Inspection on 15/08/07 for Cotleigh Care Home

This inspection was carried out on 15th August 2007.

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

Cotleigh Care Home 04/06/09

Cotleigh Care Home 05/12/08

Similar services:

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Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Cotleigh Care Home 31 Four Wells Drive Sheffield South Yorkshire S12 4JB Lead Inspector Chris Taylor Key Unannounced Inspection 15th August 2007 09:15 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 Cotleigh Care Home DS0000069439.V338843.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. Cotleigh Care Home DS0000069439.V338843.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cotleigh Care Home Address 31 Four Wells Drive Sheffield South Yorkshire S12 4JB 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) 0114 263 3800 rod.macaskill@sheffcare.co.uk Sheffcare Ltd ****Post Vacant**** Care Home 62 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (32) of places Cotleigh Care Home DS0000069439.V338843.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC. To service users of the following gender: Either. Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP, Dementia - Code DE(E). The maximum number of service users who can be accommodated is 62. New service 2. Date of last inspection Brief Description of the Service: Cotleigh Care Home is a new purpose built care home operated by Sheffcare Ltd. They provide personal care for 62 older people, 30 of whom have dementia. The home is arranged over two floors with the residential unit on the first floor and two units for those service users with dementia on the ground floor. On both floors there are lounges, dining rooms and small domestic kitchens. On the ground floor there is a café area, hairdressers and office reception area. All bedrooms are en suite. Each floor has an assisted bathroom and ample communal space. There is a large, secure and accessible garden. The weekly fees on 15th August 2007 range from £347 to £389 and do not include costs for hairdressing and chiropody. This information was supplied to the Commission For Social Care Inspection Cotleigh Care Home DS0000069439.V338843.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is what was used to write this report. • • Information about the home kept by the Commission for Social Care Inspection. Information asked for before the inspection, this is called Annual Quality Assurance Assessment. A visit to the home, which was unannounced. This lasted six hours and included talking to staff about their jobs and the training they have completed. Also spending time with people and checking some of the records polices and procedures the home has to keep. Looking at five service users’ care files in detail. • • What the service does well: People made positive comments about Cotleigh such as ‘It’s a very good place’, ‘excellent’ and the staff are ‘very kind and patient and with a sense of humour.’ A member of staff from the home visits people before they move in, they find out about the kind of support the person might need. This helps the home decide whether they have the right knowledge and experience to be able to care for the person properly and safely. People also spend a day at the home before deciding whether to move in. Medication is stored in locked trolleys in a locked room and staff have had special training about medication. This means it is easier to keep a check on medication in the home and make sure people get the correct medication at the correct time. The staff are provided with comprehensive training to improve their knowledge and skills. This promotes best practice and ensures that people receive a good quality service. The home is managed in a manner that puts service users first. It concentrates on the needs, wishes and views of the people who use the service. Cotleigh Care Home DS0000069439.V338843.R01.S.doc Version 5.2 Page 6 The way the building has been designed helps people to retain independence and orientation. The home is decorated and furnished to a high standard and has a bright warm atmosphere, this makes it a pleasant place to live and work. 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. The summary of this inspection report can be made available in other formats on request. Cotleigh Care Home DS0000069439.V338843.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 Cotleigh Care Home DS0000069439.V338843.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3. People who use this service experience good quality outcomes in this area. Peoples’ needs are properly assessed prior to admission this helps make sure that staff know they will be able to meet peoples’ needs before the person moves in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Usually the manager will visit the prospective service user and complete an assessment to make sure staff at the home will be able to provide a service, which will meet the person’s needs. The prospective service user then spends a day at the home providing the opportunity to meet staff and other service users and to get a feel for the home. If the person and home agree then a settling in period is offered. The settling in period is usually four weeks but this can be flexible depending on peoples’ needs and circumstances. People are provided with further information to help them settle into the home, this Cotleigh Care Home DS0000069439.V338843.R01.S.doc Version 5.2 Page 9 includes being assigned a specific member of staff to call upon. Following this a review is held to confirm that everyone is happy with arrangements and the person’s stay at the home is made permanent. Wherever possible unplanned admissions are avoided. People who were spoken with said that staff had taken great care to make sure they were made welcome and helped them to settle in. They also said that they were provided with sufficient information about the home before they moved in. Five people’ files were looked which confirmed that pre admission assessments had been undertaken. Cotleigh Care Home DS0000069439.V338843.