Inspection on 12/07/05 for Courtlands

This inspection was carried out on 12th July 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.

Other inspections for this house

Courtlands 24/07/06

Courtlands 28/02/06

Courtlands 01/02/05

Courtlands 28/09/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE COURTLANDS 24 Northumberland Road New Barnet Hertfordshire EN5 1ED Lead Inspector Daniel Lim Unannounced 12 July 2005 @ 09.00am 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. COURTLANDS G59 S10402 Courtlands V231349 12.07.05 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Courtlands Address 24 Northumberland Road, New Barnet, Hertfordshire EN5 1ED 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) 020 8440 1625 020 8440 2626 The Gannon Family Partnership Mrs Olivia Gannon PC Care Home only 11 Category(ies) of OP Old Age registration, with number of places COURTLANDS G59 S10402 Courtlands V231349 12.07.05 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. One specific service user who has dementia may remain accommodated in the home. 2. The home must advise the regulating authority at such times as the specific service user vacates the home. Date of last inspection 1 February 2005 Brief Description of the Service: Courtlands is a family run private home registered to provide care for a maximum of eleven older people. Its aim is to provide quality care and support for residents living in the home. The home is a large semi detached two storey edwardian house. The office, kitchen, laundry room and lounge are on the ground floor.There are three bedrooms on the ground floor. One of them is a shared bedroom. Five bedrooms are located on the first floor. Two of these are shared. Bathrooms and toilets are located on both floors. A chair lift provides access to the first floor. There is a ramp leading to the garden and another to the front door. There is a small paved area at the front of the building and a large garden at the back. There is also a patio at the back of the house. The home is situated in a residential area of Whetstone and within easy reach of public transport, shops and leisure amenities located along the high road in Finchley. COURTLANDS G59 S10402 Courtlands V231349 12.07.05 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on 12 July 2005 and took three hours to complete. The inspector found that effort had been made to comply with requirements made in the last inspection report and the quality of care provided was good. During this inspection, the inspector was accompanied by Mrs Claire Stanley (deputy manager). The inspector was able to interview six residents living in the home. The feedback received was positive and indicated that residents were satisfied with the care provided for residents. The required records such as the residents’ case records (4), accident, fire and some maintenance records were examined. The premises including the bedrooms, laundry, kitchen, lounge and gardens were inspected. Three staff who were on duty were interviewed regarding their responsibilities and the care of residents What the service does well: The premises were clean, well furnished and felt homely The garden was well maintained and attractive Staff interviewed were knowledgeable regarding the needs of residents. Residents interviewed were happy with their accommodation. COURTLANDS G59 S10402 Courtlands V231349 12.07.05 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Improvements are needed in care documentation. The registered person must ensure that pre-admission assessments are comprehensive and include risk assessments. Comprehensive care plans are also needed. These must address the holistic needs of residents. Health and safety improvements are also required. The registered person must arrange safety inspections to be carried out on the assisted baths and gas installations. Radiator guards or low temperature surface radiators must be installed in all bedrooms and communal areas within the home unless a risk assessment indicates that they are not needed. Window restrictors must be fitted to all windows unless a written risk assessment indicates otherwise. The registered person is further required to arrange fire drills for the home (at least 4 times a year. One of these must be after dark). Fire training must be arranged for all staff. The emergency lighting must be tested at least once a week. Documented evidence of these is required. The registered person must review staffing levels and undertake any actions identified out of the review so as to ensure it has sufficient staff to meet the needs of residents throughout the day and night. A report of actions undertaken following this review must be forwarded to the inspector. The registered person must arrange for staff to be provided with training in lifting and handling. A lockable facility must be provided in each bedroom in accordance with Standard 24.7. COURTLANDS G59 S10402 Courtlands V231349 12.07.05 Stage 4.doc Version 1.30 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. COURTLANDS G59 S10402 Courtlands V231349 12.07.05 Stage 4.doc Version 1.30 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 COURTLANDS G59 S10402 Courtlands V231349 12.07.05 Stage 4.doc Version 1.30 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) 3, 4 The acting manager and her staff had a good understanding of the needs of residents and were able to ensure that their needs are met. Improvements are however, needed in the pre-admission assessment to ensure that staff are fully informed of the needs of residents. EVIDENCE: The inspector interviewed six residents. The feedback received indicated that their needs had been met. The inspector observed the physical condition of residents. Residents were noted to be clean and appropriately dressed. Four case records examined contained assessments and plans of care. The inspector however, noted that some assessments