Inspection on 30/11/06 for Court House Nursing Home

This inspection was carried out on 30th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Court House Nursing Home 22/06/09

Court House Nursing Home 04/06/08

Court House Nursing Home 18/10/05

Court House Nursing Home 13/06/05

Court House Nursing Home 11/10/04

Court House Nursing Home 07/04/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Court House Nursing Home Barnards Green Malvern Worcestershire WR14 3BS Lead Inspector Nick Richards Unannounced Inspection 30th November 2006 09:00 X10029.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 Court House Nursing Home DS0000004106.V321822.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People and Care Homes for Adults 18 – 65*. 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. Court House Nursing Home DS0000004106.V321822.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Court House Nursing Home Address Barnards Green Malvern Worcestershire WR14 3BS 01684 561276 01684 577949 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) www.bupa.com BUPA Care Homes (CFHCare) Limited Kalmit Kaur Jagpal Care Home 79 Category(ies) of Dementia - over 65 years of age (19), Old age, registration, with number not falling within any other category (41), of places Physical disability (19), Physical disability over 65 years of age (41) Court House Nursing Home DS0000004106.V321822.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. A maximum of 16 people may be accommodated in Beacon House (categories OP and PD (E)). A maximum of 25 people may be accommodated in Midsummer House (categories OP and PD (E)). A maximum of 19 people may be accommodated in Bredon House (category DE (E)). A maximum of 19 people may be accommodated in Hollybush House (category PD). 18/10/05 Date of last inspection Brief Description of the Service: Court House is situated close to the shops and commanding views of the Malvern Hills. Court House provides care in four individual houses for the elderly frail, elderly mentally infirm and young physically disabled. Some bedrooms have an ensuite facility, and all are single occupancy. Most bedrooms are located on the ground floor, while the two units with accommodation on the first floor level possess a central passenger lift. The home is operated by BUPA, and is managed by Mrs K Jagpal, the registered manager who is a first level registered nurse. There is no deputy manager employed within the home, but each of the four units within the home is managed by a unit manager (who are all first level registered nurses). The home’s fees range from £452.00 per week through to £1399.00 per week. Fees do not include toiletries, hairdressing, private healthcare, escorts, newspapers and specialist equipment not available through the NHS. The home manager can be contacted via email. Her email address is; jagpalk@bupa.com Court House Nursing Home DS0000004106.V321822.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this unannounced inspection the quality of information given to people about the care home was looked at. People who use services were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the service user’s guide, statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that the Commission for Social Care Inspection (CSCI) are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk. The inspection of Court House represented the first key inspection of the home for the year 2006/07. The inspection focused on outcomes for service users resident on Hollybush House (accommodating younger adults) and Bredon House (accommodating older people with dementia). Outcomes were generally positive (see below for further details). Opportunity was taken to examine care and staffing records, examine the home’s physical environment and interview staff members, individual service users and the home’s management. Pre-inspection feedback was also analysed and the views of visiting healthcare professionals and relatives were also sought and taken into account. The overwhelming consensus of opinion supplied to the Commission was positive, and one relative explained how standards within the home had improved significantly since the current manager was appointed. What the service does well: The clinical care provided to service users is good, with physical healthcare needs being met to a positive standard. The physical healthcare state of service users is effectively monitored and addressed under the care of registered nurses who are on duty throughout the 24-hour period. Meals provided, and the quality of food provided by the home is exceptional, and the catering manager (justifiably) takes strong pride in the standard of catering services and meals provided to and for service users. Social/recreational care staff work creatively to develop and implement meaningful activities for service users thereby helping to promote social, recreational, occupational and leisure activities for service users. Court House Nursing Home DS0000004106.V321822.R01.S.doc Version 5.2 Page 6 The home continues to be managed excellently by an extremely competent and effective manager What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Court House Nursing Home DS0000004106.V321822.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Court House Nursing Home DS0000004106.V321822.