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Inspection on 15/11/05 for Courtfield Lodge Nursing & Residential Home

Also see our care home review for Courtfield Lodge Nursing & Residential Home for more information

This inspection was carried out on 15th November 2005.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The plans of care were found to be very well-written documents providing clear guidance for staff as to how individual needs were to be met. Detailed information had been obtained in relation to the past history of those living at the home to give staff a clear history of each individual. Those living at the home were respected to ensure that their privacy and dignity was protected at all times. Documentation seen demonstrated that those living at the home were supported to make individual choices so that they were able to make decisions about their preferred life style. Meal times and meals were well managed. Service users were supported to maintain their dietary requirements and were able to dine in a relaxed and pleasant environment. Adequate procedures were in place for the control of infection to ensure that those living at the home were adequately protected. Detailed induction programmes were in place for new staff and a variety of training courses had been provided, including a number of compulsory core training sessions to ensure that those working at the home were competent to do the job expected of them and to ensure that they were able to meet the assessed needs of those living at the home.The registered person, ensured safe working practices within the home in accordance with the National Minimum Standards for Care Homes for Older People and Care Homes Regulations to ensure that the safety of residents was protected. The manager of the home ensured, in general the health and safety of staff and service users, in accordance with the National Minimum Standards for Care Homes for Older People and Care Homes Regulations to ensure that those living at and those working at the home were adequately protected.

What has improved since the last inspection?

The policies and procedures of the home in relation to death and dying had been reviewed and up dated to ensure that care and comfort would be given to service users during the last days of their life and that their death would be handled with dignity. At the time of the inspection the environment was free from hazards and the health and safety of those living at the home was protected. Service users lived in a clean and pleasant environment, which was free from offensive odours. The calculation of care staff to service users was being determined in accordance with the assessed needs of those living at the home to ensure that assessed needs were being adequately met The dependency levels of residents was reviewed at regular intervals as well as when people were discharged or admitted to the home and staffing levels were adjusted accordingly.

What the care home could do better:

Those living at the home or their representative must be given the opportunity to be involved in the care planning process so that they are able to discuss any concerns or preferences which they may have. The plans of care must be kept under review to ensure that any changes in needs are accurately reflected. The plans of care should demonstrate how people are supported to continue their leisure interest and hobbies to ensure that their social care needs are being appropriately met. The home should continue to progress towards achieving a 50% ratio of care staff with an National Vocational Qualification. The accident record needed to be maintained in accordance with the Data Protection Act 1998 to ensure that information was retained in a confidential manner.

CARE HOMES FOR OLDER PEOPLE Courtfield Lodge Nursing & Residential Home 81a Marians Drive Ormskirk Lancashire L39 1LG Lead Inspector Vivienne Morris Announced 15 November 2005 9:30 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. Courtfield Lodge Nursing & Residential Home F57 F08 Courtfield Lodge Nursing and Residential Home S25553 V248422 151105 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Courtfield Lodge Nursing & Residential Home Address 81a Marians Drive Ormskirk Lancashire L39 1LG 01695 570581 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) Flightcare Limited Care Home with nursing 70 Category(ies) of LD Learning Disability (1) registration, with number OP Old Age (70) of places Courtfield Lodge Nursing & Residential Home F57 F08 Courtfield Lodge Nursing and Residential Home S25553 V248422 151105 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Up to 70 service users in the category OP (Old Age) who need nursing care. Up to 40 service users in the category OP (Old Age) who need personal care only. 1 named service user in the category of LD (Learning Disability) The service should, at all times, employ a suitably qualified and experienced manager who is registered with the NCSC. Date of last inspection 22 June 2005 Brief Description of the Service: Courtfield Lodge is a purpose built home situated in a residential area close to the town centre of Ormskirk. It provides nursing and personal care for up to 70 older people. The accommodation is on two floors. The upstairs floor is accessed by both stairs and a passenger lift. There is a lounge on each floor and