CARE HOMES FOR OLDER PEOPLE
Court House Retirement Home Church Street Cheddar Somerset BS27 3RA Lead Inspector
Kathy McCluskey Announced 16 June 2005
th 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 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. Court House Retirement Home D53 - D02 S16113 Court House V226030 160605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Court House Retirement Home Address Church Street, Cheddar, Somerset, BS27 3RA Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01934 742131 01934 742054 Mr Brian Dando Mrs Margaret Anne Thomas Care home 29 Category(ies) of Old age (29) registration, with number of places Court House Retirement Home D53 - D02 S16113 Court House V226030 160605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 3rd February 2005 Brief Description of the Service: Court House Retirement home is a large Georgian House situated in the heart of the town of Cheddar in Somerset. Accommodation is arranged in three buildings. The main house, which can accommodate 12 service users, The Courtyard is made up of 6 rooms and The Cottage which accommodates 8 service users. The Courtyard and the Cottage are situated in the grounds of the main house. The home is registered with the Commission for Social Care Inspection to provide personal care for up to 29 service users over the age of 65yrs. The home is not registered to provide nursing care. The registered providers are Mr B. & Mrs P.Dando. The registered manager is Mrs M.Thomas. Court House Retirement Home D53 - D02 S16113 Court House V226030 160605 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This announced inspection was conducted over one day (6hrs) by two CSCI inspectors, Kathy McCluskey and Jane Poole. A tour of the premises took place where a selection of bedrooms and all communal areas were seen. The registered manager and provider were available throughout the inspection. The inspectors met with fifteen service users and three staff. Fourteen completed CSCI service user comment cards were analysed. The inspectors were able to unobtrusively observe staff interactions with service users. Records relating to care, staff and health and safety were examined. The inspectors would like to thank the service users, provider, manager and staff for their time and cooperation with the inspection process. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. What the service does well:
The Court House Retirement Home offers service users ‘gracious’ living in an environment which is decorated and furnished to a very high standard whilst maintaining a ‘homely’ feel. Service users have the choice of a variety of accommodation, all of which are set in beautiful and well maintained gardens. Service users are able to furnish their own private accommodation which allows them a sense of ‘ownership’. Service users spoken with during the inspection were very positive regarding life at The Court House and comments included; ‘It’s the next best thing to home’, ‘Excellent’, ‘You couldn’t wish for anything better’.
Court House Retirement Home D53 - D02 S16113 Court House V226030 160605 Stage 4.doc Version 1.30 Page 6 The provider, manager and staff at the home are committed to ensuring that service users are treated as individuals and that the care they receive is tailored to meet their needs, expectations and aspirations. Service users were very positive regarding the care they received and all spoken with commented on the kindness and willingness of staff. Service users stated that staff always respected their privacy and dignity and that they were aware of their wishes and preferences. The home takes appropriate steps to ensure that prospective service users are provided with the information they need to enable them to make an informed decision about moving to the home. Service users are fully assessed prior to admission to ensure that the home can meet the assessed needs of the individual. Prospective service users and their families/representatives are encouraged to visit the home and meet with staff and service users before making a decision. Meals and refreshments are offered. The home takes exceptional steps to ensure that service users and visitors feel welcome and that service users remain ‘in control’ of their lives. The inspectors were able to see evidence that service users are encouraged and supported to pursue their own hobbies and interests. The home also offers a range of activities which are based on ideas from service users. As part of this announced inspection, CSCI comment cards were sent to all service users at the home. At the time of this report, 14 completed cards had been received by the CSCI and all stated that they were happy with the provision of activities offered by the home. Service users benefit from an exceptional standard and choice of meals. Fresh fruit is made available in all communal areas and service users’ private accommodation. Sherry is available in the drawing room for service users to help themselves. All service users spoken with at the inspection spoke very highly regarding the meals and choices available. This was also indicated in all of the completed CSCI comment cards. Staff morale at the home is high and this has a positive effect on service users. All service users spoken with spoke highly of the manager and staff team. Service users feel well informed. The home takes appropriate steps to reduce the risk of harm or abuse to service users by raising staff awareness and by following a robust staff recruitment procedure. The home takes appropriate steps to ensure the health and safety of service users, staff and visitors. Court House Retirement Home D53 - D02 S16113 Court House V226030 160605 Stage 4.doc Version 1.30 Page 7 What has improved since the last inspection? What they could do better:
Care records for the three most recent service users were examined at this inspection and these contained detailed records pertaining to the assessed needs of an individual but did not contain information for staff on how to meet an individual’s assessed needs. The manager and staff at the home demonstrated a good understanding of how needs should be met and there appeared to be a consistent and individualised approach to meeting the needs of service users. This was also confirmed by service users spoken with. The need to ensure that interventions are clearly documented was discussed with the manager at the time of the inspection.
