Inspection on 04/06/09 for Cotleigh Care Home

This inspection was carried out on 4th June 2009.

CQC found this care home to be providing an Adequate service.

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

Cotleigh Care Home 05/12/08

Cotleigh Care Home 15/08/07

Similar services:

Abbey The

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 25/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Cotleigh Care Home 31 Four Wells Drive Sheffield South Yorkshire S12 4JB Lead Inspector Ramchand Samachetty Key Unannounced Inspection 4th June 2009 09:30 DS0000069439.V375683.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Cotleigh Care Home DS0000069439.V375683.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Cotleigh Care Home DS0000069439.V375683.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 0114 263 3868 rod.macaskill@sheffcare.co.uk www.sheffcare.co.uk Sheffcare Limited Vacant. Care Home 62 Category(ies) of Dementia (62), Old age, not falling within any registration, with number other category (62) of places Cotleigh Care Home DS0000069439.V375683.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 2. Dementia - Code DE The maximum number of service users who can be accommodated is: 62 5th December 2008 Date of last inspection Brief Description of the Service: Cotleigh Care Home is a new purpose built care home operated by Sheffcare Ltd. It provides personal care for up to 62 older people, 30 of whom have dementia. The home provides its accommodation over two floors. There are passenger lifts and stairs to facilitate access between them. The first floor is used for older people and the ground floor for people with dementia. The doors on the ground floor are kept secure to prevent people with dementia from wandering from the building. There are lounges, dining rooms and small domestic kitchens on both floors. 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 was a secure and accessible garden. The manager informed us that the range of fees charged at 4th June 2009 was between £379.00 and £425.00 per week and this includes a top up fee of £44.00 per week. There are extra charges for hairdressing, personal toiletries and private chiropody. The home has produced its statement of purpose and service user guide, which gives detail of its services. Further information can be obtained from the manager. Cotleigh Care Home DS0000069439.V375683.R01.S.doc Version 5.2 Page 5 Cotleigh Care Home DS0000069439.V375683.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service is one star – adequate service. This means that the people who use this service experience adequate quality outcomes. This key unannounced inspection was carried out on 5 June 2009, starting at 09.30 and finished at 18.00 hours. There were 62 people in residence at the time of this inspection, 30 of whom had dementia. The new manager, Mr Roderick MacAskill was present during most of the inspection. The inspection included a tour of the premises, examination of care documents and other records, which included those of medicines, complaints and staff employment files. We spoke to eight people who lived at the home, four relatives and six members of staff. The care of three people who used the service was examined and some aspects of care provision were observed. Feedback on our findings was given to the manager and to senior members of staff. We would like to thank all the people living at the home, relatives and staff who helped with this inspection. What the service does well: The home continues to benefit from a good and committed staff team, which is working well to provide care to people who use the service. People who lived at the home and their relatives were satisfied with the standard of accommodation and facilities which were provided. People who used the service were well supported in accessing community health care services and this helped to promote their wellbeing. What has improved since the last inspection? A new manager has been appointed and the company is strengthening the management arrangements at the home, by appointing a deputy manager and senior staff to take charge of hospitality and catering. The company has allocated additional care staffing hours to be deployed at the home in order to improve overall care provision. A staff recruitment Cotleigh Care Home DS0000069439.V375683.R01.S.doc Version 5.2 Page 7 programme has started. This includes recruitment of an activities co-ordinator to work at the home on a full time basis. This will help to improve the social life of people living at the home. A supervision programme has been developed and staff were receiving more regular support and supervision. This is helping staff to improve their care practices. The management of complaints has started to improve and the service can now benefit from feedback it receives from the management of complaints. Building works have started and were nearing completion in order to ensure that there is a fully functional kitchen at the home. Arrangements were in place for staff to start preparing and cooking meals for people who live at the home. The building works also included the extension of the laundry facilities in order to improve the laundry service. A new smoking room was being developed in one of the lounges and this would help to protect the smoke free areas of the home. Hygiene and infection control, at the home, have been improved and this will benefit all who live and work in it. What they could do better: Our last key inspection of this service was carried out in December 2008. Since then action has been taken to address the shortfalls that we had highlighted. We note the improvement made so far and the plan for further improvement of the service, so that it can deliver good outcomes for people who use it. The registered provider needs to make a more sustained effort to improve the care planning system used at the home. However, we