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive all the information and support they need so that they can make a decision regarding their choice of home. The home only offers a service to people whose needs they can meet. EVIDENCE: The inspector focused on the care of three residents. One person, recently admitted to the home, was being visited by a member of her family. They confirmed that the home was chosen after intensive research Court House Nursing Home DS0000004106.V321822.R01.S.doc Version 5.2 Page 9 that had included studies of Statements of Purpose, Service Users’ Guides and inspection reports. They had visited homes and had discussions before deciding that Court House was the best they had seen. They had been impressed by the content and ‘good plain English’ of the information they had received which had included copies of the complaint procedure. The prospective resident had been visited and her needs had been assessed. This was confirmed by the pre-admission assessment on file. They confirmed that they had received a contract and clear information regarding the terms and conditions and costs. All their questions had been welcomed and fully answered. The second resident was very frail and unable to respond to most of the inspector’ questions. However she did say that she was well looked after and had no complaints. Feedback received confirmed that they had received a pack of documents that had included the contract and a complaint procedure. Regular detailed accounts for accommodation and care continue to be received. The third resident had received all written information to help her make her decision and this had included a copy of the complaints procedure. A nurse from the home had visited her ‘to see what help she needed’ before she had moved in and had ‘explained everything to her’. She thought that her son had the copy of her contract. It was observed that copies were on file and acceptable. The manager said that all residents and/or their families were sent a contract and terms and conditions of residence. People were invited to the home and could visit and discuss their situation as often as they wished to help them make a decision. Care records were assessed. These contained acceptable copies of a contract and letters from the home and the funding authority i.e. Worcestershire County Council explaining the charges. There were also copies of letters that explained why rises in charges were necessary and how much they were to be. Staff were interviewed by the inspector. They were all aware of the action they would take if inquiries were received about the home. Their roles did not require knowledge of financial details. However they rightly presumed that the managers and administrative staff dealt with such matters, and letters were sent to appropriate people when changes occurred. Three files that were assessed held acceptable pre-admission assessments and care plans. A copy of an acceptable up-to-date Statement of Purpose, Service Users’ Guide and Inspection Reports were available in the reception area. Court House Nursing Home DS0000004106.V321822.R01.S.doc Version 5.2 Page 10 The home does not provide intermediate care therefore Standard 6 is not applicable to the home. Court House Nursing Home DS0000004106.V321822.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information and training is provided so that staff provide the personal and health care that the residents need with due regard for their wishes and dignity. EVIDENCE: Court House Nursing Home DS0000004106.V321822.R01.S.doc Version 5.2 Page 12 The records indicated that initial care plans had been set up based on the preadmission assessment. This provided first information for staff on how the individuals’ needs should be met. They were acceptable. Subsequent care plans were available and more detailed as they reflected the growing knowledge of the residents’ needs and how they should be met. There was no evidence of residents’ involvement in their care planning. The residents had access to doctors, district nurses, chiropodist, opticians, dentist and other health care professionals. Records were well maintained of all visits and contacts. Regulation 37 notifications made to the Commission for Social Care Inspection demonstrate that appropriate action is taken when people became ill or have accidents. The daily records demonstrated that advice is sought and appropriate care is provided. All relatives who completed and returned questionnaires to the Commission for Social Care Inspection, and the relatives who spoke to the inspector confirmed that communication between them and home was good and they were kept well informed. A high standard of practical care and attention was observed. Medication was being appropriately managed and records were well maintained. Staff demonstrated that they knew how to respect residents’ privacy and dignity and it was observed that their relationship with residents was pleasant and courteous. Staff gave examples and it was observed that privacy and dignity was respected. It was observed that some bedroom doors, toilets and bathrooms were fitted with approved locks so that privacy could be obtained when wanted without compromising safety. Residents were able to make and receive phone calls in private. Those who chose had private phones fitted in their rooms. Mail was delivered unopened and staff assisted if required. Court House Nursing Home DS0000004106.V321822.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Facilities and events are organised so that residents have opportunities to participate in a choice of interesting social events in the home and in the community. Links are maintained with families and friends. A choice of good quality meals is provided from which residents can make a selection and enjoy nutritional food. Court House Nursing Home DS0000004106.V321822.R01.S.doc Version 5.2 Page 14 EVIDENCE: Care records demonstrated that information was sought regarding culture and religion. One person was able to confirm that she and others could attend their local church, and services took place in the home. The pre-inspection questionnaire completed by the registered manager indicated that a wide range of in-house and community activities were provided for residents. Records demonstrated their interests and participation. Residents confirmed that they were able to make choices in their daily lives. They were able to use their bedrooms and communal facilities as they wished and participate in events as they chose. Activities organisers are employed for each unit and staff confirmed that they participated and supported them and the residents. An extensive activities programme was submitted to the Commission prior to the inspection. On the day of inspection the Lead Inspector was assisted by a colleague who