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. People who use this service experience good quality outcomes in this area. Peoples’ health and personal care needs are assessed and are met promoting independence, choice and respect for individuals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Five peoples’ case records were looked at in order to check that a plan had been formulated which helps staff provide support to people according to their needs and wishes. There were forms completed which contained information about the person such as date of birth, GP, next of kin. This was followed with specific documents to record information about all aspects of the person’s life. Other documents recorded information about areas of risk, specifically with regard to moving and handling and falls; nutritional assessments, where a person may need a specific diet due to weight gain or loss. People’s files contained a lot of Cotleigh Care Home DS0000069439.V338843.R01.S.doc Version 5.2 Page 11 relevant information but it was sometimes difficult to locate what was most up to date and most relevant. The Action Plan, which is used, as the main working document doesn’t have sufficient space to record the detail found in other documents for instance the review document. This document gave a much broader picture of the person particularly about aspects of personal care routines, interests, likes and dislikes. To illustrate this on three files important information in relation to peoples’ care needs was written on notepaper and attached to the front of the daily records, the assumption being that it was placed there because the author felt this was where staff wouldn’t miss it. Throughout the day it was clear that staff held a wealth of knowledge about people particular their social histories and interests and this knowledge was used positively with people to reassure and support but this kind of information was not readily to hand and should be recorded in the main working document. It is important that staff have this information to hand particularly when supporting people with dementia as it helps settle and reassure people and helps staff understand peoples’ behaviours and routines. This was discussed with the team leader and she agreed to discuss with the management team and review how peoples’ files are arranged. Daily records provided a good picture of the daily life of people and would provide essential information to track any changes the person may experience, with ill health or involvement in social activities for instance. People are registered with the GP of their choice. People said that the GP visited every Wednesday and staff would arrange a visit if the situation was more urgent. They also said that District Nurses visited the home every day. Wherever possible staff accompany people to hospital appointments. A key-worker scheme operates in the home. The delivery of personal care is individual and flexible. Discussions with people confirmed this. They said that staff always treat them with respect and ensure their privacy and dignity. Comments heard include “staff are very kind and helpful and always cheerful” and “staff always knock on bedroom doors,” Staff were observed delivering care in a kind and helpful manner. People looked clean and well cared for. Medication is stored in locked trolleys, one for each corridor. A monitored dosage system was in use with proper procedures in place for the receipt, storage, administration, recording and return of medicines. It is usual that only senior members of staff administer medication and staff receive accredited medication training before they are permitted to do so. Lunchtime medication administration was observed and this was carried out safely and in a way that ensured people’ dignity was maintained. If people take responsibility for administering their medication they sign an agreement form and an appropriate risk assessment is completed. Cotleigh Care Home DS0000069439.V338843.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. People who use this service experience adequate quality outcomes in this area. People can choose how they spend their day. The service provides some opportunities for stimulation and interest for some people living in the home. The quality of meals provided varies. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People choose their own daily routines and are encouraged to remain independent and have as much control over their lives as is possible. People can sit in communal lounges or spend time in their rooms and can rise and retire as they wish. There are some activities on offer and staff were seen spending time with people playing scrabble or talking about current news items, but responses from people included ‘Could be more entertainment activities and stimulation.’ Cotleigh Care Home DS0000069439.V338843.R01.S.doc Version 5.2 Page 13 ‘To me there does not seem to be any activities.’ ‘I would like them to do some more activities apart from Bingo.’ The team leader said she was aware that they needed to improve on activities provided in the home but because the home was new their first priority was to move people into the new building and spend time helping people settle in. The home is currently in the process of recruiting an activities organiser and the Sheffcare activities team have started visiting the home three days per week to begin to talk to people about what activities they are interested in. The home’s aim is not just to provide large group activities but smaller group or one to one activities according to interest. There is a purpose built hairdressing room and the hairdresser was visiting on the day of the inspection. The atmosphere at the home was very relaxed. Warm and genuine relationships were witnessed between staff and service users and there was a lot of good-hearted banter. There are three main meals per day and a choice is provided at each. Special dietary needs such as low sugar diets are catered for. Meals are prepared at a central kitchen and delivered to the home in large trolleys. Responses about the quality of meals was mixed some people thought they were good, others said that it depended “some days good others food is cold” or “by the time it gets to me it is unappetising”. Someone commented that although there is a choice often you don’t get what you ordered. Sheffcare have recently carried out a survey about the quality of food and as a result of this are proposing to begin preparing all food freshly on the premises. However there are some alterations to the current kitchen, which need to take place before this can happen. There is a kitchen downstairs adjacent to the “café”. This is a social area where people can meet together. There are domestic sized kitchens on each wing where service users can make themselves a drink and staff make sure hot and cold drinks are available throughout the day with a hot drink and snack provided prior to bed. Cotleigh Care Home DS0000069439.V338843.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. People who use this service experience good quality outcomes in this area. People can be confident that concerns are listened to and appropriate action is taken. There are sufficient effective systems in place to safe guard people from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A complaints procedure is provided to people and is included in the home’s contract with services users. It is also displayed on notice boards and in the reception area along with details of local advocacy services. People said that they felt able to talk to staff and the manager of the home if they had complaints and that these would be dealt with properly. Senior staff deal with general day-to-day complaints and anything more serious is passed to the organisation’s quality assurance manager to investigate. There have been two complaints made since the home opened. All have been investigated thoroughly with the complainant being satisfied with the outcome of the investigation. No formal complaints have been made directly to The Commission for Social Care Inspection. Cotleigh Care Home DS0000069439.V338843.R01.S.doc Version 5.2 Page 15 There is a comprehensive policy and procedure with regard to adult protection and staff have a good awareness of this. Staff receive training in adult protection issues during induction and foundation training and as part of National Vocational Qualification level 2 and 3 in care. Some staff have yet to receive adult protection training but this has been planned for over the next few months. Appropriate recruitment procedures are followed, with references and Criminal Records Bureau (CRB) checks made to reduce the risk of undesirable people working in the home. Cotleigh Care Home DS0000069439.V338843.