbook to be given to all staff at Induction Improve the website. Improve the information available prior to admission to include photographs on the website. Promote the opportunity for discussion and clarification of the written contract. Annual renewal of contract for self funded residents. Ensure residents are aware that they are able to decorate their own living space to their choice. Update policies and procedures to ensure that Equality and Diversity is recognised throughout the Principles and delivery of Care. Continuation of staff training to ensure person centred care. Ensure the activity programme is further developed to ensure resident choice is paramount. Consider how the activity programme may be rolled out at weekends as well as weekdays. Annual Service Review Page 7 of 10 We have adapted the complaints procedure to make it clear that residents and representatives can contact CQC direct without first having to go through the internal complaints procedure. Arrange for staff to attend external Protection of Adults Alerters courses. The Manager has attended an advanced Protection of Adults Alerters course. We have introduced a mental capacity checklist and best interests checklist into the care planning process. The manager is now responding to complaints independently of senior management team. Who are now available to complainants who feel that a complaint has not been addressed as they wish. From April 2009, introduce a Deprivation of Liberty screening tool and policy and procedure for residents who lack capacity to make informed decisions. Ensure our complaints procedure is given to health care professionals supporting the home. Ensure all staff to attend external Protection of Adults Alerters courses. Ensure The Manager has attended an advanced Protection of Adults Alerters course. Revise the complaints policy to make it more user friendly. Continue the process of ongoing maintenance as set out in the current maintenance. To continue to recruit and retain permanent staff. To foster improved team working. To continue to source good external training. Additional training and support for the Manager. Additional support from the Senior Managers. Promotion of Equality and diversity at the heart of person centred care. An improved internal Quality Assurance programme. Review of the Health and Safety policy and procedures. The AQAA tells us that the home has not received any complaints and no safe guarding of vulnerable adults referrals have been to social services safe guarding team. The home has been sending us regulation 37 notifications and information read shows that that these are managed appropriately. What are we going to do as a result of this annual service review? We are not going to change our inspection plan, and will do a key inspection by 30th September 2010. However we can inspect the service at any time if we have concerns about the quality of the service or the safety of the people using the service. Annual Service Review Page 8 of 10 Annual Service Review Page 9 of 10 Reader Information Document Purpose: Author: Audience: Further copies from: Annual service review CQC General Public 0870 240 7535 (national contact centre) Our duty to regulate social care services is set out in the Care Standards Act 2000. The content of which can be found on our website. Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a copy of the findings in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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