Court House Retirement Home D53 - D02 S16113 Court House V226030 160605 Stage 4.doc Version 1.30 Page 8 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. Court House Retirement Home D53 - D02 S16113 Court House V226030 160605 Stage 4.doc Version 1.30 Page 9 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 Standards Statutory Requirements Identified During the Inspection Court House Retirement Home D53 - D02 S16113 Court House V226030 160605 Stage 4.doc Version 1.30 Page 10 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 standard(s) 1, 2, 3, 4 and 5. Standard 6 is not applicable as the home is not registered to provide intermediate care. Prospective service users are provided with the information they need to make an informed decision about moving to the home. The home takes appropriate steps to ensure that the assessed needs and aspirations of a prospective service user can be met. EVIDENCE: The home has produced a Statement of Purpose and Service User Guide. Both documents are provide information about the home and services offered. These are made available to service users, prospective service users and their representatives. The manager takes time to ensure that all information is discussed with prospective service user and/or their representatives. The home’s current fee range is between £313 and £460 per week. Extra charges are met by the service user for personal toiletries, hairdressing and manicures.
Court House Retirement Home D53 - D02 S16113 Court House V226030 160605 Stage 4.doc Version 1.30 Page 11 The home provides a range of daily newspapers, alcoholic beverages and chiropody treatment at no extra cost to the service user. The manager visits a prospective service user in their home/hospital where information relating to their assessed needs, wishes and preferences is discussed. As recommended at the last inspection, the manager has reviewed the home’s recording systems and has developed a very detailed and informative pre-admission assessment. Completed and detailed assessments were seen in the care files for the three most recent service users. Prospective service users and their families and friends are encouraged to visit the home, meet the staff team and other service users prior to making a decision about whether to move to the home. Meals and refreshments are made available. This was confirmed by the three most recent service users spoken with. Service users stated that they had been made to feel very welcome during visits and had been provided with all the information they required to enable them to make an informed choice about the home. All service users are issued with a contract which clearly states the terms and conditions of occupancy, fees to be charged and room to be occupied. Service users are able to choose which room they would like as appropriate. This was confirmed by service users spoken with. Court House Retirement Home D53 - D02 S16113 Court House V226030 160605 Stage 4.doc Version 1.30 Page 12 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 standard(s) 7, 8, 9 and 10 The home ensures that the privacy and dignity of service users is upheld. The assessed needs of service users are clearly identified in the plan of care though the home needs to document clear instructions for staff on how to meet needs. The home’s procedures for the management and administration of medication are good. EVIDENCE: The inspectors examined care records for the three most recent service users. Care plans contained detailed pre-admission assessment records and assessments relating to moving and handling needs, reducing the risk of pressure sores and, as appropriate, risk assessments. All records were seen to be up to date. Whilst assessed needs of service users were clearly identified, it was noted that instructions for staff on how to meet individual needs were not being recorded.
