Inspection on 18/01/07 for Courthill

This inspection was carried out on 18th January 2007.

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

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

Other inspections for this house

Courthill 25/06/08

Courthill 04/07/07

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOMES FOR OLDER PEOPLE Courthill 2 Court Road Caterham Surrey CR3 5RD Lead Inspector Kenneth Dunn Unannounced Inspection 18th January 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Courthill DS0000067720.V331820.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. 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. Courthill DS0000067720.V331820.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Courthill Address 2 Court Road Caterham Surrey CR3 5RD 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) 01883 341024 01883 341024 Ms Simlah Panchoo Mr Roshan Panchoo Ms Simlah Panchoo Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (6) of places Courthill DS0000067720.V331820.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection N/A Brief Description of the Service: At the request of Mr & Mrs Panchoo Fulton lodge has formally changed its name to Courthill. The CSCI officially agreed to the name change on the 31st of January 2007. However for the purpose of this report the name Fulton Lodge will be retained as the name change took place after the inspection was completed. The service is registered with the CSCI (Commission for Social Care Inspection) to provide accommodation and care home for six people with learning disabilities who are over the age of 65 years. Fulton Lode is a large detached family styled house is in a residential street in Caterham-on-the-Hill. The service is close to shops, public amenities and transport in addition the service has its own transport to enable the service users to enjoy a flexible service. The accommodation is arranged over two floors of the house. On the ground floor one large bedroom with an en suite, a communal lounge, separate dining room, kitchen one toilet and the office. The first floor has five good-sized bedrooms and the bathroom. There is a moderately sized garden at the rear of the property, and a limited amount of off street parking for cars at the front of the house. The service does not have a lift. The provider is owner/manager involved in the day-to-day provision of care and management of the service. At the time of this inspection 18/01/2007 the fees ranged from £434.00 per week to £511.00 per week. Courthill DS0000067720.V331820.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) undertook an unannounced site visit using the new ‘Inspecting for Better Lives’ (IBL) process. Regulation Inspector Mr K Dunn was assisted throughout the site visit by the owner/manager of the establishment. Fulton Lodge changed ownership on the 2nd of August 2006 and is now owned by Mr & Mrs Panchoo and is managed on a day-to-day base by Mrs Panchoo. The service was in the final process of a full refurbishment programme to improve the facilities being offered to the service users. Mrs Panchoo has reviewed every aspect of the home and has actioned changes at every level, to ensure that the service fully complies with the National Minimum Standards for Older People and offers the service users a fully adaptable home for them to enjoy and feel safe and secure. The inspection started at 09.30hrs and finished at 13.30hrs. The inspection process included a tour of the premises, interviews with staff and informal conversation with the service users, direct observation, and a review of documents and records. The inspector noted service users at the home have some communication difficulties and judgements were made about them based on their mood, behaviour and information given by staff. In addition the inspector has received several comment cards from external stakeholders, the information they have provided has also been included in the report. The inspector would like to thank the manager, staff and the service users for their contribution to the inspection. What the service does well: What has improved since the last inspection? There has been a complete transformation of the physical environment of the home resulting in a bright, open and flexible place for the service users to live in. The manager has introduced all new policies and procedures into the Courthill DS0000067720.V331820.R01.S.doc Version 5.2 Page 6 service to ensure the rights of the service users are being effectively safeguard. 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. Courthill DS0000067720.V331820.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Courthill DS0000067720.V331820.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 6 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for assessing the needs of potential service users has been improved with the introduction of new policies and procedures to ensure that the service can offer the most appropriate care for all service users. EVIDENCE: The inspector conducted a review of the newly introduced policies and procedures for assessing the needs of potential service users. The policies are designed to ensure that the needs of any potential service users can be effectively met and enhanced by the home. They appeared to offer a robust set of guidelines to safeguard future service users entering the home. The service has not admitted any new service users since 2000. The home does not offer any form of intermediate care. Courthill DS0000067720.V331820.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for care planning have improved however the service is still in the process of a full review of all documents and these must be fully actioned to safeguard the welfare of service users. The systems for healthcare are good ensuring service users have access to healthcare services. The management of medications is good however there is an ongoing storage problem that of needs improving. The arrangements for privacy and dignity are satisfactory ensuring service users are treated with respect. EVIDENCE: There was limited evidence of care plans being in place and only one of the 3 service users file sampled contained some elements of a care plan. The manager explained that because of the major building works it was deemed safer to store confidential files and records in a secure storage facility at the sister home to Fulton Lodge. The remaining documents were simple Courthill DS0000067720.V331820.R01.S.doc Version 5.2 Page 10 daily sketches designed to allow the staff to assist the service users in their most basic of needs. Observations