Inspection on 06/02/06 for Country Court

This inspection was carried out on 6th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 17/10/05

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 Eileen Engelmann Unannounced Inspection 6th February 2006 10:00 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.V280106.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. Country Court DS0000000843.V280106.R01.S.doc Version 5.1 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.V280106.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Exception statement - permitted to provide care for one named person under pensionable age. 17th October 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.V280106.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out with the registered manager; staff and residents of Country Court care home. The inspection took 3 hours and included a tour of the premises, examination of staff and resident files and records relating to the service. Some of the residents were spoken with, as well as chats with staff members as they worked. All the key standards have been inspected in the past year and information on these and their outcomes can be found in the report for 17th October 2005 and this one. What the service does well: What has improved since the last inspection? What they could do better: Training in vulnerable adults protection needs to be carried out with all staff members. This will improve the staffs understanding of their role and responsibilities in this area of care and help protect the residents from risk of harm. Country Court DS0000000843.V280106.R01.S.doc Version 5.1 Page 6 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.V280106.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 Country Court DS0000000843.V280106.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. All residents undergo a full needs assessment and are given sufficient information about the home and its facilities prior to admission, to enable them to be confident that their needs can be met by the service. EVIDENCE: The home continues to meet this key standard. All residents at the home have their own personal file and the two looked at were for fairly new residents. Each individual had a need assessment completed by the funding authority and the home has also completed its own needs assessment before a placement was offered to the resident. The home develops a comprehensive care plan from the assessments, identifying the individual’s problems, needs and abilities using the information gathered from the resident and family. Country Court DS0000000843.V280106.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 9. The health, personal and social care needs of the residents are clearly documented and are being met by the service and staff. The medication at the home is well managed promoting good health. EVIDENCE: The home continues to produce and keep clear and well-written care plans for the residents. Individual care plans are in place for all residents and clearly set out the health, personal and social care needs identified for each person. Risk assessments are carried out for all individuals and two of the plans looked at have been evaluated on a monthly basis. Any changes to the care being given is documented and implemented by the staff. The medication policy for the home says that individuals can self-medicate if they want to and after a risk assessment has been completed and agreed. Since the last inspection the staff have altered their practice in that medication already held in the home when a new delivery is receipted in, is added to the Country Court DS0000000843.V280106.R01.S.doc Version 5.1 Page 10 supplies on the medication record sheets. This is done so as to ensure a running total is available at all times. Checks of the medication records and the system used showed that these are up to date, accurate and well managed. There were no controlled drugs in the home at the time of this inspection. Country Court DS0000000843.V280106.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12. Residents are provided with choice and diversity in the activities provided by the home, enabling them to meet their social and recreational interests and needs. EVIDENCE: The home continues to meet this key standard. Residents said that they are offered choice and flexibility in their care and activities of daily living, and expressed their satisfaction about the relaxed and friendly approach of the staff and the welcoming atmosphere within the home. There is a range of social activities on offer within the home and trips out into the community. A religious morning service is held in the home on a monthly basis for those who wish to attend and the hairdresser comes into the home each week on a Wednesday. Country Court DS0000000843.V280106.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 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: The home has a clear and simple complaints procedure that residents, relatives and staff are aware of and are confident of using if needed. The complaints records show that there has been one complaint made to the home since the last inspection; this has been investigated by the manager and resolved. Complaints are currently recorded in a book, but this does not offer individuals confidentiality because the format means that anyone writing in the book can see previous complaints that have been made by different people. The inspector recommended that a separate complaints form should be developed that can be filled in by the complainant and filed away by the manager once an issue has been investigated and resolved. Discussion with the manager indicated the home is working towards meeting the requirements around Protection of Vulnerable Adults from Abuse (POVA), raised at the last inspection. A procedure and policy for the prevention of abuse to vulnerable adults is available and this contains information on whistle blowing and is linked to the information in the Local Vulnerable Adults protocols. The home has applied for places on the next POVA training programme run by John Curry, and places Country Court DS0000000843.V280106.R01.S.doc Version 5.1 Page 13 have also been asked for on the challenging behaviour courses run by Hull Social Care and Health. Country Court DS0000000843.V280106.R01.S.doc Version 5.1 Page 14 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. The standard of the environment within this home is satisfactory, providing residents with a comfortable and homely place to live. EVIDENCE: The home has an ongoing programme of routine maintenance and decoration that ensures the environment is kept safe, clean and well presented. There are three minor areas that need to be looked at and they are: ∗Observation of the home showed that the front door handle from the outside needs repairing, and the manager assured the inspector that this is on order and will be fitted as soon as possible. ∗The main lounge is well used by the residents, being the place where the majority come to sit and talk to each other and visitors. Subsequently the carpet is showing signs of wear and tear, with stains visible despite regular deep cleaning. The inspector recommended that this floor covering be considered for replacement in the next year. Country Court DS0000000843.V280106.R01.S.doc Version 5.1 Page 15 ∗Two bedroom carpets (1 and 9) have been faded by the sun, which has changed their colour in patches from a deep red to a greenish colour. The inspector recommended that these carpets were also considered for replacement. Country Court DS0000000843.V280106.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): 27. Sufficient staff are employed to ensure there is a good match of well-qualified staff offering consistency of care within the home. EVIDENCE: Information in the staffing rotas shows that the home continues to employ sufficient staff to meet the needs of the residents. Residents spoken to are very happy with the amount of staff on duty and said ‘they are always helpful and available to see to anything you need doing and nothing is too much bother’. Country Court DS0000000843.V280106.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. The management of the home is satisfactory overall, and the completion of a management qualification will enhance the leadership style. 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 said that she hopes to complete this by June 2006. Country Court DS0000000843.V280106.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X X STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X X X X Country Court DS0000000843.V280106.R01.S.doc Version 5.1 Page 19 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 OP18 Regulation 12 Requirement Training for all staff must be made available in relation to the protection of vulnerable adults (given timescale of 31/12/05 was not met). Timescale for action 01/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard OP16 OP19 OP19 OP19 OP31 Good Practice Recommendations The manager should consider developing the complaintrecording format to produce a separate form that can be filed away so information is kept confidential. The front door handle should be repaired and left in good working order. The main lounge carpet should be considered for replacement within the next twelve months. Bedrooms 1 and 9 should have the faded carpets within them considered for replacement over the next twelve months. The registered manager should achieve an NVQ level 4 or equivalent in care and management by June 2006. Country Court DS0000000843.V280106.R01.S.doc Version 5.1 Page 20 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.V280106.R01.S.doc Version 5.1 Page 21 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!