Court House Retirement Home D53 - D02 S16113 Court House V226030 160605 Stage 4.doc Version 1.30 Page 13 The manager and staff at the home demonstrated a good understanding of how needs should be met and there appeared to be a consistent and person centred approach to meeting needs and this was also confirmed by service users spoken with. The need to ensure that interventions are clearly documented was discussed with the manager at the time of the inspection. As recommended at the last inspection, the manager has reviewed the home’s care plan reviewing system. Records were seen in the three care plans examined. The outcome of each review was clearly documented and had been signed by the service user, key worker and manager. This is felt to be positive. The home ensures that all service users have access to appropriate healthcare professionals. Where appropriate or where requested, staff will assist service users to attend appointments. The inspectors were able to see evidence that the advice and input of specialist healthcare professionals is sought where required. Details of visits/appointments are clearly recorded in the individual’s plan of care. The inspectors met with a number of service users at this inspection and, without exception, all commented on the kindness of staff and stated that their privacy and dignity was always respected. Service users also commented that their call bells were answered promptly by staff. At the time of this inspection, staff were observed interacting with service users in a kind and respectful manner. Staff were seen to knock on doors prior to entering a service users room. Service users are addressed in their preferred form of address. This is also recorded in the individual’s plan of care. As part of this announced inspection, CSCI comment cards were sent to all service users at the home. At the time of this report, 14 had been returned to the CSCI. Without exception, all stated that they felt well cared for and that their privacy and dignity was always respected by staff. All stated that they felt safe at the home. The home’s procedures for the management and administration of medication was examined at this inspection and was found to be well maintained. The home uses the sealed ‘cassette system’ with pre-printed medication administration records (MAR). All medicines, including controlled drugs, were seen to be appropriately stored. MAR charts and the controlled drugs register were found to be appropriately completed. As recommended at the last inspection, an appropriate thermometer has been supplied in the fridge storing medication and a daily record of the minimum, maximum and current temperature is maintained.
Court House Retirement Home D53 - D02 S16113 Court House V226030 160605 Stage 4.doc Version 1.30 Page 14 Risk assessments were seen to be in place for those service users who ‘selfmedicate’. This is kept under regular review by the manager. Stocks of medication appeared satisfactory and, following the last inspection the manager had taken appropriate action to ensure that all medicines no longer in use were returned to the pharmacy. Records of returns are maintained and the manager was advised to record the reason for medicines returned. Court House Retirement Home D53 - D02 S16113 Court House V226030 160605 Stage 4.doc Version 1.30 Page 15 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 standard(s) 12, 13, 14 and 15 The home goes to great lengths to ensure that service users live in an environment which promotes an individual’s preferred lifestyle, expectations and preferences. The home takes exceptional steps to ensure that service users visitors feel welcome and that service users remain ‘in control’ of their lives. Service users benefit from an exceptional standard and choice of meals. EVIDENCE: Service users spoken with were very positive regarding the flexible lifestyle promoted by the home. All service users spoken with during the inspection informed the inspector that they choose how to spend their day. Many preferred to spend time in their private rooms. The home offers a range of activities based on ideas from the service users. The inspectors were able to see evidence to support this from the minutes of service user meetings. The home maintains records of activities that have taken place. The inspectors were also able to see evidence that service users are supported and encouraged to pursue their own hobbies and interests.