a dining room on the ground floor. The rooms are predominantly single but facilities are available if service users choose to share, either at the time of admission or following admission. The rooms all benefit from the provision of en-suite facilities. Service users had personalised their rooms with ornaments, photos and pictures. The menu provideed a variety of food, although alternatives were available if desired. Specialised diets were catered for if required. Courtfield Lodge Nursing & Residential Home F57 F08 Courtfield Lodge Nursing and Residential Home S25553 V248422 151105 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over one day during November 2005. The inspection process focused on the outcomes for people living at the home. During the course of the inspection 5 service users and 3 staff were spoken to, relevant records and documents were examined and a tour of the premises took place, when a random selection of private accommodation was viewed and all communal areas and service areas were seen. The Commission for Social Care Inspection had received one complaint about this service since the last inspection, which was referred back to the provider for investigation. The issues of the complaint were in relation to general care issues, medication, staffing, confidentiality, food, infection control and security. Some elements of the complaint were substantiated, others not substantiated and others unresolved. What the service does well: The plans of care were found to be very well-written documents providing clear guidance for staff as to how individual needs were to be met. Detailed information had been obtained in relation to the past history of those living at the home to give staff a clear history of each individual. Those living at the home were respected to ensure that their privacy and dignity was protected at all times. Documentation seen demonstrated that those living at the home were supported to make individual choices so that they were able to make decisions about their preferred life style. Meal times and meals were well managed. Service users were supported to maintain their dietary requirements and were able to dine in a relaxed and pleasant environment. Adequate procedures were in place for the control of infection to ensure that those living at the home were adequately protected. Detailed induction programmes were in place for new staff and a variety of training courses had been provided, including a number of compulsory core training sessions to ensure that those working at the home were competent to do the job expected of them and to ensure that they were able to meet the assessed needs of those living at the home. Courtfield Lodge Nursing & Residential Home F57 F08 Courtfield Lodge Nursing and Residential Home S25553 V248422 151105 Stage 4.doc Version 1.40 Page 6 The registered person, ensured safe working practices within the home in accordance with the National Minimum Standards for Care Homes for Older People and Care Homes Regulations to ensure that the safety of residents was protected. The manager of the home ensured, in general the health and safety of staff and service users, in accordance with the National Minimum Standards for Care Homes for Older People and Care Homes Regulations to ensure that those living at and those working at the home were adequately protected. What has improved since the last inspection? What they could do better: Those living at the home or their representative must be given the opportunity to be involved in the care planning process so that they are able to discuss any concerns or preferences which they may have. The plans of care must be kept under review to ensure that any changes in needs are accurately reflected. The plans of care should demonstrate how people are supported to continue their leisure interest and hobbies to ensure that their social care needs are being appropriately met. The home should continue to progress towards achieving a 50 ratio of care staff with an National Vocational Qualification. The accident record needed to be maintained in accordance with the Data Protection Act 1998 to ensure that information was retained in a confidential manner. Courtfield Lodge Nursing & Residential Home F57 F08 Courtfield Lodge Nursing and Residential Home S25553 V248422 151105 Stage 4.doc Version 1.40 Page 7 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. Courtfield Lodge Nursing & Residential Home F57 F08 Courtfield Lodge Nursing and Residential Home S25553 V248422 151105 Stage 4.doc Version 1.40 Page 8 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 Courtfield Lodge Nursing & Residential Home F57 F08 Courtfield Lodge Nursing and Residential Home S25553 V248422 151105 Stage 4.doc Version 1.40 Page 9 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) No standards from this section were assessed on this occasion. EVIDENCE: One key standard from this section was fully met at the previous inspection and was therefore not assessed on this occasion. The other key standard was not applicable to this service. However, the inspector noted that the statement of purpose and the service users’ guide needed updating to reflect the recent changes in the management structure so that readers are aware of the management arrangements within the home. Courtfield Lodge Nursing & Residential Home F57 F08 Courtfield Lodge Nursing