CARE HOMES FOR OLDER PEOPLE
Cottingham Hall 195-197 Cottingham Road Hull East Yorkshire HU5 2EG Lead Inspector
Simon Morley Unannounced Inspection 22nd March 2006 09:30 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 Cottingham Hall DS0000000842.V263642.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. Cottingham Hall DS0000000842.V263642.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Cottingham Hall Address 195-197 Cottingham Road Hull East Yorkshire HU5 2EG 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) 01482 441144 Shelphan Resource Limited Ms Kay Dickinson Care Home 31 Category(ies) of Dementia - over 65 years of age (31), Old age, registration, with number not falling within any other category (31) of places Cottingham Hall DS0000000842.V263642.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 5th July 2005 Brief Description of the Service: Shelphan Resource Limited, a family business own Cottingham Hall, one of a small number of homes owned by the company. The home is registered to provide personal care and accommodation for up to 31 people of either gender over the age of 65, some of whom may have dementia. The home is situated on Cottingham Road close to: the local university; the busy Newland Avenue shopping area; churches; pubs and the local bus services stop outside the home. The home has ground and first floor accommodation accessible by a passenger lift. There are two modern, purpose built, ground floor extensions to the rear of the home. These provide quality accommodation for the residents. There are 23 single bedrooms, 18 of which have en-suite facilities and 4 double rooms. Some accommodation is in the main part of the home, Victorian in style. There are large dining and lounge areas on the ground floor with disability access to the rear courtyard and garden area. The courtyard has seating for residents and looks out onto the well-kept rear gardens. There is also a quiet lounge at the front of the home and a private meeting room. There is a gravelled car park at the front of the home for visitors to use. Cottingham Hall DS0000000842.V263642.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was a surprise inspection that lasted for six hours. The inspector talked to seven residents, three staff and the manager about the home. The inspector had a look around the home to check the quality of the accommodation, looked at some care records and other documentation in relation to running a home. What the service does well: What has improved since the last inspection?
The manager has helped staff that want to, to undertake basic skills training in literacy and numeracy. This has helped them improve their self-esteem, be more confident at work and undertake the required care qualification. Cottingham Hall DS0000000842.V263642.R01.S.doc Version 5.1 Page 6 She has also introduced an eye care training programme to help staff provide better care to people with a visual impairment. She has obtained information and an exercise video from Age Concern, which is used in the home. This helps residents undertake gentle exercise to promote their health and fitness. She has also started an informal support group for relatives of residents to talk about any concerns they have about the health and care of residents. 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. Cottingham Hall DS0000000842.V263642.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 Cottingham Hall DS0000000842.V263642.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 The admissions process ensures that residents’ needs were assessed before moving into the home, so that they can be assured they will be well looked after. EVIDENCE: Residents spoken to were happy that their care needs were being met. Staff spoken to were very knowledgeable about individual resident’s needs and what they needed to do for them. Individual care records are kept for each resident. An inspection of the records for two residents recently admitted showed that they had had their care needs assessed prior to moving into the home. The manager uses a different assessment format for residents paying for their own care than the one used for residents funded by the local authority. For those funded by the local authority the manager also obtains the local authority assessment. Cottingham Hall DS0000000842.V263642.R01.S.doc Version 5.1 Page 9 It was recommended the manager use one assessment format for all residents regardless of who pays the fees. This was the one used for privately funded residents, as it was more thorough and detailed. An individual plan of care is then written for residents based on the assessment of their needs. Cottingham Hall DS0000000842.V263642.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 8 There were good arrangements for making sure residents received good personal and health care. EVIDENCE: Residents spoken to were happy with their care and how staff looked after them. They said that they were helped to have regular health checks and any necessary health care. Visitors were full of praise for the home and communicated a sense of relief knowing that their relative in the home was being well looked after. Of the two sets of records examined both had very good, detailed plans of care describing what staff need to do for each resident. These were reviewed regularly and any necessary changes made. Care plans included general health and personal care needs. They also covered specific issues relating to residents dietary needs, skin conditions, social activities, mobility needs and a range of risk assessments aimed at keeping residents safe whilst promoting their independence. Cottingham Hall DS0000000842.V263642.R01.S.doc Version 5.1 Page 11 Care records included thorough details of residents’ health issues and there was regular contact with community health professionals to help promote residents’ good health. Cottingham Hall DS0000000842.V263642.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 and 15 There was a good quality of daily life and social activities for residents in the home. EVIDENCE: Residents spoken to were happy with their lifestyles in the home. Their social interests and hobbies are recorded on admission to the home and they are supported to follow these. The home arranges gentle exercise sessions, games, parties, reminiscence slide shows and visits from local churches for residents who want to take communion. Staff also take residents out shopping and visits to local pubs, coffee bars and churches. One carer was going round spending one to one time with residents who don’t enjoy group activities. If residents wish to spend time in their rooms, watching television, listening to music or reading, their privacy is respected. Residents also said that they felt able to make their own choices about how they spend their time. They can have keys to their rooms, get their own post and can have daily newspapers. Staff knock on bedroom doors before they enter and call residents by their preferred name.
Cottingham Hall DS0000000842.V263642.R01.S.doc Version 5.1 Page 13 Residents said they were well fed and liked the food served in the home. Their dietary needs were recorded on admission and any special diets are catered for. Cottingham Hall DS0000000842.V263642.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The key standards were included in the last inspection report. EVIDENCE: Cottingham Hall DS0000000842.V263642.R01.S.doc Version 5.1 Page 15 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Cottingham Hall is well kept, clean, comfortable, homely and smells fresh. EVIDENCE: The home is well decorated, furniture is comfortable and homely. The home is clean and smells fresh; there are no malodours. There were good procedures for managing clinical waste to help promote a healthy environment. Residents were pleased with the home and it’s surroundings. There is a very pleasant garden and courtyard at the back of the home. The home is well maintained and maintenance certificates were available Cottingham Hall DS0000000842.V263642.R01.S.doc Version 5.1 Page 16 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 There are good arrangements to make sure residents are in safe hands at all times. EVIDENCE: Over 50 of care staff have achieved the NVQ level 2 care qualification. This meets the target set in the minimum standard. Staff also undertake a range of basic and specialist training to be good carers and look after residents well. This was confirmed by talking to staff and was detailed in staff training records. Cottingham Hall DS0000000842.V263642.R01.S.doc Version 5.1 Page 17 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. There were good management arrangements to ensure the home is well run for the benefit of residents. EVIDENCE: The manager is qualified, competent and experienced to run the home in a way that ensures a good quality of care. She undertakes regular training to keep her skills up to date. Staff, residents and visitors were all complementary about her ability to run the home well. Residents, relatives and other visitors are all asked their views about the home in an effort to make improvements. The owners also visit the home monthly. These visits include talking to residents and staff, and checking records to help ensure the home keeps good standards of care.
Cottingham Hall DS0000000842.V263642.R01.S.doc Version 5.1 Page 18 The manager keeps small amounts of personal allowance for some residents. But does encourage them to look after their own money. Detailed records are kept of all money handled on behalf of residents. These were accurate and up to date. The home was well maintained and maintenance certificates were available for inspection. Cottingham Hall DS0000000842.V263642.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 Cottingham Hall DS0000000842.V263642.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? N/A 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 Refer to Standard OP3 Good Practice Recommendations The assessment format used for privately funded residents should be used for all residents. Cottingham Hall DS0000000842.V263642.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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