Inspection on 24/07/06 for Courtlands

This inspection was carried out on 24th July 2006.

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 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

Courtlands 28/02/06

Courtlands 12/07/05

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 Key Unannounced Inspection 24th July 2006 01:00 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 Courtlands DS0000010402.V301104.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. Courtlands DS0000010402.V301104.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Courtlands Address 24 Northumberland Road New Barnet Hertfordshire EN5 1ED 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) 020 8440 1625 020 8440 2626 The Gannon Family Partnership Mrs Olivia Emily Gannon, Mr Stephen David Gannon, Mrs Claire Patricia Stanley, Mrs Anne Marie Probert Ms Rani Desscan Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (11) of places Courtlands DS0000010402.V301104.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One specific service user who has dementia may remain accommodated in the home. The home must advise the regulating authority at such times as the specific service user vacates the home. 28th February 2006 Date of last inspection Brief Description of the Service: Courtlands is a family run private home registered to provide care for a maximum of eleven older people. The stated aim of the home is to provide a high quality of care for residents and to treat them with respect and dignity and assist them in reaching their full potential. 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 in New Barnet. The fees charged by the home range from £500 - £570 each week. The provider must make information about the service available (including reports) to service users and other stakeholders. Courtlands DS0000010402.V301104.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out on 24 July 2006 and took a total of four hours to complete. The inspector found that the overall quality of care provided was good. During this inspection, the inspector was assisted by Ms Rani Desscan, the newly registered manager of the home. The inspector was able to interview three residents. The feedback received from them indicated that they were satisfied with the care provided. Statutory records were examined. These included three residents’ case records, the maintenance records, accident records, complaints’ record and fire records of the home. The premises including residents’ bedrooms, communal bathrooms, laundry, kitchen, garden and communal areas were inspected. Three staff on duty were interviewed on a range of topics associated with their work. Staff records, including supervision records, evidence of CRB disclosures, references and training records were examined. In addition, the minutes of staff and residents meetings were examined. (A second visit was made to the home on 26 July 2006 to view documents not available on 24 July 2006) What the service does well: What has improved since the last inspection? Courtlands DS0000010402.V301104.R01.S.doc Version 5.2 Page 6 Radiator guards had been provided over radiators in the home. Fire drills had been arranged for staff. Window restrictors had been fitted to windows. The required recruitment procedures (including obtaining CRB disclosures and references) had been followed. 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. Courtlands DS0000010402.V301104.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 Courtlands DS0000010402.V301104.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4, 6 The quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Satisfactory arrangements were in place to ensure that residents admitted into the home are assessed and appropriate. This ensures that the home can meet the needs of residents accommodated there. EVIDENCE: The three residents who were interviewed informed the inspector that they were well cared for and their care needs had been attended to. This was reiterated in completed questionnaires received from four residents and five relatives. Comments made by residents included, “happy with care”, “well cared for” and “well treated by staff”. Courtlands DS0000010402.V301104.R01.S.doc Version 5.2 Page 9 A sample of three residents’ case records which was examined contained the required assessments. These included risk assessments. The inspector observed that residents in the home were clean, appropriately dressed and appeared well cared for. The inspector was informed by the manager that the home does not provide intermediate care. Courtlands DS0000010402.V301104.R01.S.doc Version 5.2 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 the following standard(s): 7, 8, 9, 10 The quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The arrangements for healthcare and personal care were generally satisfactory. This ensures that residents needs in these areas are met at the home. Improvements are however, required in care documentation. EVIDENCE: The four residents interviewed, indicated that their healthcare needs had been met. Comments made included, “I can see the doctor if I need to” and “my medication has been given promptly”. The sample of three case records examined were up to date and plans of care had been reviewed regularly. Records of medical and healthcare treatment including appointments with the doctor, optician and community nurse were documented. Courtlands DS0000010402.V301104.R01.S.doc Version 5.2 Page 11 The inspector noted that not all care plans examined addressed the cultural and spiritual needs of residents. This is required to ensure that the holistic needs of residents are attended to. Residents were able to confirm that they had been given their medication. The home had a record of temperatures of the room where medication was stored. These were within the required temperature range. There was evidence that staff had been provided with training in the administration of medication. The inspector discussed the topics of diversity and equalities with the manager, deputy manager and responsible individual. He was informed by them that diversity among residents is appreciated and the home has a policy on ensuring that staff and residents are treated equally and not discriminated against. Courtlands DS0000010402.V301104.