Inspection on 17/10/05 for Country Court

This inspection was carried out on 17th October 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Country Court 12/05/09

Country Court 18/02/09

Country Court 16/11/06

Country Court 06/02/06

Country Court 10/02/05

Country Court 29/10/04

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

CARE HOMES FOR OLDER PEOPLE Country Court Southcoates Lane Hull East Yorkshire HU9 3TQ Lead Inspector Malcolm Stannard Unannounced Inspection 17th October 2005 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 Country Court DS0000000843.V259990.R01.S.doc Version 5.0 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. Country Court DS0000000843.V259990.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Country Court Address Southcoates Lane Hull East Yorkshire HU9 3TQ 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 702750 Pearl Dusk Limited Susan Weldon Care Home 34 Category(ies) of Dementia - over 65 years of age (34), Old age, registration, with number not falling within any other category (34) of places Country Court DS0000000843.V259990.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Exception statement - permitted to provide care for one named person under pensionable age. 10th February 2005 Date of last inspection Brief Description of the Service: Country Court is purpose built building, which provides care for up to 34 older people, who may also suffer from dementia. All accommodation is on the ground floor with all rooms providing single accommodation. Nine rooms have en-suite facilities. There is a large lounge available along with a dining room and a conservatory. A smaller lounge also has a conservatory attached. An inner courtyard is available and accessible for residents to use should they wish to sit outdoors. The home is situated to the East of the city of Hull, with shops, health facilities, community services and public transport all easily accessible A small car park is available at the front of the home Country Court DS0000000843.V259990.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 4 hours. Some parts of the building were looked around and a few of the records were inspected. Some of the residents were spoken with, as well as chats with staff members as they worked. The manager and deputy manager were available during the inspection. What the service does well: What has improved since the last inspection? The home have ensured that all staff have undergone an enhanced criminal records check, even if they may have been working there for some time. A full internal and external training package is now available for all staff members, which includes an induction package. A controlled drugs register is now available should this be required. Residents care plans have been addressed to make sure they contain the required information and are reviewed regularly. A new system of recording this information has been introduced. All risk assessments for the premises are now complete and will be reviewed as appropriate. Country Court DS0000000843.V259990.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Country Court DS0000000843.V259990.R01.S.doc Version 5.0 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 Country Court DS0000000843.V259990.R01.S.doc Version 5.0 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): 1, 3, 4, & 5. The admission procedure ensures that a proper assessment is carried out prior to people moving into the service. This process means that a resident and their representatives can be sure the home will meet their needs. Information relating to the home is available to view. EVIDENCE: The home has a statement of purpose and service user guide. The service user guide has been rewritten and now includes all the information required by the National Minimum Standards. It is presently in draft form and is to be finalised soon. Copies of the guide will be given to all residents upon completion. All prospective residents are assessed by a member of senior staff prior to admission to the home; this is in addition to the local authority care management assessment. Each of the residents has an individual file, which contains a copy of the assessment. The information in the assessment is used to make up the plan of care for each resident. Country Court DS0000000843.V259990.R01.S.doc Version 5.0 Page 9 Staff members knew about each residents needs. The assessments ensure that the home is able to meet the needs of any prospective resident. Pre visits to the home are available for residents or relatives wishing to view the facilities prior to making a decision. The home does not offer intermediate care. Country Court DS0000000843.V259990.R01.S.doc Version 5.0 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, 8, 9 & 10. Health care needs of residents are identified and met. Residents are able to live in the home experiencing respect and privacy. EVIDENCE: Each resident has an individual plan of care, which contains details of their health, personal and social care needs. Each plan is reviewed on a monthly basis. Any change of information is transferred onto short-term care plan notes. Health requirements of residents, including the recording of nutritional assessments are met. All doctors, dentists, chiropodist and opticians appointments are made in a proactive manner. Residents spoken with explained that they could access a doctor when they felt they needed one. The medication system is generally well recorded and robust, with only one area needing attention. Medication already held in the home when a new delivery is receipted in is not added to the supplies on the medication record sheets. This should be done so as to ensure a running total is available at all times. Country Court DS0000000843.V259990.R01.S.doc Version 5.0 Page 11 No medication is dispensed from a generic stock. The home have a controlled drugs register in which any administration is recorded. Privacy and dignity for residents is covered in staff training and during the visit staff were seen to knock on all room doors prior to entering. Country Court DS0000000843.V259990.R01.S.doc Version 5.0 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, 13, 14 & 15. A range of recreational activities is provided in the home and resident’s preferences are accommodated. Daily choice for residents is enabled and contact with friends, family and within the local community is encouraged where appropriate. Residents have choice, diversity and experience good quality in the meals provided. EVIDENCE: Daily routines enable residents to make choice, allowing their individual needs to be met along with those of the group. A religious morning service is held in the home on a monthly basis for those who wish to attend. A full range of divisional activities are available both in and external to the home. Activities include music, visiting artists, slide shows, trips out and a party is planned for the forthcoming bonfire celebrations. The home also plan to celebrate their tenth anniversary shortly. Country Court DS0000000843.V259990.R01.S.doc Version 5.0 Page 13 A hairdresser visits the home on a Wednesday each week. Food provision at the home is wholesome and nutritious; residents confirmed that they are able to exercise choice over what they eat and the choices for breakfast and teas were displayed in the dining room. A full menu is also displayed. The lunch on the day of visit was beef stew and dumplings, this was of a good quality and several residents commented on the food. Assistance is given to those who require it in a sensitive manner and appropriate adapted cutlery was utilised. The home also has a resident’s fund, which is used for recreational