Court House Retirement Home D53 - D02 S16113 Court House V226030 160605 Stage 4.doc Version 1.30 Page 16 Fourteen completed CSCI service user cards have been received and all indicated that service users were happy with the provision of activities offered by the home. The home goes to great lengths to ensure that service users family/friends and visitors are made to feel welcome at any reasonable time. This was confirmed by all service users spoken with. Visitors are offered refreshments and are welcome to stay for meals. Service users may receive their visitors in the privacy of their private rooms or may use any of the communal areas and gardens. This ensures service users retain a ‘sense of ownership’ and enables them to live life as they would in their own homes. On request, service users are provided with a fridge and facilities to make hot drinks. Service users are also able to offer their visitors a sherry, which is available in the drawing room. Service users furnish their private rooms with their own furniture and personal possessions. All meals are freshly prepared and cook by the home’s cook. Service users spoken with were very positive regarding the food and choices available at The Court House. Positive comments were made on all CSCI completed service user comment cards. Copies of a two week menu were made available to the inspectors. Three choices are available for all meals. The main meal is enjoyed at lunch time and can be taken in the home’s main dining room, cottage conservatory or in the privacy of the service users private rooms. Menus were observed to be imaginative and varied. The home makes good use of fresh meat, fish and vegetables. Sweets and cakes are homemade. On the day of this inspection, lunch was seen being prepared and served. Meals were beautifully presented and were enjoyed in a very comfortable and relaxed atmosphere. Many service users were seen enjoying a glass of sherry in the drawing room prior to lunch. Staff were observed taking sherry to those service users who had requested to have in their rooms. The home ensures that any special diets or preferences are recorded in the individual’s plan of care. Copies are also maintained in the kitchen areas for staff. Service users stated that their preferences were respected. Fresh fruit is made available in all communal areas and service users private rooms. This was observed on the day of the inspection and service users confirmed that this was always the case. Court House Retirement Home D53 - D02 S16113 Court House V226030 160605 Stage 4.doc Version 1.30 Page 17 The inspectors were able to see evidence that service users are encouraged to express their views regarding the meals available. This was available in the minutes of the last service user meeting and the inspectors were able to see evidence that the home had taken action to meet the requests of service users. Meals to the Cottage and Courtyard are carried over by staff from the main home. This arrangement should be kept under review to ensure that it does not pose a health & safety risk to staff. Court House Retirement Home D53 - D02 S16113 Court House V226030 160605 Stage 4.doc Version 1.30 Page 18 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 standard(s) 16, 17 and 18 The home takes appropriate steps to ensure service users are protected from the risk of abuse. The home has a good complaints process in place with evidence that the views of service users are listened to and acted upon. EVIDENCE: The home has a complaints procedure which is made available to service users, staff and visitors. Copies of this are also found in the home’s Statement of Purpose and Service User Guide. All service users spoken with at this inspection informed the inspectors that they would not hesitate in raising any concerns should they have any. Service users stated that they found the registered provider, manager and staff very approachable and that their views are always encouraged. No complaints have been received by the home since the last inspection and no concerns or complaints have been raised directly with the CSCI. All service users are registered to vote. The home takes appropriate steps to ensure that service users are protected from the risk of abuse. Staff are made aware of the home’s ‘whistle blowing’ policy and the policy on abuse. The home follows appropriate staff recruitment procedures.
Court House Retirement Home D53 - D02 S16113 Court House V226030 160605 Stage 4.doc Version 1.30 Page 19 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 standard(s) 19, 20, 21, 22, 23, 24, 25 and 26 Service users live in an environment which is maintained, furnished and decorated to a very high standard. Service users enjoy ‘gracious living’ and can personalise their private accommodation as they so choose. The standards of cleanliness within the home were noted to be high and the home takes appropriate steps to reduce the risk of the spread of infection. EVIDENCE: During this inspection, the inspectors viewed all communal areas and a selection of bedrooms in the main house, the cottage and the courtyard. The Court House Retirement Home is conveniently situated in the heart of the small town of Cheddar, which allows easy access to all local amenities. The home has beautiful well maintained gardens which are accessible to all service users. The majority of service users private accommodation has views out on to the gardens.
