Inspection on 04/06/08 for Court House Nursing Home

This inspection was carried out on 4th June 2008.

CSCI found this care home to be providing an Good service.

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 30/11/06

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 27/09/2008.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Court House Nursing Home 3-5 Court Road Barnards Green Malvern Worcestershire WR14 3BS Lead Inspector Sarah Blake Key Unannounced Inspection 4th June 2008 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.V366034.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.V366034.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Court House Nursing Home Address 3-5 Court Road 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) Ltd Miss Alison Elizabeth Ough Care Home 79 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (19), Old age, not falling within any other of places category (41), Physical disability (19), Physical disability over 65 years of age (41) Court House Nursing Home DS0000004106.V366034.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). 30th November 2006 Date of last inspection Brief Description of the Service: Court House provides care in four individual houses for the elderly frail, people with dementia and young physically disabled people. Some bedrooms have an en-suite 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 situated in a residential area, close to local shops and with views towards the Malvern Hills. The home is operated by BUPA, and is managed by Alison Ough, the registered manager, who is a registered nurse. Each of the four units within the home is managed by a unit manager, all of whom are registered nurses. Information relating to the fees charged for the service is available on request from the home. Fees do not include toiletries, hairdressing, chiropody, newspapers and specialist equipment not available through the NHS. Court House Nursing Home DS0000004106.V366034.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good outcomes. The inspector spent a day at the home, talking to the people who use the service and the staff, and looking at the records which must be kept by the home to show that it is being run properly. These include records relating to the care of people who use the service. The service had previously completed an Annual Quality Assurance Assessment (AQAA). The AQAA is a self-assessment and a dataset that each registered provider has to complete each year and send to us within agreed timescales. The document tells us about how providers of services are meeting outcomes for people who use the service and is an opportunity for them to share with us what aspects of the service they believe they are doing well. Some of the manager’s comments have been included within this inspection report. We also received completed survey forms from eight people who use the service and from ten members of staff. The information from these sources helps us understand how well the agency is meeting the needs of the people using the service. What the service does well: The service provides good information to help people make a decision on their choice of home. The service carries out a thorough assessment of the needs of the people who use the service, and their care is planned to take into account their wishes and preferences. Care is delivered to a high standard. There is a good range of activities and social events, and the meals provided by the service are appealing and nutritious. The home is kept clean and there is a friendly, informal atmosphere. People know how to tell the management about any concerns, and the manager listens to complaints and resolves them satisfactorily. Staff receive good training to prepare them for working in the home. Recruitment processes are thorough, and help to protect the people who use the service. The home benefits from having an experienced manager whose priority is the wellbeing of the people who use the service. Court House Nursing Home DS0000004106.V366034.R01.S.doc Version 5.2 Page 6 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.V366034.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.V366034.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, 3, 5, 6 (1, 2, 4) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are provided with enough information to enable them to make a decision about their choice of home. They can visit the home to make sure it is the right place for them. Senior nurses from the home visit and assess people’s needs before they come to live at the home, so that the staff can provide the care that is needed. The home does not provide intermediate care (Standard 6). Court House Nursing Home DS0000004106.V366034.R01.S.doc Version 5.2 Page 9 EVIDENCE: We talked to three residents and relatives about their experience of choosing the home. They said that they were satisfied with the amount of information they were given, and that they had been given the opportunity to visit the home to help them make up their minds. The manager told us that she encourages people to visit the home before they decide to live there. There is a copy of the home’s Statement of Purpose, Service User Guide and the current inspection report in the reception area. We saw written assessments of people’s needs which had been carried out by senior staff before admission to the home. These were thorough and would give staff enough information so that they could provide the care that people need as soon as they enter the home. People who use the service told us that they had written contracts, so that they knew exactly what they could expect from the home. Contracts were available for us to see. Court House Nursing Home DS0000004106.V366034.R01.S.doc Version 5.2 Page 10 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 (6, 9, 16, 18, 19, 20) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service receive a thorough assessment of their needs. Their personal care is carefully planned to take into account their wishes and preferences. They can be confident that they will receive a good standard of care. Court House Nursing Home DS0000004106.V366034.R01.S.doc Version 5.2 Page 11 EVIDENCE: We looked at care plans for four people who use the service. The care plans had been written following a full assessment of needs. The assessment included all aspects of daily living, and also identified potential risk areas such as pressure sores and the risk of falling. The care plans were detailed and had been reviewed and updated