note that the provider has stated that staff are working with Sheffield social services department, to improve the care plans. There is a continuing need to ensure that care plans are appropriately developed and implemented, with proper record of care provided. They must be appropriately evaluated and reviewed to ensure people’s changing needs are met. The management and audit of medicines at the home needs to be further improved in order to safeguard the health and wellbeing of people who use the service. Management and staff need to review and improve the provision of social and recreational activities with regards to the needs, preferences and capabilities of people who use the service, in particular, those who have dementia. These actions will help improve their quality of life. There is a continuing need to improve the home’s staff recruitment and selection procedures by ensuring all pre-employment checks are appropriately Cotleigh Care Home DS0000069439.V375683.R01.S.doc Version 5.2 Page 8 undertaken and are timely in manner. This will promote the safety and wellbeing of vulnerable people who live at the home. The registered provider should continue to review the care staffing levels at the home so that sufficient staff are deployed to meet the needs of people who use the service, at all times. The registered provider needs to ensure that appropriate quality monitoring methods and quality assurance system are used effectively, in order to improve the service. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Cotleigh Care Home DS0000069439.V375683.R01.S.doc Version 5.2 Page 9 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.V375683.R01.S.doc Version 5.2 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who used the service had sufficient information to help them choose the home. Peoples’ needs were usually assessed before their admission. However, relevant needs assessment information was not always obtained on time and this could affect their choice of home. EVIDENCE: A statement of purpose and service user guide was available to people living at the home and to those who were interested in using the service. The manager stated that these documents had been updated and that they now included the relevant information on the home’s complaints procedure. We were also told that further information would be added on the home’s provision of care for people who have dementia. Cotleigh Care Home DS0000069439.V375683.R01.S.doc Version 5.2 Page 11 People who lived at the home and their relatives told us that they had sufficient information to help them choose the home. We looked at the care files of three people who had been admitted since the last inspection (December 2008). They showed that their needs had been assessed by their placing social workers. However, in two instances, the assessment documents were dated shortly after their admission to the home. It was unclear whether staff had the necessary information to decide, prior to admission, that the needs of the people concerned could be met. The home does not provide intermediate care services. Cotleigh Care Home DS0000069439.V375683.R01.S.doc Version 5.2 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home were satisfied with the care they were receiving, which they felt was ensuring their health and wellbeing. The planning, provision and review of care and the management of medicines were not always satisfactory. These could affect the health and welfare of people living at the home. EVIDENCE: People who used the service and who were able to express their views told us that they were satisfied with the care they were receiving. They described care staff as ‘hard working and friendly’. We spoke to a few relatives and they said that the care was generally good. Some of the relatives felt there was still not enough staff to provide the care and attention that their loved ones needed. People who used the service and their relatives confirmed that personal care was always provided in private. We noted that people who lived at the home Cotleigh Care Home DS0000069439.V375683.R01.S.doc Version 5.2 Page 13 and who we met during our inspection were in good attire. This helped to ensure that their dignity and rights were respected and promoted. We looked at the care plans of three people who used the service. They were broadly based on their care needs and risks. However, we noted that parts of the care planning documents were left blank. These included sections on personal profiles and mental capacity assessments. There was therefore a lack of information to inform the care planning process. Actions to be taken to meet needs were not always clearly laid out. While certain aspects of physical care were appropriately addressed, mental health and psychological care needs like depression and low mood, which had been identified as presenting problems were less well addressed. The care provided was often recorded in a generalised way and therefore did not reflect the care being provided. This led to inadequate evaluation and review of care. Care plans were being reviewed on a monthly basis and sooner if required, but it was not clear what information had been used to justify the outcomes, which were mostly, that ‘no change was required’. The care plans that we checked indicated that people living at the home were supported in accessing the appropriate community health care services as needed. Care records showed that the services of district and community psychiatric nurses, chiropodists, dieticians and GPs were appropriately accessed. In discussion, the manager stated that senior managers of the company were working closely with the local social services department to develop and improve the care planning system. We looked at the way medicines were handled and administered at the home. Medicines were stored in a small room in each of the four wings of the building. We noted that a lack