and Residential Home S25553 V248422 151105 Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,9 and 10 The care plans were well-written documents, clearly identifying assessed needs. However, residents had not been involved in the formulation of the plans of care and the assessed needs had not consistently been reviewed to ensure that current needs were being fully met. EVIDENCE: The care of four people living at the home was ‘tracked’ during the course of the inspection. The plans of care were found to be well written documents, providing clear guidance for staff as to how individual assessed needs were to be met. The information recorded had been gathered during the pre-admission process to show that the care plans included assessed needs of those living at Courtfield Lodge. Social care profiles had been completed, which demonstrated that staff had determined what residents enjoyed doing in relation to leisure interests and hobbies. These profiles provided a clear picture of individual’s past life, which promoted a holistic approach to those living at the home. However, the plans of care did not show how people were supported to continue their individual Courtfield Lodge Nursing & Residential Home F57 F08 Courtfield Lodge Nursing and Residential Home S25553 V248422 151105 Stage 4.doc Version 1.40 Page 11 interests and hobbies to demonstrate that social care needs were being maintained. The care files examined did not consistently show that those living at the home had been given the opportunity to be involved in the planning of their care so that they were able to discuss any concerns or preferences which they may have. The plan of care for one resident had not been revised for a number of months to show that staff had reviewed and updated their care needs. A variety of risk assessments had been conducted to show that strategies had been put in place to minimise or eliminate any identified risk. The pharmacy inspector assessed the management of medications at this inspection. A detailed report of the findings will be forwarded to the home with any requirements and recommendations made. The plans of care demonstrated that the privacy and dignity of those living at the home was protected at all times. Staff were instructed during induction about how to treat service users with respect and were seen to be knocking on resident’s bedroom doors before entering and were seen to be talking with residents in a respectful manner demonstrating that service users were treated well. One service user commented “staff treat me with respect, they really are lovely” and “all the staff are very kind and respect me. The manager is very nice and friendly”. Courtfield Lodge Nursing & Residential Home F57 F08 Courtfield Lodge Nursing and Residential Home S25553 V248422 151105 Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 14 and 15 Those living at the home were supported to exercise autonomy and choice so that they were able make decisions about their preferred life style. Meals and mealtimes were being very well managed to ensure that adequate nutrition was being maintained. EVIDENCE: Standard 12 was not fully assessed on this occasion. However, the requirement from the previous inspection remained outstanding. One bathing facility was not in operation, which did not provide those living at the home with the option of using this bathroom, should they so wish. The inspector was provided with evidence that a new parker bath was to be installed three days after the inspection so that all bathrooms would then be fully operational. Courtfield Lodge Nursing & Residential Home F57 F08 Courtfield Lodge Nursing and Residential Home S25553 V248422 151105 Stage 4.doc Version 1.40 Page 13 At the time of the inspection there were two service users living at the home who were being supported to manage their own finances, which demonstrated that residents were able to exercise choice about their personal affairs and were supported to maintain control over this area of their lives. Policies and procedures demonstrated that the home would access an independent body to act on behalf of a resident, should the resident so wish in order to provide some protection and to help them to make decisions about their life. Service users were able to bring personal possessions to the home with them, which individualised their own accommodation. An audit of service users’ belongings was not being consistently conducted on admission to the home, in order to protect their personal items. At the time of the inspection meals were being very well managed to ensure adequate nutritional intake. At lunchtime a calm environment prevailed and service users were enjoying the dining experience. Meals were served in service users’ bedrooms if they preferred their privacy whilst dining. Nutritional risk assessments had been conducted, which identified anyone who was at risk of malnutrition, in which case advice was sought from the dietician and nutritional care planning was developed in accordance with individual need to ensure that adequate dietary intake was being maintained. Those living at the home confirmed that they were asked every day what they would like for their meals and that were able to choose from the menu or were able to select an alternative if they so wished. The meals served were recorded and were seen to be attractively presented