were not sufficiently comprehensive as they did not include risk assessments. These are needed to inform staff of potential risks which may be encountered. This was discussed COURTLANDS G59 S10402 Courtlands V231349 12.07.05 Stage 4.doc Version 1.30 Page 10 with the manager who reassured the inspector that the necessary risk assessments would be included. COURTLANDS G59 S10402 Courtlands V231349 12.07.05 Stage 4.doc Version 1.30 Page 11 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) 7,8,9,10 The personal and healthcare needs of residents had on the whole, been met at the home. The inspector however, noted that improvements are needed in the plans of care prepared. EVIDENCE: The feedback received from residents indicated that they had been treated with respect and dignity. Staff interviewed were generally knowledgeable regarding the care to be provided to residents. The sample of four case records examined contained plans of care which had been reviewed monthly. Records of residents’ medical and healthcare treatment were available. The community nurse who was visiting the home was interviewed. She stated that the home had maintained close liaison with her and she was of the opinion that the healthcare needs of residents had been COURTLANDS G59 S10402 Courtlands V231349 12.07.05 Stage 4.doc Version 1.30 Page 12 met. She also informed the inspector that her instructions regarding the care of residents had been followed by staff. The plans of care examined did not always address the mental, cultural and spiritual needs of residents. This is needed to ensure that the holistic needs of residents are attended to. The inspector further noted that the plans of care of a resident with dementia did not include a mental health / psychological care plan. This is required to ensure that the needs of the resident concerned are responded to. Residents who were interviewed indicated that they had been given their medication and there was documented evidence that staff had been provided with training on the administration of medication. COURTLANDS G59 S10402 Courtlands V231349 12.07.05 Stage 4.doc Version 1.30 Page 13 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) 12,13,14,15 The daily life and routines of residents were well organised and they were able to exercise choice and control over their lives. Residents were generally satisfied with the activities provided and the meals served. EVIDENCE: Residents who were interviewed indicated that they were generally satisfied with the activities provided. Activities provided included exercise sessions, entertainment sessions, music and board games. One resident stated that she liked the music Bingo games organised and suggested that this be held regularly. This was brought to the attention of the manager who reassured the inspector that it would be done. Residents who were interviewed stated that they had been visited by their relatives. There was also documented evidence of consultation meetings with residents. Residents indicated that suggestions made by them had been responded to. COURTLANDS G59 S10402 Courtlands V231349 12.07.05 Stage 4.doc Version 1.30 Page 14 The manager was able to provide examples of how residents could exercise choice and control in their lives (such as choice of meals, daily routine and items kept in bedrooms). The bedrooms inspected had been personalised by residents with their personal items such as photos and souvenirs. The kitchen and arrangements for the provision of meals were examined. Daily fridge and freezer temperatures had been recorded. These were satisfactory. The menu examined was varied and balanced. There was documented evidence that staff had been provided with food hygiene training. COURTLANDS G59 S10402 Courtlands V231349 12.07.05 Stage 4.doc Version 1.30 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, 18 There was evidence that the rights of residents were protected and residents were well treated. EVIDENCE: The complaints record was examined. No complaints were recorded. The manager explained that none had been received. Staff who were interviewed were found to be knowledgeable regarding adult protection procedures. The staff records examined indicated that staff had been provided with training in adult protection. All residents who were interviewed stated that they had been well treated. COURTLANDS G59 S10402 Courtlands V231349 12.07.05 Stage 4.doc Version 1.30 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) 19,20,21,23, 25, 26 The home was clean and well maintained, therefore providing a nice environment for residents to live in. Further improvements are however, needed to ensure the safety of residents. EVIDENCE: The premises were inspected and found to be clean and well maintained. The hot water was tested and found to be within the required safe temperature range of no higher than 43 C. The gardens were attractive and seating had been provided. The communal areas were well decorated, furnished to a high standard and appeared cosy. COURTLANDS G59 S10402 Courtlands V231349 12.07.05 Stage 4.doc Version 1.30 Page 17 The annual emergency lighting and portable appliances testing certificates were available for inspection. However, safety certificates for the assisted baths and gas installations were not available. These are required. The laundry was inspected and staff interviewed were aware of the need to wash soiled and infected laundry at a temperature of at least 68C for at least 10 minutes. The inspector noted that some bedrooms did not have a lockable facility. This is required to ensure that residents are able to lock away their valuables. The registered person is also required to ensure that radiator guards or low temperature surface radiators are installed in all bedrooms and communal areas within the home to ensure the safety of residents. This is required unless a risk assessment indicates that it is not needed. COURTLANDS