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26. People who use this service experience good outcomes in this area. People stay in a clean, comfortable and safe home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Cotleigh is purpose built and was opened in April 2007. People spoke very positively about the bedrooms, communal areas and decoration. Staff said the design and layout of the building made it a good working environment to support people in. Most people said that the home was spotlessly clean but two people commented that there wasn’t enough domestic staff to really bottom everywhere. The team leader did say that there were domestic vacancies and people on annual leave, which could account for these views. Sheffcare do provide a team of cleaners to come into the home once a week to concentrate on communal areas, which tend to get more wear and tear. Cotleigh Care Home DS0000069439.V338843.R01.S.doc Version 5.2 Page 17 On the day of the inspection the home was free from offensive smells. Hand wash scrub, gloves and aprons are available throughout the home so as to minimise the risk of cross infection from one person to another. Repairs are usually carried out promptly and there is an effective computer system to log and track these. One issue was raised by a service user and this was logged as urgent and resolved by the end of the inspection. The manager ensures compliance with the local fire service and environmental health department so that service users are kept safe. Cotleigh Care Home DS0000069439.V338843.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. People who use this service experience good outcomes in this area. Staff are properly vetted and trained to ensure people receive the care and support they need. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Prospective staff complete an application form and if short listed attend a formal interview. Written references and POVA (Protection of Vulnerable Adults) first checks are made and staff are not permitted to work in the home until they have a CRB (Criminal Records Bureau) check. Records of the recruitment process are scanned and stored on the computer and those staff most recently recruited were checked; all had completed an application form, had CRB check and two written references. Staff complete two days induction held at head office followed by a home specific induction. There is probationary period of twelve months and during this time further statutory training and NVQ (National Vocational Qualification) training is undertaken. Cotleigh Care Home DS0000069439.V338843.R01.S.doc Version 5.2 Page 19 Records confirmed staff training completed and included a rolling programme to ensure staff complete mandatory health and safety training. Staff said that training opportunities were good. The manager and senior staff work alongside staff and as such monitors their practice. At every shift change there is a handover where specific issues relating to service users are discussed. Polices and procedure are discussed at regular staff meetings. Staff receive formal recorded supervision and an annual appraisal. Cotleigh Care Home DS0000069439.V338843.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38. People who use this service experience excellent outcomes in this area. The home is managed in such a way that promotes the best interests of people. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager of the home was taking annual leave at the time of the inspection. The senior member of staff in charge demonstrated good management skills and was able to assist with the inspection competently. There is always a senior carer on duty to take responsibility for the smooth, safe running of the shift. Tasks are appropriately delegated so that the safety of service users, and the safe running of the home, is shared out among the Cotleigh Care Home DS0000069439.V338843.R01.S.doc Version 5.2 Page 21 more senior members of staff. Staff spoken to were very enthusiastic and committed to making sure they “ do a good job”. The manager asks for service users opinions so that the home can be run the way people living in it want it to be run. The home has only been open for four months and the first questionnaires to service users, their relatives and other professionals’ views have been distributed. Once returned, responses will be analysed and included in the quality assurance report and action plan. The home already demonstrated that it listens to the views of service users with the proposals to change the preparation of meals system. Regular, internal audits make sure that all the necessary health and safety checks are being carried out. The Quality Assurance Manager visits the home monthly and allows time for service users to talk about their satisfaction with the service. The organisation has a good IT system which supports the manager’s roles and responsibilities and provides a electronic task list, this not only ensures specific tasks are completed but frees up management time from paperwork. The fire procedure is prominently displayed throughout the home and fire detection and fire-fighting equipment is tested and maintained regularly. Records were seen which confirmed that other equipment in the home is maintained and serviced appropriately. Staff are trained and able to administer first aid should a service user get injured or require immediate treatment for a minor injury. Cotleigh Care Home DS0000069439.V338843.R01.S.doc Version 5.2 Page 22 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 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Cotleigh Care Home DS0000069439.V338843.R01.S.doc Version 5.2 Page 23 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. Standard Regulation Requirement Timescale for action 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. 2. Refer to Standard OP7 OP15 Good Practice Recommendations They way in which information about service users is recorded should be reviewed to make sure the most up to date information is available on one working document. The home should make sure their decision to begin to prepare meals on the premises happens as soon as possible. Managers should think about the security of the building particularly the front entrance doors in order to keep people safe from harm. 3. OP38 Cotleigh Care Home DS0000069439.V338843.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Cotleigh Care Home DS0000069439.V338843.R01.S.doc Version 5.2 Page 25 - 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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