monthly. Within the care plans, we saw evidence that people’s individual needs and wishes had been taken into account. For example, one resident with poor eyesight had a care plan which set out clearly how staff could help her to make the best of her sight. We did not see any evidence that the people who use the service are involved in planning or reviewing their own care, although staff told us that this is an important part of care planning. The manager told us that she will make sure that staff write down the views of the people who use the service when planning and reviewing care. We observed staff working with the people who use the service in each of the four units. The staff showed respect for the privacy and dignity of the residents. This was confirmed in some of the comments from residents and relatives. One young resident told us: “they look after me well here” and a relative told us: “The standard of care here is extremely high … they do everything to maintain people’s dignity.” People who use the service told us that they receive the medical help that they need. We looked at the records of a resident who had required medical attention, and we saw evidence that the GP had visited promptly. The daily records showed that the treatment prescribed by the GP had been administered. The home has a system for identifying and managing weight loss. We saw records on Beacon unit, which showed that people are routinely weighed monthly and any residents who are losing weight are highlighted on the chart and weighed weekly until their weight stabilises. The unit manager informs the kitchen and a high protein diet is provided. If the resident is still losing weight after two weeks, medical advice is sought from the GP or the dietician. We looked at residents’ medication records. These were fully completed, and medication was stored safely. Staff told us that residents are given the opportunity to take responsibility for their own medication, but that currently none of them do so. Court House Nursing Home DS0000004106.V366034.R01.S.doc Version 5.2 Page 12 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, 15 (12, 13, 15, 17) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have opportunities to participate in social activities. These are well run by a team of dedicated staff. Meals are nutritious and wellbalanced. Court House Nursing Home DS0000004106.V366034.R01.S.doc Version 5.2 Page 13 EVIDENCE: The home employs a team of activities coordinators, who work to provide a range of social opportunities for the people who use the service. A member of the activities team meets each new resident, and completes a “Map of Life” with them. Recently the residents have been very involved in planning and planting the garden area. We observed residents discussing the plants and vegetables to be grown, and assisting with potting up seedlings. The activities coordinator told us that many of the residents had expressed an interest in gardening, and that the ideas for the garden had come from them. Weekly watercolour botanical painting sessions are popular, and several residents mentioned how enjoyable they find them. The home organises outings, and one resident told us how much she had enjoyed a recent trip to Sea Life. We observed a PAT (Pets as Therapy) dog in the lounge of Bredon unit. The residents obviously enjoyed his visit, and they told us that PAT dogs are often brought to the home. One member of staff told us “More could be done for activities – if the financial resources were available to make these improvements. Activity provision within the limitations of the home are excellent”. Some residents told us that there was not always enough to do to keep them fully occupied. We talked to several residents, one of whom told us that he is happy at the home; he enjoys reading the newspaper (today’s paper was folded up beside him on the chair), he also likes the garden and he chatted animatedly about the new planting in the garden. The home welcomes visitors, and we spoke to relatives of two residents, who told us: “we are always welcomed” and “staff are always obliging”. The manager told us that she has been working with the unit managers to improve interaction between the units, and we were told about events such as themed evenings which take place in the large lounge in Midsummer unit. The local vicar visits to celebrate Holy Communion every month, and a Catholic priest visits every week. Staff told us that there are currently no residents of other faiths, but that they would meet the needs of other faiths as required. We looked at the menus, which showed a wide range of nutritious and wellbalanced meals with vegetarian options at each meal. The manager told us that the home is in the process of setting up a residents’ food group so that Court House Nursing Home DS0000004106.V366034.R01.S.doc Version 5.2 Page 14 new meal options can be identified. These will be passed to the catering manager, who will check them for nutritional value and will put them on the menu if appropriate. On each unit, there is a box in the fridge with snacks such as yoghurt, to be used at any time of the day or night by the residents. The staff keep a record so that if a resident might need extra food or a late snack on a regular basis, this can be arranged. We observed lunch being served in Hollybush unit. The food was presented attractively, and staff who were supporting residents to eat, sat next to them and chatted with them. Residents were eating outside round the table, and there was a homely, informal atmosphere. Court House Nursing Home DS0000004106.V366034.R01.S.doc Version 5.2 Page 15 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): 16, 18 (22, 23) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service can be confident that their views will be listened to, and that any concerns will be dealt with appropriately. Staff recruitment is thorough, and relevant training for staff helps to protect people. EVIDENCE: The home has a clear complaints procedure, and most residents who we spoke to said that they know how to complain if they need to. Residents are given a copy of the complaints procedure. We looked at the complaints register held by the home. The two complaints received over the past year had been fully investigated and satisfactorily resolved. Court House Nursing Home DS0000004106.V366034.R01.S.doc Version 5.2 Page 16 We looked at staff files, which showed that all pre-employment checks are carried out. Training records showed that staff receive training on the protection