Court House Retirement Home D53 - D02 S16113 Court House V226030 160605 Stage 4.doc Version 1.30 Page 20 Accommodation for service users is set out in 3 ‘units’ all in close proximity to each other. The main house is a beautiful Grade II listed property which has been tastefully restored to provide ‘gracious living’ for service users. Furniture, décor and fixtures are of a very high standard. The décor and period furniture are in keeping with the Georgian period of the house. The main house has a drawing room, dining room, kitchen and can accommodate 12 service users. All rooms are fitted with en-suite toilets and bath or shower facilities. Access to the first floor is via stairs which have been fitted with a stair lift. The Courtyard provides 6 rooms at ground floor level, all of which have ensuite bathing and kitchenette facilities. Service users can enjoy a more independent lifestyle if they so choose. The Cottage can accommodate 8 service users and has a very pleasant lounge and conservatory/dining area. Once again, all rooms are fitted with en-suite and kitchenette facilities. A stair lift is available to assist service users to access their first floor accommodation. The very high standards of décor and furnishings continue through all areas. A new Axminster carpet had recently been fitted in the dining area. All personal rooms are decorated and re-carpeted prior to a service user moving to the home. One new service user informed the inspectors that they were able to choose the colour scheme for their room prior to moving in. Service users bring their own personal possessions and furniture so their private rooms are as ‘homely’ as possible. Service users spoken with were very positive about their private accommodation and of all communal areas in the home. Service users private accommodation is fitted with a lock, which can be overridden by staff only in the case of an emergency. Service users confirmed that they could choose where to spend their day and this was evident on the day of the inspection. Without exception, all service users spoken with informed the inspectors that they enjoyed living at The Court House and felt safe and well cared for. The home has a laundry area and all service users personal laundry is washed on an individual basis. Standards of cleanliness in all areas of the home seen were of a high standard. The home takes appropriate steps to reduce the risk of the spread of infection.
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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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 The home provides an adequate number of staff who have been appropriately trained. Staff morale is high which has a positive effect on service users. The home’s recruitment procedures are good and reduce the risk of abuse or harm to service users. EVIDENCE: As part of this inspection, copies of a 4 week staff rota were made available to the inspectors. This indicated and staff confirmed that care hours are covered as follows; 4 care staff in the morning, during which period 2 staff are based in the main house with the other 2 providing support to service users living in the Courtyard and Cottage. During the afternoon 3 are based in the main house and provide assistance to the Cottage and Courtyard as required. An additional carer is on duty between 1830 and 2100hrs. Night staff are based in the main house and consist of 1 waking and 1 sleep-in staff. In addition to care staff, the home employs cooks and supper cooks to cover a 7 day period and cleaning staff. Staff and service users spoken with did not express any concerns regarding staffing levels at the home.
Court House Retirement Home D53 - D02 S16113 Court House V226030 160605 Stage 4.doc Version 1.30 Page 22 The registered provider and manager informed the inspectors that staffing would always be increased where required to ensure that the assessed needs of service users could be met. The home uses agency staff only where absolutely necessary to cover shortfalls. Information made available to the inspectors indicate that at present 18 care staff are currently employed by the home and that 6 have achieved an NVQ level 2 in care. Records indicated that staff had received up to date training in moving and handling techniques, 10 staff have a first aid certificate and 12 staff are due to attend training in Health & Safety. The manager also advised that she was in the process of arranging further training for staff in the safe handling of medicines. Staff spoken with confirmed that they felt appropriately trained to enable them to meet the needs of service users living at the home and they would not hesitate in raising any concerns or training issues with the manager. The home has employed one staff member since the last inspection. The staff recruitment file was examined and was found to contain all information as required under Regulation 19 Schedule 2 of the Care Home Regulations 2001. This included an Enhanced CRB check and POVAFirst check. Detailed information had been recorded by the manager relating to the staff member’s induction and supervision. Without exception, all service users spoken with during the inspection commented on the kindness of staff. Some comments received included; ‘they are marvellous’, ‘they will do anything for you’, nothing is too much trouble’. The home has a low staff turnover and staff spoken with informed the inspectors that they enjoyed working at The Court House and that they felt well supported. Staff morale appeared high. Court House Retirement Home D53 - D02 S16113 Court House V226030 160605 Stage 4.doc Version 1.30 Page 23 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35, 36, 37 and 38 The management style of the home is open, inclusive and gives great emphasis on a ‘person centred approach’ for service users. The systems for service user consultation are good with a variety of evidence that indicates that service user views are both sought and acted upon. The home takes appropriate steps to ensure the health and safety of service users, staff and visitors. EVIDENCE: The registered manager is Margaret Thomas who has worked at the home for 14 years and has been registered manager for the past 7 years.