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 14, 15 The quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The daily life and routines of residents were well organised. This ensures that the dietary, cultural and social preferences of residents are met. EVIDENCE: The home had a weekly programme of activities. These included music sessions, bingo, gentle exercise and indoor games. The bedrooms inspected had been personalised by residents with their personal items such as photos and souvenirs. The kitchen was clean and well equipped. The menu examined was varied and balanced and reflected the cultural preferences of residents. There was a choice of main dish provided. A record of daily fridge and freezer temperatures had been kept. These were satisfactory. There was documented evidence that staff had been provided with food hygiene training. Courtlands DS0000010402.V301104.R01.S.doc Version 5.2 Page 13 Resident interviewed were generally satisfied with the meals provided. They confirmed that there was a choice of alternative main dish. Courtlands DS0000010402.V301104.R01.S.doc Version 5.2 Page 14 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 the following standard(s): 16, 18 The quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The arrangements for responding to complaints and for adult protection were satisfactory. This ensures that residents (and their representatives) are listened to and protected from abuse and harm. EVIDENCE: The complaints record was examined. There was documented evidence that complaints recorded had been promptly responded to. The manager and two of her staff who were interviewed were found to be knowledgeable regarding adult protection procedures. The staff records examined indicated that staff had been provided with instruction and guidance on adult protection. The three residents who were interviewed stated that they had been treated with respect. Courtlands DS0000010402.V301104.R01.S.doc Version 5.2 Page 15 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 the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 The quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home was clean, well equipped and felt cosy. This ensures that residents live in a pleasant environment. EVIDENCE: The premises were clean and well maintained. The gardens were attractive. The communal areas were well furnished and appeared cosy. Bedrooms inspected had been personalised by residents. Residents interviewed stated that they were happy with their accommodation. No offensive odours were detected. Courtlands DS0000010402.V301104.R01.S.doc Version 5.2 Page 16 There was documented evidence that safety inspections had been carried out on the assisted bath, water supply, portable appliances and electrical installations. Bedlinen in bedrooms were inspected and noted to be clean. Courtlands DS0000010402.V301104.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 The quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Residents’ needs were on the whole, met by the skill mix of staff. However, a deficiency was noted in the staffing arrangements. EVIDENCE: The staff records were examined. There was evidence that most of the required training (such as first aid, health & safety, lifting and handling) had been arranged for staff. This was also confirmed by staff interviewed. The inspector noted that a staff member had not been provided with refresher training in moving & handling within the past four years. This is required to ensure that staff are fully trained training and a requirement is made accordingly. The duty rota was examined. It indicated that in addition to the manager and deputy manager there was normally at least 3 care staff during the morning shift, 3 care staff during the afternoon and evening shifts and 2 care staff on duty during the night shift (one on waking night duty). Courtlands DS0000010402.V301104.R01.S.doc Version 5.2 Page 18 Staff and residents interviewed were of the opinion that the staffing levels were adequate. The staff records examined contained the required documentation such as CRB disclosures, references, supervision records and passport photos. Courtlands DS0000010402.V301104.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 The quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Health and safety arrangements were in place and residents and their representatives had been consulted. This ensures that the home is run in the best interest of residents. EVIDENCE: The manager was noted to be knowledgeable and she had the required qualifications (RMA award). Staff and residents interviewed were of the opinion that the home was well managed. This was confirmed by five relatives who returned completed questionnaires. Courtlands DS0000010402.V301104.R01.S.doc Version 5.2 Page 20 There was evidence that residents and relatives had been consulted regarding the management of the home. This was evidenced in the minutes of meetings examined. Window restrictors were fitted and these were engaged. A risk assessment had been documented (in relation to a resident) for a bedroom window without a restrictor. This indicated that the resident concerned was not at risk due to the absence of a restrictor. Fire alarm checks and fire drills had been documented. One had been carried out after dusk. The fire alarm had not been tested in the previous week. This was carried out on the day of inspection and noted to be in working order. A fire risk assessment was in place. This had been updated redcently. The gas installations had not been inspected within the past twelve months. The deputy manager explained that an appointment had been made for this to be done ( in three weeks time ) and documented evidence of this appointment was provided. A requirement is made for the registered person to forward a copy of the gas installations safety inspection certificate to CSCI. A current certificate of insurance was displayed. The financial records of residents were examined. These were noted to be satisfactory. Quality assurance systems were in place to monitor and ensure that the quality of care is maintained at a high standard. Courtlands DS0000010402.V301104.R01.S.doc Version 5.2 Page 21 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 3 X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Courtlands DS0000010402.V301104.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 12(4)(b) 13(1) Requirement The registered person must provide comprehensive care plans which address the holistic needs of service users (this must include details of how their mental, social, cultural and spiritual needs are met). The registered person must ensure that the care staff identified to her receive refresher training in moving & handling. The registered person must forward a copy of the gas installations safety inspection certificate to CSCI. Timescale for action 30/09/06 2 OP30 18(1)(c) 30/10/06 3 OP19 13(4) 23(2)(a) (b)(c) 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Courtlands DS0000010402.V301104.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Southgate Area Office 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. Extracts may not be used or reproduced without the express permission of CSCI Courtlands DS0000010402.V301104.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. 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