pursuits; both management and residents are signatories on the account, along with a residents committee who meet regularly. A tuck shop is also run by residents offering the availability for small purchases. Appropriate contact with friends and family is encouraged and a telephone room is available for calls to be made in private. Six residents have their own phones in their rooms. Country Court DS0000000843.V259990.R01.S.doc Version 5.0 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): 16, 17 & 18. The home has a complaints procedure, which meets the needs of residents, and relatives who feel their views are listened to. A vulnerable adults procedure and policy is available, however all staff require cascaded training in order to protect residents from abuse. EVIDENCE: A clear complaints procedure is available in the home, residents spoken with said they would now how to raise an issue if they had any concerns. Records of complaints made showed that they had been dealt with in a timely manner and to the satisfaction of the complainant. Residents are assisted to vote in any election should they so wish. A procedure and policy for the prevention of abuse to vulnerable adults is available and this contains information on whistle blowing. A copy of the local vulnerable adults procedures is available, however the homes policy does not contain details of how these merge together. Information in regard to this should be made available in the homes policy. Senior staff members have attended training in adult protection however this information and guidance still hasn’t been cascaded to all staff members. It is important that this is done as soon as possible to ensure protection for residents. Country Court DS0000000843.V259990.R01.S.doc Version 5.0 Page 15 All staff members are checked via the Criminal Records Bureau including a POVA 1st check and supervision is carried out on a two monthly basis. Two residents spoke with stated that they would feel able to speak with someone if they did have any concerns. Formal supervision of staff is carried out on a two monthly basis. Country Court DS0000000843.V259990.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 23, 24, 25 & 26. The home provides a safe, comfortable and clean environment for residents, which is pleasant and homely. Rooms available meet the needs of individual residents. EVIDENCE: All of the premises were well presented, been clean tidy and hygienic. The home is light and airy with all furnishings domestic in nature. Private and communal sitting areas are available throughout the home. There are ample toilet and bathing facilities in the home, with bathrooms been provided with a hoist. The laundry area in the home was well equipped and fitted with an infection control system. Country Court DS0000000843.V259990.R01.S.doc Version 5.0 Page 17 The home is well equipped with aids and adaptations to meet the needs of residents. Resident’s rooms can be personalised with personal processions, photographs and ornaments. A call system is provided to enable residents to summon assistance if required. Ventilation and heating is satisfactory in the communal areas of the home and in those residents’ rooms seen during the visit. All small electrical equipment has been tested and fire prevention and detection equipment is serviced by a main contractor. Country Court DS0000000843.V259990.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Procedures for the recruitment of staff are satisfactory and offer protection for the residents in the home. Staff training enables good quality care to be offered. EVIDENCE: The homes staff group has a very small turnover rate and works well as a team. Well over 50 of the homes care staff are qualified to NVQ level 3 or equivalent, a further six care staff are presently enrolling on the training qualification. Ancillary staff also hold an appropriate NVQ qualification. A full staff training programme is now in use with records held for all staff. An induction programme is followed which is then supplemented by accessing training provided by the Local Authority. Rotas seen demonstrate that numbers of staff on duty are sufficient to cater for the needs of the residents. All staff undergo the homes recruitment process, which includes the taking of references, checks on qualifications and a criminal records bureau check at an enhanced level. All staff have now undergone these checks, including those who were already employed at the home. Country Court DS0000000843.V259990.R01.S.doc Version 5.0 Page 19 On a couple of occasions, residents were observed in wheelchairs, which did not have, footrests fitted. Conversations with these residents confirmed that this was their choice. I would suggest that staff members are reminded of the dangers, which could be created when using wheelchairs in this manner. Country Court DS0000000843.V259990.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 37 & 38. The management of the home is carried out with leadership and appropriate guidance; ensuring residents receive a quality of care, which is consistent. A resident centred ethos is promoted within the home. The completion of a management qualification will enhance the leadership style. Health and safety provision within the home is addressed positively. EVIDENCE: The registered manager has many years experience working with the client group, has been the manager at the home for over two years and is presently undertaking the registered managers award, which covers care and management issues. She intends to complete this by the end of 2005. Country Court DS0000000843.V259990.R01.S.doc Version 5.0 Page 21 Any monies which are held on residents behalf are recorded and held individually, receipts are obtained for any spending, such as on hairdressing or the tuck shop. Work place risk assessments, including fire risk assessments. are carried out on all areas of the home and these are now complete. It is intended that these will be reviewed in March 2006. Health and safety of residents is protected by the management ensuring safety certificates are up to date. Peninsular systems also visit to carry out health & safety inspections. Accident records were completed appropriately. Visits are undertaken by the registered provider on a monthly basis to compile a Regulation 26 report, which a copy of is forwarded to the Commission for Social Care Inspection. Country Court DS0000000843.V259990.R01.S.doc Version 5.0 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 3 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 3 3 X 3 3 3 3 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 2 3 3 3 3 X 3 3 Country Court DS0000000843.V259990.R01.S.doc Version 5.0 Page 23 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 OP9 Regulation 13 Requirement All medication received into the home or carried over from one period to the next must be recorded on the MAR sheet. Training for all staff must be made available in relation to the protection of vulnerable adults. The homes policy on prevention of abuse must show how it links to the local multi disciplinary procedure. Timescale for action 17/10/05 2 3 OP18 OP18 12 12 31/12/05 31/12/05 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 OP31 Good Practice Recommendations The registered manager should achieve an NVQ level 4 or equivalent in care and management by 31/12/2005. Country Court DS0000000843.V259990.R01.S.doc Version 5.0 Page 24 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 © 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 Country Court DS0000000843.V259990.R01.S.doc Version 5.0 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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