Court House Retirement Home D53 - D02 S16113 Court House V226030 160605 Stage 4.doc Version 1.30 Page 24 Margaret has over 35 years experience on caring for older people and updates herself through personal learning. She has also achieved the A1 NVQ assessors award (previously D32/33) The manager has an open and inclusive management style which promotes a ‘person centred’ approach for service users at the home. This was very evident through discussion with service users and staff and on examination of records. Service users and staff were very complementary regarding the manager. Regular meetings are held for service users and service users confirmed that their views/suggestions are encouraged and acted upon. Minutes are maintained. The last meeting was held on 18/05/05. The home also has an effective quality assurance system which regularly seeks the views of service users. Staff are supported through regular staff meetings and one-one supervision sessions. Records were seen at this inspection. Staff spoken with were positive about the support they received and commented that the manager was very approachable and accessible at any time. The home has a range of policies and procedures available to staff. A selection were seen at this inspection and the inspectors were able to see evidence that these had been kept under regular review. Service users have access to their records in accordance with the Data Protection Act 1998. Service user care plans are stored in the individual’s private rooms. The home displays appropriate and up to date employers liability which expires on 11/02/06. At the time of this inspection, the home is taking appropriate steps to ensure the health and safety of service users, staff and visitors to the home. A tour of the premises took place and the following records were examined; FIRE SAFETY – The home conducts weekly checks on the home’s fire detection systems and monthly checks on emergency lighting. Records are maintained. Fire detection systems and fire fighting equipment is serviced by an outside contractor on an annual basis. This was last recorded as 15/02/05. Records indicated that regular fire training is conducted for all staff. This was last recorded as taking place on 14/06/05. ELECTRICAL SAFETY – The home’s portable appliances (PAT) are tested annually. This was last carried out in August and December ’04. The home has an up to date electrical hardwiring certificate which is valid until 2006.
Court House Retirement Home D53 - D02 S16113 Court House V226030 160605 Stage 4.doc Version 1.30 Page 25 GAS SAFETY – The home’s last annual gas safety check was conducted on 04/10/04. EQUIPMENT SERVICING – Servicing records were available to confirm that the home’s hoists and stair lifts had been serviced, in accordance with LOLER regulations on 05/05/05. ACCIDENTS – The home maintains appropriate records for all accidents. Records seen indicated that there had been 17 service user accidents since the last inspection. Accident records include any action taken and follow up required. All accident records were seen to be appropriately stored in accordance with the Data Protection Act 1998. HOT WATER OUTLETS/SURFACES – The home maintains records of monthly checks on all hot water outlets. Records seen indicated that bath hot water outlets were within HSE recommended limits. Records indicated that all staff had received up to date training in moving and handling. The last recorded training took place 18/03/05. Staff spoken with confirmed that they had received appropriate training. Court House Retirement Home D53 - D02 S16113 Court House V226030 160605 Stage 4.doc Version 1.30 Page 26 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 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 4 14 3 15 4
COMPLAINTS AND PROTECTION 4 4 3 3 3 4 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 3 3 3 3 3 Court House Retirement Home D53 - D02 S16113 Court House V226030 160605 Stage 4.doc Version 1.30 Page 27 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. 1. Standard OP7 Regulation 15(1) Requirement The registered person must take appropraite steps to ensure that instructions for staff on how to meet an individuals assessed needs, are clearly documented in the service users plan of care. Timescale for action 05/08/05 and on admission for a future service users. 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 Good Practice Recommendations Court House Retirement Home D53 - D02 S16113 Court House V226030 160605 Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection Riverside Chambers Tangier Taunton TA1 4AL 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 Court House Retirement Home D53 - D02 S16113 Court House V226030 160605 Stage 4.doc Version 1.30 Page 29 - 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!
