CARE HOMES FOR OLDER PEOPLE
China Cottage Nursing Home 154 Owston Rd Carcroft Doncaster South Yorkshire DN6 8EA Lead Inspector
Ramchand Samachetty Unannounced Inspection 16 March 2006 10:30 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 China Cottage Nursing Home DS0000053683.V273070.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. China Cottage Nursing Home DS0000053683.V273070.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service China Cottage Nursing Home Address 154 Owston Rd Carcroft Doncaster South Yorkshire DN6 8EA 01302 724815 01302 728954 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) Doncaster Property Investment Fund Ltd Mrs Sandra Thomas-Blount Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places China Cottage Nursing Home DS0000053683.V273070.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The service may admit persons between the ages of 60 - 65 years. Date of last inspection 9th August 2005 Brief Description of the Service: China Cottage is a care Home registered to provide personal care and nursing care for up to 33 persons in the category of older adults. The Home is situated in the village of Carcroft, which is about six miles from the town of Doncaster. It is a two-storey building with 29 single and 2 double bedrooms. There is a passenger lift to facilitate access between the floors. Accommodation for residents is provided on both floors. The lounges, dining areas, kitchen and laundry facilities are located on the ground floors. There is also a hair dressing facility for residents. There are patio and lawn areas at the rear of the Home and car parking spaces to the front. China Cottage Nursing Home DS0000053683.V273070.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 16 March 2006, starting at 10.30 hours and finished at 15.30 hours. It consisted of a tour of the premises, conversations with six residents and three relatives, examination of care documentation and other records and observation of some aspects of care provision. The inspector also spoke to four members of staff. The inspector reviewed the progress made since the last inspection and checked those standards that were not addressed. What the service does well: What has improved since the last inspection?
A programme of decoration and refurbishment has been undertaken. The office and the reception areas have been decorated and rearranged. New computers with Internet access have been installed. Three conservatories, a small lounge and four residents’ bedrooms have been decorated. Care assessments and care records have been improved. Staff training and development have progressed well. China Cottage Nursing Home DS0000053683.V273070.R01.S.doc Version 5.1 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. China Cottage Nursing Home DS0000053683.V273070.R01.S.doc Version 5.1 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 China Cottage Nursing Home DS0000053683.V273070.R01.S.doc Version 5.1 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): 3 Residents care needs were appropriately assessed on admission, so this ensured that the Home was able to meet their needs. EVIDENCE: The care files of two service users, who were more recently admitted to the Home, were checked. They showed that their needs had been assessed by both the placing social workers and by staff at the Home. All relevant aspects of their care and support needs were addressed. These also included an assessment of risks. China Cottage Nursing Home DS0000053683.V273070.R01.S.doc Version 5.1 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 and 9. Residents are provided with appropriate plans of care, to guide staff in meeting their individual care needs. Some shortfalls in the management of medicines were identified. These could place residents at risk and they must be addressed. EVIDENCE: A sample of care plans was checked. An improvement has been noted in the way care is documented. Actions to be taken to meet specified needs were clearly laid out. The record of care provided was referenced to the required actions. Care plans were regularly reviewed. Residents spoken to, stated that they were satisfied with the care they were receiving. Receipt, storage and administration of medicines were checked. The receipt of medicines at the Home was appropriately undertaken and recorded. A separate room, with locked cupboards and metal trolleys, is used to store all medicines.
China Cottage Nursing Home DS0000053683.V273070.R01.S.doc Version 5.1 Page 10 Medicines administration records (MAR) sheets were checked. These were contained in a file, but were not secured and were falling apart. Some MAR sheets for residents were left blank and did not indicate whether medicines had been administered or not. In one instance, medicines, which appeared to have been administered by night staff, were not signed for, over a period of three consecutive nights. The Home’s coding system for residents who refuse and who do not require their medicines was not clear and was used interchangeably. China Cottage Nursing Home DS0000053683.V273070.R01.S.doc Version 5.1 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): The key standards were checked at the previous inspection. EVIDENCE: China Cottage Nursing Home DS0000053683.V273070.R01.S.doc Version 5.1 Page 12 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. Residents are satisfied that their concerns and complaints are listened to, and that that they are addressed. There are, however, some shortfalls in the procedures being used and these must be remedied. EVIDENCE: Residents spoken to, stated that they could speak to staff about their concerns, knowing that they would ‘put things right’. The Home’s complaint procedure and two complaints, that had been received and dealt with, were checked. A complaint register is kept in the reception hall, inviting relatives to write in their concerns and complaints. The registered manager explained that staff would check the register and bring up any issues recorded in it. This method of ‘logging’ a concern or complaint did not appear to protect confidentiality or privacy of information. Documentation regarding two complaints, which had been investigated and resolved, was checked. The manager explained that she had investigated and upheld them. The complaints records consisted only of letters sent out to complainants to apologise and to say that things will be put right. There were no details of investigations carried out and of outcomes achieved. China Cottage Nursing Home DS0000053683.V273070.R01.S.doc Version 5.1 Page 13 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): The key standards were checked at the previous inspection. EVIDENCE: China Cottage Nursing Home DS0000053683.V273070.R01.S.doc Version 5.1 Page 14 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): 30 There is ongoing training for staff and this ensures that they are equipped to provide as good a standard of service as possible. EVIDENCE: Staff spoken to, confirmed that they have received training on various topics to help them provide a good standard of care to the client group. These topics include adult protection, health and safety, basic food hygiene and moving and handling. Out of 19 care staff employed at the Home, 9 have qualified to NVQ level in Care. Four other care staff are currently undertaking this course. On completion, the Home will meet the target of 50 of its care staff being qualified to NVQ level 2 in Care. In discussion, the manager stated that she was undertaking the ‘Registered Managers’ Care Award’. A list of training planned and undertaken in 2005-2006 was made available to the inspector. Whilst most planned training had been delivered, a number of care staff still needed training on first aid and fire safety. China Cottage Nursing Home DS0000053683.V273070.R01.S.doc Version 5.1 Page 15 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): 35. Appropriate procedures are in place to ensure that the financial interests of residents, whose personal allowances are managed by the Home, are safeguarded. EVIDENCE: The registered manager stated that the Home was managing the personal allowances of six of their residents. Their personal allowances were paid in their individual accounts. Three of the six residents have their own bank accounts and they are the signatories. Relatives also leave small amount of cash to the Home for safekeeping and for use on behalf of their loved ones as they wish. These accounts were appropriately recorded. China Cottage Nursing Home DS0000053683.V273070.R01.S.doc Version 5.1 Page 16 A sample of residents’ account was checked. Income and expenditure were recorded and there were two signatures to witness each transaction. Receipts are appropriately kept and help to track expenditure. The balances to the accounts checked, were correct. Residents’ accounts are audited, by the registered manager, on a monthly basis and findings are recorded. China Cottage Nursing Home DS0000053683.V273070.R01.S.doc Version 5.1 Page 17 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 3 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X X China Cottage Nursing Home DS0000053683.V273070.R01.S.doc Version 5.1 Page 18 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 2 Standard OP9 OP16 Regulation 12, 13 12, 22 Requirement The management of medicines at the Home must be improved to address the shortfalls identified. The receipt of concerns and complaints at the Home must be handle in a more private and confidential manner. Details of all complaints investigations and their outcomes must be appropriately recorded and kept at the Home. Training on first aid and fire safety must be provided to all staff who have not undertaken such training. Timescale for action 19/06/06 19/06/06 3 OP16 12, 22 19/06/06 4 OP30 12, 18 30/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations China Cottage Nursing Home DS0000053683.V273070.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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