and information given by staff would indicate that the service users are all able to perform elements of self care with the most fundamental of prompting. The Inspector discussed with the manager and informed her that all documents pertaining to Fulton Lodge must be retained within the premises and not stored externally and that the manager should have made alternative arrangements within the home. The manager stated that the service users have access to healthcare and the inspector was able to sample records and noted service users were registered with a GP in the local area, all 3 service users had access to chiropody and dental services again within the local community. The manager has introduced a new set of guidelines for the safe storage and handling of medications. There was evidence of the policy for handling and administering medication being effective and ensuring the safety of the service users. However the systems in place for the storage of medication was not sufficient for the quantities of medication held on the premises. During the medication audit the inspector found all blistered medication stored out with the metal storage cabinet because the quantity was to great to fit the cabinet supplied. The service users were however safeguarded because the blister packs were still being stored behind a locked door. The manager has made enquiries to source a large storage unit but has not yet actioned a replacement. The manager stated that the home had a policy on privacy and dignity and staff treated service users with dignity and respect. Observations confirmed staff addressed service users by their preferred names and the manager was observed knocking on doors before entering service users bedrooms. Courthill DS0000067720.V331820.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13 14 and 15 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities provided were satisfactory and the home offered a good range of activities to suit the needs of the service users. Visitors are welcome in the home at anytime. The meals provided at the home meet service users needs. Service users exercise choice and control over their lives. EVIDENCE: A copy of the programme of activities was provided and this showed a varied range of activities that was provided to suit a wide range of service users known likes dislikes and individual needs. On the day of inspection all three service users were at home either in the lounge or in their own rooms. The manager stated service users had opportunities for social contact and activities and the home had a minibus to promote community access and participation. However it was difficult to review collaborating evidence of the trips or activities the service users participate in because of the lack of recording appropriate information. It was discussed with the manger the need to record activities and outing the service users participate in to allow the appropriate parties to understand what is on offer at Fulton Lodge. Courthill DS0000067720.V331820.R01.S.doc Version 5.2 Page 12 The manager stated that families and friends of the service users are welcomed into the home at any time and no restriction is in place to limit visitors. A review of the visitor’s book indicated that the service users receive regular visitors both personal and professional. Comments received from stakeholders also indicated that they are always made very welcome when visiting the home and the staff are “very courteous and efficient”. The manager commented that service users are helped to exercise choice over their lives and are free from any restrictions within a risk-assessed environment. In addition the policies and procedures ensure that service users admitted to the home are entitled to bring personal possessions to the home. Observations confirmed that staff supported service users in preferred activities and domestic tasks to maximise personal choice. The inspector noted service users were unable to manage their financial affairs and the registered provider acted as appointee to safeguard the interests of service users. The manager stated the home had written a 4 weekly menu plan however this can be altered depending upon the service users needs, if they prefer an alternative the staff will try there best to accommodate the request. The inspector sampled menu plans and noted it offered variety and choice. Courthill DS0000067720.V331820.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are confident that their concerns are listened to, taken seriously and acted upon. The service users are safeguarded against abuse. EVIDENCE: There is an official complaints procedure though no complaints have been received since the last inspection. Records sampled indicated that staff have had training in safeguarding vulnerable adults in their rights and responsibilities training in their induction. Staff stated that they were aware that they must report any incidents they feel are abuse and discussed the types of abuse that can occur. The home has a local procedure and has a copy of the local multi-agencys procedures. Courthill DS0000067720.V331820.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The total refurbishment of the service will when completed offers the service users a safe and pleasant environment to live in. At the time of the inspection the builders were still on site and therefore the areas they were working in were not assessed. The home however was very clean and hygienic. EVIDENCE: The new owners of the service have made a large investment into the home to bring it up to an acceptable standard. At the time of the inspection the refurbishment work was almost 85 completed with the builders estimating a further two weeks left of the major building stage. The works that have been completed appeared to be of a very good standard and now offered the service users a flexible and a very pleasant environment to live in. The service users expressed their views on the works carried out and they all indicated that it was good and they liked what has been done to the home. The manager has conducted a series of risk assessment throughout the Courthill DS0000067720.V331820.R01.S.doc Version 5.2 Page 15 refurbishment process to ensure that at all times the service users continue to live in an environment that is safe and secure. However the building work has impacted upon the service users ability to use and enjoy the full house and gardens and this must be taken into consideration for the purpose of this inspection. In addition the Inspector was unable to fully access all of the rooms, as they were restricted due to the building works. The final stage for the internal refurbishment of the home is the kitchen, which at the time of the inspection was in a poor state. The manager stated that the new kitchen had been ordered and “if all goes well will be fitted in early February 2007”. The service is however to be commended for keeping the home clean and free from any mal odours during the refurbishment. Courthill DS0000067720.V331820.