of people from abuse. Court House Nursing Home DS0000004106.V366034.R01.S.doc Version 5.2 Page 17 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, 20, 24, 26 (24, 30) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service will benefit from the extensive work planned for the next twelve months, but efforts have been made to make it pleasant for the people who live there. The home is kept clean and residents are encouraged to personalise their bedrooms with their own furniture and ornaments. Court House Nursing Home DS0000004106.V366034.R01.S.doc Version 5.2 Page 18 EVIDENCE: The four units at Court House are all in need of refurbishment, and there are plans for major work to be done during the next twelve months. However, it is obvious that the staff have put time and energy into trying to make the environment as pleasant as possible. On the day of the inspection, all parts of the home were clean and wellmaintained. The corridors were free of obstructions, so that people could move freely and safely through the buildings. Feedback from surveys had indicated that there was occasionally an unpleasant odour, but this was not apparent on the day of the inspection. The garden areas were pleasant and easily accessible to the people who use the service. There was adequate seating in the garden, some with shading to protect people from the sun. The communal areas and private bedrooms were of sufficient size to accommodate the people who use the service. Each unit has its own lounge and dining area, and these were seen to be well-furnished with a homely atmosphere. We looked at bedrooms in each of the four units. Many of the bedrooms contained residents’ own items of furniture and ornaments. The manager told us that residents are encouraged to bring their own possessions with them, and one of the residents told us that it had meant a great deal to her to have so many of her own personal items around her. There are alcohol hand cleanser dispensers in the reception area of each unit, and all waste is disposed of appropriately. This helps to prevent the spread of infection. Court House Nursing Home DS0000004106.V366034.R01.S.doc Version 5.2 Page 19 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, 30 (32, 34, 35) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are recruited and trained to a good standard. There are enough staff to meet the needs of the people who use the service. EVIDENCE: The service has good recruitment procedures and carries out all preemployment checks. We saw evidence of this in staff files. These checks help to protect the people who use the service by ensuring that staff are trustworthy. Court House Nursing Home DS0000004106.V366034.R01.S.doc Version 5.2 Page 20 We looked at the duty rosters, which showed that enough staff were available to care for the residents. The rosters showed that the ratio of nurses to care staff is satisfactory. We observed staff carrying out their duties in a professional manner: they did not hurry the residents and appeared to have a good rapport with them. One relative told us: “it’s good that they don’t seem to have so many agency staff recently”. We checked staff records and spoke to members of staff to make sure that they had received the training they need to be able to care for the people who use the service. The records showed that there are plenty of training opportunities, and this was confirmed by both nursing and care staff. One staff member told us: “The company are supportive and provide education and training opportunities and resources to help support us”. Court House Nursing Home DS0000004106.V366034.R01.S.doc Version 5.2 Page 21 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): Court House Nursing Home DS0000004106.V366034.R01.S.doc Version 5.2 Page 22 31, 33, 35, 38 (37, 38, 39, 42) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is well managed and benefits from an experienced manager who makes sure that the people who live in the home get the best possible service. There are clear areas of responsibility within the staff team. The manager’s priority is the wellbeing of the people who use the service. EVIDENCE: We heard many positive comments about the new manager from both staff and residents. She was described as being approachable and supportive. Some of the comments we received from staff were: “under the current manager Court House is flourishing again” and “she always makes herself available”. Health and Safety meetings are held every three months, and these include an analysis of accidents, which identifies trends and residents who might be at risk. From this analysis, risk assessments lead to strategies to reduce the risk of harm to the people who use the service. Residents’ and relatives’ meetings are a new initiative. We saw notes from the most recent meeting held in Beacon unit. The manager told us that these meetings are planned to take place three or four times a year, and the day and time will be varied so that as many relatives as possible can attend. We looked at risk assessments for four residents. One resident had an incomplete risk assessment for the use of bed rails, which might have put her at risk of harm. However, when we spoke to staff about this, they demonstrated a good understanding of the potential risks, and had put strategies in place to minimise the risk. All other risk assessments seen by the inspector had been fully completed. Court House Nursing Home DS0000004106.V366034.R01.S.doc Version 5.2 Page 23 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 X 3 3 4 X 5 3 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 2 13 3 14 2 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 3 20 2 21 X 22 X 23 X 24 3 25 X 26 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 X 37 X 38 2 Court House Nursing Home DS0000004106.V366034.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 OP7 Good Practice Recommendations People who use the service should be encouraged to be involved in the planning and review of their care, and records should be kept of their involvement. Risk assessments should be fully documented and should reflect the current situation. 2. OP38 Court House Nursing Home DS0000004106.V366034.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection West Midlands Office West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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.V366034.R01.S.doc Version 5.2 Page 26 - 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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