of ventilation in these areas. It was not clear whether the temperature could be maintained at 25 degrees centigrade at all times. We also noted storage of other non-medicines related items in these areas. We checked a sample of medicines administration records (MAR) sheets. In a few instances, the quantity of medicines received was not recorded on these sheets. In two instances, the prescribed medicines for one person were not administered because the person was sleeping. There was no record of any action taken or of any advice sought from the person’s GP. There was no evidence that the handling and administration of medicines was quality monitored by staff. These shortfalls could affect the health and welfare of people using the service. None of the people living at the home were administering their own medicines. Cotleigh Care Home DS0000069439.V375683.R01.S.doc Version 5.2 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Social and recreational activities provided at the home were not always sufficient and appropriate for people who lived there. This meant that they were not able to enhance their quality of life. EVIDENCE: People living at the home were observed spending time, in between meals and care interventions, sitting in lounges, foyer areas in the units and in their bedrooms. Televisions were left playing in the main lounges and some people were watching them. Staff were observed to spend time, on occasions, talking and listening to people who they were caring for. The interactions were friendly and courteous. However, we also saw a number of people, particularly those who had dementia, sitting in lounges with limited staff interaction. Staff told us that they had started a gardening group for people who have an interest in that activity. Cotleigh Care Home DS0000069439.V375683.R01.S.doc Version 5.2 Page 15 People who lived at the home told us that some events and outings had taken place. They said that there had been a sing along and that an entertainer had recently performed at the home. A relative said that her mother who has dementia and a number of other people with the same condition were not included in that show and were ‘left downstairs’. We noted that a number of people were not capable of or interested in taking part in some of the activities that were organised. These activities were not always based on individual social care needs, capabilities and preferences. In discussion, the manager stated that efforts were being made to recruit an activities coordinator in order to improve the planning and provision of social and recreational activities at the home. We spoke to relatives who were visiting their loved ones. They said that they were always welcomed at the home. They commented that routines at the home seemed fairly flexible. People could get up and retire to bed at times that suited them. Some relatives said that their loved ones could not express their preferences concerning their care or about things they liked to do and they were confident that staff did their best to help them. We noted that meals were still being cooked at another site and being transported to the home. People who lived at the home and their relatives, told us that the food, served at the home was not at its optimum temperature and that this compromised its quality. They told us that they were still waiting for the new kitchen at the home to start working. In discussion, the manager said that work in the kitchen was nearly completed. Arrangements were being made for staff to start cooking meals on site. At lunch time, we observed staff helping people to make their choice of food. We noted that some staff were assisting people in their care to eat their lunch. Cotleigh Care Home DS0000069439.V375683.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home and their relatives were satisfied that they could express their concerns to staff and that these would be addressed. The service was able to protect vulnerable people from harm and abuse. EVIDENCE: There was a complaints procedure in place and copies of it had been provided to people who lived at the home and their representatives. People said that they were aware of the procedure and would use it if they needed to do so. The manager had stated in the ‘Annual Quality Assurance Assessment’ document that was sent to us before the inspection, that the home had received six complaints in the last twelve months. One of those complaints was received after our last inspection in December 2008. We checked the way this complaint had been managed and found that it was satisfactorily dealt with. The manager confirmed that the home had an adult safeguarding policy and a whistle blowing policy in order to promote the safety and welfare of people using the service. Staff were aware of these policies and had received training on their implementation. Cotleigh Care Home DS0000069439.V375683.R01.S.doc Version 5.2 Page 17 The manager stated that there had been five referrals to the local adult safeguarding team in the last twelve months. Two of them had been made after our inspection in December 2008. The manager confirmed that all the adult safeguarding issues had been investigated and concluded. Cotleigh Care Home DS0000069439.V375683.