and of a good nutritious standard. Liquidised diets were served in individual portions, so that food items could be easily identified to promote appetite and to aid in nutrition. Detailed records were available about individual diets and staff were aware of residents’ dietary needs and preferences, which ensured that service users received a nutritious diet in accordance to their needs. Appropriative training had been provided to relevant staff to ensure that food hygiene standards were maintained. The chef had completed a ‘creative catering in palliative care’ training course to ensure that specific nutritional needs were being met. Residents confirmed that a snack was provided in the evening and that food and beverages were available at all times, should they wish to have something to eat between meals. Appropriate food was provided for those requiring special diets due to medical conditions to ensure health care needs were being met. Staff were seen to be supporting those who required assistance with feeding in a sensitive and discreet manner by sitting with them and chatting to them to encourage dietary intake. However, staff were also seen to be encouraging residents to eat by them selves as far as possible to encourage independence. Meal times were unrushed and those living at the home were allowed to eat at their own pace so that they did not feel uncomfortable and so that adequate dietary intake was promoted. Courtfield Lodge Nursing & Residential Home F57 F08 Courtfield Lodge Nursing and Residential Home S25553 V248422 151105 Stage 4.doc Version 1.40 Page 14 Comments received from those living at the home included “I can have my breakfast when I get up”, “The food is excellent and we get plenty to eat”, ”I always like the food. It is very good and we do get a good selection” and “you can have what you want, when you want, you just have to ask”. Courtfield Lodge Nursing & Residential Home F57 F08 Courtfield Lodge Nursing and Residential Home S25553 V248422 151105 Stage 4.doc Version 1.40 Page 15 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 Complaints were taken seriously and appropriate investigations were conducted. However, information provided in relation to complaints was not consistent. EVIDENCE: Two complaint procedures were in place to inform people of the process to take should they wish to make a complaint and which incorporated appropriate timescales for responses to be forwarded to the complainant. However, these procedures provided some conflicting information, which had a potential to be confusing for those wishing to make a complaint. The one contained in the policy and procedure manual indicated that complainants could only contact the Commission for Social Care Inspection once other avenues have been exhausted and contact details for the Commission for Social Care Inspection were not included to ensure that readers were aware of their rights to refer a complaint to the registering authority at any stage, should they so wish. A record was retained of all complaints made to the home, which showed that detailed investigations had been conducted. Courtfield Lodge Nursing & Residential Home F57 F08 Courtfield Lodge Nursing and Residential Home S25553 V248422 151105 Stage 4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 26 Service users lived in a clean and pleasant environment, which was free from offensive odours. Adequate procedures were in place for the control of infection. EVIDENCE: Detailed policies and procedures were in place in relation to the control of infection so that staff were aware of measures to take in order to protect those living at the home. Laundry facilities were appropriately sited to reduce the possibility of cross infection. Hand washing facilities were not currently available within the laundry department to promote infection control. However, the inspector was informed that a replacement hand basin was to be installed to ensure adequate hand hygiene was maintained. The registered person should be able to demonstrate that services and facilities comply with the Water Supply (Water Fittings) Regulations 1999. Courtfield Lodge Nursing & Residential Home F57 F08 Courtfield Lodge Nursing and Residential Home S25553 V248422 151105 Stage 4.doc Version 1.40 Page 17 Two requirements, in relation to the environment remained outstanding from the previous inspection:The registered provider must ensure that sufficient numbers of baths fitted with a hot and cold water supply are available to provide those living at the home with the option of using any bathroom within the home. (Timescale of 12.03.05 and 31.10.05 not met); The registered person must ensure that equipment provided at the care home for use by service users or persons who work at the home is maintained in good working order, including the nurse call system to ensure that residents receive a prompt response to the summons for assistance. (Timescale of 31.05.05 and 31.10.05 not met). One service user commented “I am very satisfied with the care, although occasionally my buzzer isn’t answered for some time”. Another comment received in relation to the environment was “my room is quite big and it is nicely decorated. I am very lucky”. Courtfield Lodge Nursing & Residential Home F57 F08 Courtfield Lodge Nursing and Residential Home S25553 V248422 151105 Stage 