undertook a SOFI analysis (Short Observational Framework for Inspection). The essence of this was to look at the care provided to certain residents who do not have the mental capacity to express their viewpoints (the SOFI tool is based on Dementia Care Mapping), and to observe their experience(s) of the care provided. The outcomes from the observational exercise raises questions about some staff competencies in recognising and meeting the social, recreational and occupational needs of people with memory loss problems. It is noted that, during interview, an activities organiser/co-ordinator claimed that no specific accredited training had been provided in relation to the provision of social, recreational and occupational care. Opportunity should be taken to identify training that will enable staff responsible for the provision of social, recreational and occupational care to effectively address the social care needs of individuals using the service. Samples of menus were sent to the CSCI. They demonstrated that a choice of well-balanced meals was always provided. Residents told the inspector that; they ate well, enjoyed “fantastic meals”, and “They (meals) can’t be better”. The catering manager takes appropriate and understandable pride in the quality of meals that are served, and is committed to ensuring all residents have a high level of satisfaction with the food provided. A “hotel” services approach is adopted, which aspires to attain a “5 star” rating for food provision and resident satisfaction. The organisation has compiled a compendium of cultural information that enables the catering department to provide appropriate meals based on the religious and cultural requirements of minority groups. Court House Nursing Home DS0000004106.V321822.R01.S.doc Version 5.2 Page 15 Given the exemplary standards promoted by the catering manager, it is rather unfortunate that the service provision is somewhat compromised by nursing staff not effectively communicating at times with the catering department regarding issues such as resident weight loss – particularly as the catering manager has some excellent nutrition and dietary strategies that could, if accessed by nursing staff, help to rectify residents’ weight loss. Court House Nursing Home DS0000004106.V321822.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have access to the information they need so that they raise issues that concern them. Concerns are then investigated and responded to appropriately Staff are appropriately recruited and trained so that vulnerable people are not put at risk. EVIDENCE: The home has a simple and clear complaints procedure. A copy of the complaints procedure had been given to all residents, and was available to visitors and relatives. Residents spoken to were confident that concerns could be raised with the home. The Commission has not received any complaints about the service since the time of the previous inspection. The complaints register was examined, and clearly demonstrated that concerns, no matter how small, are taken on board, investigated and addressed. The home also retains letters of appreciation. The letters of appreciation strongly outweigh any letters of concern. Court House Nursing Home DS0000004106.V321822.R01.S.doc Version 5.2 Page 17 A procedure for responding to allegations of abuse is available, and staff have received training in abuse recognition and minimisation. Court House Nursing Home DS0000004106.V321822.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Investment within the home’s physical environment has been undertaken helping to enhance the appearance of all four units. However, the physical limitations of the buildings present challenges to the service. EVIDENCE: Court House Nursing Home DS0000004106.V321822.R01.S.doc Version 5.2 Page 19 Many bedrooms seen had been furnished with residents’ personal possessions, thereby generating ownership and a sense of autonomy for individuals, and several residents confirmed that they appreciated the physical environment. However, there were some areas within the home (predominantly Midsummer House and Bredon House) where bedrooms could be enhanced through redecoration and the provision of better quality furnishings – which were, in several bedrooms, looking worn. It was also noted that many bedroom doors failed to possess approved locking devices, which would enable residents to lock their doors for privacy purposes and open their doors when they are within their room using just one movement. Several relatives had fed back to the Commission their disappointment about the home’s environment, and their opinion that environmental standards within Court House could be improved. Although the environmental layout of Midsummer is generally suitable for residents, it was noted that corridors were narrow, making it difficult for residents with mobility problems to independently manoeuvre around the unit. This has resulted in walls and coverings being marked and scratched. Hollybush House had benefited significantly from refurbishment and redecoration, and residents were very appreciative of the environmental standards within the unit. Hot water temperatures have been risk assessed and had been regulated to prevent people being accidentally scalded when they have a bath. Water temperatures were being routinely checked to ensure that temperatures were safe. Radiators had been guarded and restricted to prevent people being accidentally burnt through intentional or unintentional contact, and all the windows located above first floor level had been restricted to prevent people from being injured through falling out of the windows (accidentally or deliberately). All areas within the home were clean, tidy and free from offensive odours. Court House Nursing Home DS0000004106.V321822.