G59 S10402 Courtlands V231349 12.07.05 Stage 4.doc Version 1.30 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) 27,28,29,30 The recruitment process in place ensures that residents’ needs are met by an appropriate group of staff. Concern was however expressed by three residents regarding staffing levels (especially in the afternoons). EVIDENCE: Staff who were on duty were interviewed and noted to be knowledgeable regarding their roles and responsibilities. Residents who were interviewed stated that staff were respectful and caring towards them. Three residents however, informed the inspector that the staffing levels were inadequate during the afternoons. This was discussed with the manager. The staff rota and staffing arrangements were examined in detail. The rota indicated that there was normally three carers on duty (in addition to the manager) during the day shift and two carers on waking duty during the night. The manager and staff interviewed stated that the staffing levels were adequate. Due to concerns expressed, the registered person is required to review staffing levels with residents and staff. This review must include the manner in which staff are deployed (especially in the afternoons) to ensure that the needs of residents are met. A report of this review must be forwarded to the inspector. COURTLANDS G59 S10402 Courtlands V231349 12.07.05 Stage 4.doc Version 1.30 Page 19 The training records examined, indicated that staff had been provided with some of the essential training required. However, further training is required for some staff in fire safety and lifting and handling. Staff records examined indicated that the required CRB disclosures had been obtained for staff. COURTLANDS G59 S10402 Courtlands V231349 12.07.05 Stage 4.doc Version 1.30 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) 33, 36, 38 Systems were in place to ensure that the rights and interests of residents were safeguarded. Improvements are however, needed in the home’s health and safety arrangements to ensure that residents live in a safe environment. EVIDENCE: When interviewed on a range of topics associated with the care of residents and staff management, the deputy manager was found to be knowledgeable. Staff and residents interviewed expressed confidence in the way the home was managed. COURTLANDS G59 S10402 Courtlands V231349 12.07.05 Stage 4.doc Version 1.30 Page 21 There was evidence in the minutes of meetings examined to indicate that residents had been consulted regarding the management of the home. Staff records examined, indicated that staff had been provided with formal supervision sessions. The fire logbook examined indicated that weekly checks of the fire alarm had been carried out. However, fire drills and fire training had not been arranged and the emergency lighting had not been checked weekly. These are required for safety reasons. Window restrictors had not been fitted to all bedrooms. These are required for safety and security reasons unless a written risk assessment indicates otherwise. COURTLANDS G59 S10402 Courtlands V231349 12.07.05 Stage 4.doc Version 1.30 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 2 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 3 x 3 2 2 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x 3 x 2 COURTLANDS G59 S10402 Courtlands V231349 12.07.05 Stage 4.doc Version 1.30 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 3 Regulation 14(1) Requirement Timescale for action 20/8/05 2. 7 3. 19 4. 24 5. 25 The registered person must ensure that pre-admission assessments are comprehensive and include risk assesments. 13(1) The registered person must 15(1) provide comprehensive care plans which address the holistic needs of residents (these plans must include plans to meet the residents physical, mental, cultural, social and spiritual needs). 23(1)(2) The registered person must arrange safety inspections to be carried out on the assisted baths and gas installations. 16(2) The registered person must arrange for a lockable facility to be provided in bedrooms in accordance with Standard 24.7. 13(4)(a)(c The registered person is required ), to ensure that radiator guards or 23(2)(p) low temperature surface radiators are installed in all bedrooms and communal areas within the home. This is required unless a risk assessment indicates that it is not needed. [timescale of 31/1/05 not met]This requirement is restated and reworded. G59 S10402 Courtlands V231349 12.07.05 Stage 4.doc 1/10/05 13/9/05 12/10/05 12/9/05 COURTLANDS Version 1.30 Page 24 6. 27 18(1)(a) 7. 30 18 (1) (c) (i) 23(4) 23(4) 8. 9. 30 38 10. 38 23(2)(c) (p) 11. 38 13(4) The registered person must review staffing levels and and undertake any actions identified out of the review so as to ensure it has sufficient staff to meet the needs of residents throughout the day and night. A report of actions undertaken following this review must be forwarded to the inspector. The registered person must arrange for staff to be provided with training in lifting and handling. The registered person must arrange for all staff to be provided with fire training. The registered person is required to arrange fire drills for the home (at least 4 times a year. One of these must be after dark). The registered person is required to ensure that the emergency lighting is tested at least once a week. Documented evidence of these is required. The registered person must ensure that window restrictors are fitted to all windows unless a written risk assessments indicates otherwise. 1/10/05 1/10/05 13/9/05 12/9/05 20/8/05 13/9/05 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 COURTLANDS G59 S10402 Courtlands V231349 12.07.05 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Solar House 1st Floor, 282 Chase Road Southgate London N14 6HA 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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