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Although the environment was adequately maintained, there were a few minor repairs that had not been attended to and they could constitute potential hazards. EVIDENCE: On the day of this inspection, building works were being carried out to improve the kitchen and laundry facilities and to create a separate smoking room on the top floor. No arrangements had been made before and during the work, about protecting the health and safety of people who lived at the home, particularly those who have dementia and who were using communal areas adjacent to the works, on the ground floor. Also equipment had been moved Cotleigh Care Home DS0000069439.V375683.R01.S.doc Version 5.2 Page 19 and was left on the corridor. The matter was discussed with the manager and it was promptly addressed in order to protect people living at the home. We checked the premises and also viewed a few bedrooms with the permission of people who occupied them. The main door to the front of the building was kept secure by the use of an electronic keypad and this ensured the security of people who lived at the home. The communal areas were found to be tidy and clean. We noted that two window restrainers on the ground floor, were broken and an area of carpet, on ‘wing 1’, that was becoming loose and was lifting up. We pointed out that this could constitute a tripping hazard. We noted that nonmedicines related items were still being stored in medicines rooms and thus caused clutter. The bedrooms that we viewed were adequately decorated and clean. People who lived at the home said that they were ‘happy with their accommodation’ and that they found the home ‘comfortable and pleasant’. People who lived at the home also commented that the laundry service had improved. In discussion, staff commented that additional domestics had been working at the home and this had helped to improve its general maintenance and hygiene. We noted that some people were able to use part of the grounds for their gardening activities. The surrounding grounds were appropriately maintained for the time of the year. Cotleigh Care Home DS0000069439.V375683.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff recruitment and selection procedures, staff training and the staffing levels at the home were not sufficiently robust to promote the safety and wellbeing of people living at the home, at all times. EVIDENCE: At the time of this inspection, there were 62 people in residence at the home, 30 of whom had dementia. The care staff on duty on the morning shift, besides the manager, comprised of nine care workers and two team leaders. There were other support staff, which included clerks and domestics. We checked the duty rota and it showed that there were often fewer care workers on duty for the same number of residents and with similar level of needs. In one instance, there were only seven care staff for an afternoon shift. In another instance only three care staff were deployed to work during the night. People who lived at the home and their relatives told us that they felt the staffing levels at the home were improving. A few relatives told us that there was a continuing practice of leaving only one care staff on a wing, for 15 people at some periods. They felt that at those times their loved ones would not able to receive appropriate attention if they needed it. In discussion, we noted that Cotleigh Care Home DS0000069439.V375683.R01.S.doc Version 5.2 Page 21 efforts were being made to recruit additional care workers and an activities coordinator to work at the home. A number of new employees had joined the home since our last inspection. We looked at the procedures that were used in staff recruitment and selection. We checked the employment files of four new members of staff. They had all been checked against the ‘Protection of Vulnerable Adults’ (POVA) list before they started to work at the home. However, the home had not received their disclosures from the Criminal Records Bureau before they were deployed on duty. The manager explained that the company’s policy is to carry out a risk assessment and employ the concerned individuals under supervision. We checked the references for two care workers. In each case, only one written reference was received by the home and one of them was not from a last employer. We noted that new staff were provided with induction training and new care workers were given the opportunity to observe the provision of care by more experienced staff before they had provide care themselves. The manager stated that there was a corporate training and development programme, which was available to staff at the home. A range of training topics had been provided and these included moving and handling, first aid, food hygiene, fire safety, infection control, adult safeguarding and dementia care. We spoke to some care workers and they confirmed that they had received training on various topics and on occasions, refresher training. The manager explained that further training on dementia care and on mental capacity act was being organised. We noted from the notifications of incidents that we had received from the home, that some staff who administer medicines required further training to do so. The manager confirmed that this training had been provided. The manager had stated in the ‘Annual Quality Assurance Assessment’ document, which was provided to us, that 18 out of 38 permanent care workers at the home had achieved their ‘National Vocational Qualification’ (NVQ) level 2 in care. The manager stated that other care workers were enrolling for this training. Cotleigh Care Home DS0000069439.V375683.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Adequate management arrangements were in place to ensure the proper dayto-day running of the home. However, there were shortfalls in the monitoring and evaluating the service in order to continually improve it. EVIDENCE: The company has appointed a new manager a few months after our last inspection (December 2008). The manager had been transferred from another home of the company. The new manager stated that he has experience in working and managing residential care for older people and that he had Cotleigh Care Home DS0000069439.V375683.R01.S.doc Version 5.2 Page 23 achieved the ‘Registered Manager Award’. He confirmed that he would be applying for registration with this commission. People who used the service and relatives told us that they felt that there were ‘too many changes of manager’, which they found unsettling. Some relatives said that they had raised