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Sufficient suitable staff are recruited and employed to provide the skilled care that residents need. Training is ongoing to ensure staff have the knowledge and skills to provide the care residents need. EVIDENCE: The pre-inspection questionnaire and samples of duty rosters indicated that sufficient staff were available to care for the residents. The home had based these calculations on dependency levels that were regularly re assessed. However several relatives’ questionnaires expressed an opinion that there were not always sufficient staff on duty Court House Nursing Home DS0000004106.V321822.R01.S.doc Version 5.2 Page 21 The staff who were interviewed said that they considered the staffing levels to be acceptable. Since the last inspection 59 staff had left the home. The pre inspection questionnaire stated that there were 50 care staff employed, 21 of whom had National Vocational Qualifications to level two or above. This amounts to 42 of the total number of carers employed. The home should be aiming to ensure that 50 of all carers hold NVQ Level 2 or equivalent. In addition to care staff, the home also employs 23 registered nurses and 13 ancillary staff. The home’s staffing compliment has increased since the time of the previous inspection, and staffing levels (based on the dependencies of residents) are above those levels cited using the Department of Health’s staffing tool (2,488 hours per week staff time provided as opposed to 2,460 hours per week staff time calculated (DoH)). The training matrix and records demonstrated that mandatory training was closely monitored and provided for all staff. Other opportunities were accessed and staff expressed their appreciation of the commitment to training. All staff said that they received 1:1 supervision with a senior, which they found useful and supportive. The staff who spoke to the inspector confirmed they had been correctly recruited. Their records indicated that they had completed application forms, references had been taken up, checks undertaken by the Criminal Records Bureau and they had been interviewed. Positive comments regarding the staff were received in the questionnaire responses from residents, staff, and health care professionals and from the residents and relatives who spoke to the inspector. Court House Nursing Home DS0000004106.V321822.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home has an experienced and trained manager who ensures it is run in the best interests of the people who live and work there. Court House Nursing Home DS0000004106.V321822.R01.S.doc Version 5.2 Page 23 There is clear leadership, guidance and direction to staff to ensure residents receive consistent care, resulting in practices that promote and safeguard the health, safety and welfare of the people using the service. EVIDENCE: Staff and residents spoke very highly of the manager, and significant diligence and action has been undertaken to improve the quality of the service provided by the home. Residents clearly expressed their opinion that the home was being run in their best interests. The homes financial recording system remains robust. Staff were being formally supervised in accordance with the National Minimum Standards. Supervision is important to ensure that staff understand their roles, the homes philosophy of care and how that philosophy is put into practice. It is also necessary to ensure that staff development needs are understood, recognised and actioned accordingly – with a view to improving service delivery. Annual questionnaires are distributed by the home and completed by residents and it was seen that these had been analysed and the results were readily available. Concerns that were expressed had been addressed and areas where development and the service could be improved were identified attention. A number of systems in the home were regularly monitored and audited, and inspections undertaken in accordance with Regulation 26 provided more information on the quality of the service. These methods formed the quality assurance system for the home. The pre-inspection questionnaire indicated that the equipment and services in the home were regularly monitored, maintained and serviced. The documentation in the home supported this statement. Accident records were well maintained. A Fire Risk Assessment for the home had been undertaken, and the provider was addressing any issues that had been identified within the risk assessment. Fire safety checks and training were being undertaken at an acceptable frequency, and staff were receiving training in other health and safety topics. Court House Nursing Home DS0000004106.V321822.R01.S.doc Version 5.2 Page 24 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 3 2 3 3 3 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 3 20 3 21 3 22 2 23 3 24 3 25 3 26 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 4 32 X 33 4 34 X 35 3 36 X 37 X 38 4 Court House Nursing Home DS0000004106.V321822.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP12 Good Practice Recommendations Service users’ involvement in care planning should be encouraged and documented. Training should be provided that will enable staff responsible for the provision of social, recreational and occupational care to effectively address the social care needs of individuals using the service. The home should develop formal communication and reporting pathways between nursing staff and catering staff in relation to service users’ dietary needs. The doors of residents private accommodation should be fitted with a lock suited to the residents capabilities and accessible to staff in emergencies. Midsummers corridors should be reviewed, and appropriate action taken to ensure that accessibility for mobility-restricted service users is promoted and facilitated. All fatigued items of bedroom furniture should be replaced. The home should aim to ensure that 50 of carers hold an DS0000004106.V321822.R01.S.doc Version 5.2 Page 26 3 4 5 OP15 OP24 OP22 6 7 OP24 OP30 Court House Nursing Home NVQ Level 2 in Care (or equivalent). Court House Nursing Home DS0000004106.V321822.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. Court House Nursing Home DS0000004106.V321822.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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