4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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 and 30 The assessed needs of those living at the home were adequately met by the numbers and skill mix of staff. Training provided for staff demonstrated that service users were in safe hands at all times. EVIDENCE: A clear staff rota was in place at the home demonstrating which staff were on duty at any time of the day and night and in what capacity they were employed, demonstrating that the skill mix of staff was appropriate to the needs of those living at the home. A clear procedure was in place for calculating the ratio of care staff to service users in relation to individual dependency assessments in accordance with guidance provided by the Department of Health to ensure that adequate care was provided to those living at the home. In addition, extra staff were being deployed to ensure that the needs of those requiring a high level of care intervention were being met. Evidence was available to demonstrate that the system used for calculating the ratio of care staff to service users was reviewed when the occupancy of the home changed due to discharges or admissions and that regular dependency reviews were being conducted, when the ratio of care staff to service users was adjusted accordingly to ensure that assessed needs of those living at the home were being consistently met. The use of agency staff was minimal to ensure that continuity of care was maintained. Courtfield Lodge Nursing & Residential Home F57 F08 Courtfield Lodge Nursing and Residential Home S25553 V248422 151105 Stage 4.doc Version 1.40 Page 19 The home was found to be clean, tidy and free from unpleasant odours, providing those living there with a homely environment in which to reside. There were 32 care staff employed, 11 of whom had completed a National Vocational Qualification (NVQ), showing that the home was working towards achieving 50 of care staff being trained to NVQ level 2 or above to ensure that staff were appropriately trained to meet the needs of those living at the home. In depth Induction training had been provided for all staff within the first six weeks of employment, which was recorded in individual work books demonstrating that new staff had been provided with relevant information in relation to the aims and objectives of the home. Staff had been provided with a variety of training courses, including a number of compulsory core training sessions. The plans of care were very well written providing staff with clear guidance as to how individual needs were to be met and staff spoken to were knowledgeable in relation to the needs of those living at the home. Individual training and development programmes were in place so that the manager of the home could determine at what stage staff were at in relation to their training needs and to ensure that those working at the home were competent to do the job expected of them and to ensure that they were able to meet the assessed needs of those living at the home. One service user commented “They (the staff) are all angels – every single one of them. I haven’t met any that are not nice” and one staff member stated “we have a good staff team”. Courtfield Lodge Nursing & Residential Home F57 F08 Courtfield Lodge Nursing and Residential Home S25553 V248422 151105 Stage 4.doc Version 1.40 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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) 38 Service users and staff were adequately protected in relation to health and safety issues and safe working practices within the home. EVIDENCE: At the time of the inspection the manager of the home had not been registered with the Commission for Social Care Inspection, although her application was in the process of approval. Therefore, standard 31 could not be fully assessed on this occasion. However one comment received was “The manager has turned this place around. She has worked very hard and is approachable and supportive”. Standard 38 was assessed by the examination of relevant documents and service certificates and through discussions with staff working at the home to ensure that the health and safety of service users and staff was protected and that safe working practices had been implemented. Courtfield Lodge Nursing & Residential Home F57 F08 Courtfield Lodge Nursing and Residential Home S25553 V248422 151105 Stage 4.doc Version 1.40 Page 21 The registered person, ensured safe working practices within the home in accordance with the National Minimum Standards for Care Homes for Older People and Care Homes Regulations. The manager of the home ensured, in general the health and safety of staff and service users, in accordance with the National Minimum Standards for Care Homes for Older People and Care Homes Regulations. However, the following item required attention: Accidents were recorded in an accident book. However, this record needed to be maintained in accordance with the Data Protection Act 1998 to ensure that information was retained in a confidential manner. The registered person had conducted a variety of risk assessments for safe working practice topics and significant findings of the risk assessment were recorded to ensure that risks were identified and appropriate strategies were put in place to minimise or eliminate the risk factor. All new staff had received induction and foundation training