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for NVQ need strengthening to ensure service users are supported by competent and qualified staff at all times. Recruitment and vetting policies and procedures have been improved in order to safeguard the welfare of service users. Training and development needs to continue to improve to ensure service users individual and joint needs are met by appropriately trained staff. EVIDENCE: The service has fully reviewed all policies and procedures for the recruitment and retention of staff. A review of the recruitment documents would indicate that they are designed to ensure that the service users will be safeguarded for and protected by there implementation. However the staff files were not available to be reviewed on the day of the inspection, the manager completed a risk analysis of the safety of confidential files during the refurbishment work being carried out at the home. The manager informed the inspector that the net result of the risk analysis was the confidential files were removed from the service and were being securely stored at Fulton Lodge’s sister home. After a discussion with the manager, she will now ensure that all files are maintained on site and if in the event of more work being carried out in the home, a secure alternative will have to be found within the home. Courthill DS0000067720.V331820.R01.S.doc Version 5.2 Page 17 The manager stated that the home is committed to staff training and development and the company has an agreement with an approved provider for NVQ training for staff however this has not been actively perused by staff in the past and but the manager is attempting to ensure that the home will meet its obligations to have at least 50 of all staff NVQ trained. The manager stated the home has an induction package and staff have induction training, this was supported by the staff on duty during the inspection, one stated that” the new owners are very happy to help me with my training and keep coming to me with more options for future training courses”. Observations made at the time of inspection by the Inspector confirmed that staff were accessible, approachable and comfortable with service users and there appeared to be a genuine rapport between the staff on duty and the service users. Courthill DS0000067720.V331820.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 37 and 38 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for the day- to- day management of the home need strengthening to ensure service users benefit from a well run home. The systems for quality assurance require to be reviewed to ensure that service users, relatives and stakeholders participate in the running of the home. Health and safety within the service has been strengthened to promote safe working practices. EVIDENCE: Fulton lodge was purchased by the current owner/manager on the 2nd of August 2006. The manager sated that, since the completion of the sale “we have embarked upon a complete refurbishment of the home in order to get it out to the high standard we want to operate in”. The manger has introduced new policies and procedures and there is evidence that the staff are regularly instructed in the changes, one member of staff Courthill DS0000067720.V331820.R01.S.doc Version 5.2 Page 19 informed the inspector that they “do look at the policies regularly and they are always available when I need to use them”. The manager appears to provide stability, leadership and direction to the staff team. The manager informed the inspector that she has completed her NVQ level 4 and the RMA (Registered Manager Award) but has yet to be credited with the qualification. Further evidence confirmed the home had a management structure with clear lines of communication and accountability and during discussions a member of staff stated ‘‘the manager is making changes for the better and every change is being discussed with feedback from the staff team’’. The home had a policy on quality assurance and a questionnaire has been introduced to obtain feedback about the home from relatives and other stakeholders however this was not open the service users. The manager stated that the service users could at any time offer feedback, which will be recorded in the daily log. A requirement has been made that the current questionnaire should be reviewed and made available to all persons with relevant contact to the service. The home had a policy on health and safety and staff have training in health and safety, fire safety, basic food hygiene and first aid. Further evidence confirmed the home had a current gas safety certificate and service inspection reports for fire equipment, small portable appliances and emergency lighting. The home had information about health and safety displayed in the home and a policy on COSHH (Control of Substances Hazardous to Health) to promote safety. Courthill DS0000067720.V331820.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X 2 3 Courthill DS0000067720.V331820.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? N/A 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 OP2 OP7 OP29 OP37 Regulation 5(1), 15, 19, 17. Requirement The Registered Person must ensure that all confidential documents pertaining to Fulton Lodge the service users or staff must not be removed from the property. In the events of possible breaches of confidence, alternative sources of storage within the building must be sourced. The Registered Person must ensure that appropriate medications storage safe is purchased and fitted. The Registered Person must ensure that all outings and activities must be appropriately recorded. The Registered Person must ensure that the quality questionnaire should be reviewed and made available to all persons with relevant contact to the service. Timescale for action 18/03/07 2 OP9 13(2) 18/03/07 3 OP12 16(20) 18/03/07 4 OP33 24 18/03/07 Courthill DS0000067720.V331820.R01.S.doc Version 5.2 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Courthill DS0000067720.V331820.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Courthill DS0000067720.V331820.R01.S.doc Version 5.2 Page 24 - 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!