the matter in a relatives’ meeting with the chief executive of the company and that they were reassured that there would be no further changes of the home manager. The new manager stated that management arrangements at the home had been improved. There was now one team leader on each floor and that a ‘hospitality’ team leader had been appointed to deal with catering and domestic matters. Staff also continued to have access to corporate services like ‘Human Resources and training’. However, we noted that the previous manager was involved with some aspects of the home management. She confirmed that she was acting in her new role as quality assurance manager for the company. In discussion, she stated that she was leading the work on the development of new care plans for the home. We looked at quality assurance methods being used at the home. The manager stated that team leaders were undertaking monthly spot checks and health and safety audits. Some care plan audits had been carried out. However, the outcomes of such audits were not clear. We again advised that regular and effective audits of care and medicines management would have highlighted some of the shortfalls we noted in these areas. We also looked at three reports of the provider’s monthly visit to the home. These visits took place in February, March and April 2009. Comments made in the reports were general in nature. Two of the reports carried an action plan, which showed that some issues from the previous year were still being worked on. The manager told us that two ‘Relatives’ meetings had been held at the home since the last inspection. The minutes of these meetings showed that they were called to discuss mainly finance issues, which concerned relatives. The manager commented that he was calling another meeting for relatives in the next few days and would use it to get feedback on how to further improve the service. Arrangements were in place to support people living at the home with the management of their personal monies. All financial transactions undertaken on their behalf were appropriately recorded, witnessed and signed for and receipts were kept. These procedures ensured that their financial interest was being safeguarded. The manager stated that he and the team leaders had received training on staff supervision. He said that a staff supervision programme has been developed to make sure all staff receive regular supervision. Staff confirmed Cotleigh Care Home DS0000069439.V375683.R01.S.doc Version 5.2 Page 24 that they were receiving supervision from senior workers and managers more regularly than before. Cotleigh Care Home DS0000069439.V375683.R01.S.doc Version 5.2 Page 25 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 3 X 3 Cotleigh Care Home DS0000069439.V375683.R01.S.doc Version 5.2 Page 26 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 OP7 Regulation 14 Requirement Individual care plans must be improved to ensure they are appropriately developed and implemented. The care provided must be properly recorded, evaluated and reviewed. This will ensure that the care needs of people using the service are appropriately addressed. (Previous timescale of 09/03/09 not met) The quantity of medicines received at the home must be appropriately recorded so that they can be accounted for. Prescribed medicines must be appropriately administered. These actions will help protect the health of people living at the home. (Previous timescale of 09/03/09 not met) The social care needs of people using the service, in particular those who have dementia, must be properly assessed and catered for, as part of individual care plans. Staff must make sure that the recreational activities organised reflect the preferences DS0000069439.V375683.R01.S.doc Timescale for action 18/07/09 2. OP9 13 18/07/09 3. OP12 16 18/07/09 Cotleigh Care Home Version 5.2 Page 27 and capabilities of people using the service. This will help to ensure that they receive appropriate social stimulation to improve their quality of life. 4. 5. OP19 OP29 23 19 The items of repair, as identified, 18/07/09 must be carried out. This will help to make the place safer. The recruitment and selection 18/07/09 procedures must be improved to ensure that all the required preemployment checks are carried out before staff are employed at the home. These checks include the appropriate disclosures and two written references. This is necessary in order to help protect vulnerable people who live at the home. The registered provider must 18/07/09 ensure that effective quality monitoring tools and methods are developed and consistently used in order to improve the service. This quality monitoring process must include the views of people who use the service and their relatives. This will ensure that their views are taken into consideration. 6. OP33 24 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 OP3 Good Practice Recommendations Staff should ensure that care assessment documents relating to people being admitted are sought and obtained in a timely manner. This would assist them in deciding whether a person’s needs could be met prior to admission DS0000069439.V375683.R01.S.doc Version 5.2 Page 28 Cotleigh Care Home to the home. 2. OP27 The care staffing levels at the home should continue to be reviewed and improved in order to ensure that the needs of people who live at the home are appropriately met at all times. Management arrangements at the home should be reviewed and consolidated to ensure clarity of roles and consistency for the benefit of people who use the service. 3. OP31 Cotleigh Care Home DS0000069439.V375683.R01.S.doc Version 5.2 Page 29 Care Quality Commission Yorkshire & Humberside Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.yorkshrehumberside@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary 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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