to meet TOPSS specification to ensure that they were fully aware of their responsibilities in relation to safe working practice topics. A number of recommendations were made at the previous inspection in relation to standard 33 of the National Minimum Standards for Care Homes for Older People and although this standard was not fully assessed on this occasion the inspector noted that some of the recommendations remained outstanding, although others had been appropriately addressed. The quality assurance monitoring system should include feedback from stakeholders in the community to determine their views on how the home is achieving goals for service users. The results of service users’ surveys should be published so that prospective and current service users are able to see how the home is achieving it’s goals. The policies and procedures of the home should be reviewed on a regular basis to reflect changes in legislation and good practice guidelines. Action should be progressed within agreed timescales to implement requirements identified in CSCI inspection reports to ensure that the home provides a high standard of service for those living at the home. Courtfield Lodge Nursing & Residential Home F57 F08 Courtfield Lodge Nursing and Residential Home S25553 V248422 151105 Stage 4.doc Version 1.40 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 2 15 4 COMPLAINTS AND PROTECTION x x x x x x x 2 STAFFING Standard No Score 27 4 28 2 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x x x x x x x x 2 Courtfield Lodge Nursing & Residential Home F57 F08 Courtfield Lodge Nursing and Residential Home S25553 V248422 151105 Stage 4.doc Version 1.40 Page 23 YES 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 OP1 Regulation 4(1)(c)Sh edule 1 Requirement The statement of purpose and service users guide needs to be reviewed and updated to reflect the current management arrangements within the home. The registered person must supply a copy of the updated statement of purpose to the Commission for Social Care Inspection. Timescale for action 31.01.06 2. OP7 3. OP7 4. OP12, OP21, Unless it is impracticable to carry 31.01.06 out such consultation, the registered person shall, after consultation with the service user, or a representative of his, prepare a written plan as to how the service users needs in respect of his health and welfare are to be met. (Timescale of 31.10.05 not met). 15(2)(b)(c The registered person shall keep 31.01.06 )(d) the service users plan under review and shall revise the plan in consultation with the service user or their representative, notifying them of any such revision. (Timescale of 31.10.05 not met). 23(2)(j) The registered provider must 30.11.05 ensure that sufficient numbers of F57 F08 Courtfield Lodge Nursing and Residential Home S25553 V248422 151105 Stage 4.doc Version 1.40 Page 24 15(1) Courtfield Lodge Nursing & Residential Home OP22 OP38 5. OP22 13(4)a c 23(2)b c 6. OP26 16(2)(j) baths fitted with a hot and cold water supply are available. (Timescale of 12.03.05 and 31.10.05 not met) The registered person must ensure that equipment provided at the care home for use by service users or persons who work at the home is maintained in good working order, including the nurse call system. (Timescale of 31.05.05 and 31.08.05 not met) Hand washing facilities must be provided in areas where infected linen is handled. 30.11.05 31.01.06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. Refer to Standard OP7 OP14 OP16 OP26 OP28 OP33 Good Practice Recommendations The plans of care should identify how people are to be supported to maintain their leisure interests and hobbies. An audit of service users personal belongings should be consistently maintained on admission to the home. The complaints procedures should be reviewed and amalgamated to ensure that information provided is consistent. The registered person should be able to demonstrate that services and facilities comply with the Water Supply (Water Fittings) Regulations 1999 It is recommended that the home continue to work towards achieving 50 of care staff being trained to a National Vocational Qualification at Level 2 or above. The quality assurance monitoring system should include feedback from stakeholders in the community to determine their views on how the home is achieving goals for service users. The results of service users’ surveys should be published so that prospective and current service users are able to see how the home is achieving it’s goals. The policies and procedures of the home should be reviewed on a regular basis to reflect changes in legislayion and good practice guidelines. F57 F08 Courtfield Lodge Nursing and Residential Home S25553 V248422 151105 Stage 4.doc Version 1.40 Page 25 7. OP33 Courtfield Lodge Nursing & Residential Home 8. 9. OP33 OP38 Action should be progressed within agreed timescales to implement requirements identified in CSCI inspection reports. The record of accidents should be retained in accordance with the Data Protection Act 1998. Courtfield Lodge Nursing & Residential Home F57 F08 Courtfield Lodge Nursing and Residential Home S25553 V248422 151105 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection Levens House Ackhurst Business Park Foxhole Road Chorley PR7 1NW 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. 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