Inspection on 28/02/06 for Courtlands

This inspection was carried out on 28th February 2006.

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 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 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 Margaret Flaws Unannounced Inspection 28th February 2006 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 Courtlands DS0000010402.V271083.R01.S.doc Version 5.0 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.V271083.R01.S.doc Version 5.0 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 Mrs Olivia Emily Gannon Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (11) of places Courtlands DS0000010402.V271083.R01.S.doc Version 5.0 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. 12th July 2005 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. Its aim is to provide quality care and support for service users 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 service userial area of Whetstone and within easy reach of public transport, shops and leisure amenities located in New Barnet. Courtlands DS0000010402.V271083.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on 28 February 2006 by Inspector Margaret Flaws as part of the routine schedule of inspections for the home. The Registered Provider, the Deputy Manager and the prospective Manager assisted throughout the inspection. The inspector spoke to four service users, one friend and three staff. The feedback received was positive and indicated that service users were very satisfied with the care provided for service users. A tour of the premises, an inspection for service user case records, and other home records completed the inspection. What the service does well: What has improved since the last inspection? What they could do better: Three health and safety requirements are restated. Radiator guards or low temperature surface radiators are still to be installed in all bedrooms and communal areas within the home unless a risk assessment indicates that they are not needed. Some have been installed but other areas remain outstanding. Window restrictors must still be fitted to all windows unless a written risk Courtlands DS0000010402.V271083.R01.S.doc Version 5.0 Page 6 assessment indicates otherwise. Fire drills must be held at least four times per year, including a drill at dusk. One new requirement is made. An up to date Criminal Records Bureau check must be obtained for one new staff member. 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.V271083.R01.S.doc Version 5.0 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.V271083.R01.S.doc Version 5.0 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 Staff had a good understanding of service users’ needs to ensure that these needs are met. Improvements have been made in the pre-admission assessments covering areas of risk. EVIDENCE: Five service user’ case files examined contained good assessments and care plans. All now contained risk assessments. Staff spoken to were able to describe specific risks for several service users. There were assessments completed by the placing authorities. There were eleven service users in the home at the time of the inspection. Service users spoken to said that their needs had been fully assessed prior to admission to the home. The home does not provide intermediate care. Courtlands DS0000010402.V271083.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 10 Service users can be confident that their personal and healthcare needs will be met by the home. Care plans, while basic, cover the service users’ identified needs. EVIDENCE: Five service user’ case records were examined. These all contained care plans, which were reviewed monthly, along with risk assessments. Records of service users’ medical and healthcare treatments and appointments were kept up to date. A district nurse visited the home during the inspection to provide care to one service user. She was positive about the care provided by the home. The inspector spoke at length to the Registered Person and to the Deputy Manager. They had a very thorough knowledge of the service users’ health care needs. Nutrition and weight is carefully monitored and most service users had gained weight (within reason). One example of good practice is how the home photographs each service user on admission and then at regular intervals to record visible changes in wellbeing. Staff also provide some aromatherapy to the service users, having been trained by the visiting aromatherapist. Courtlands DS0000010402.V271083.R01.S.doc Version 5.0 Page 10 There have been some improvements to care plans to ensure that they are more holistic in scope and have more information about the mental health and other needs of the service users. Service users spoken to said that they were treated with respect by the staff and that their dignity was well preserved when they were provided with personal care. All said that they were very happy in the home. For example, one person said, “I love it here. The staff are kind and polite, I don’t feel sad at giving up my own home at all.” Another said, “Being here is like coming home, I’m one of the luckiest women in the world to be here.” Staff interviewed were knowledgeable about the care needed by the service users. Courtlands DS0000010402.V271083.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 The daily life and routines of service users were well organised and they were able to exercise choice and control over their lives. Service users were generally satisfied with the activities provided and the meals served. EVIDENCE: The home provides a small range of activities in the home for the service users. On the day of the inspection, there was a keep fit class, which most people attended. Other activities include music and other entertainment, board games and bingo. One staff member is also a beauty therapist and provides beauty care regularly. Some service users also attend church services, a vicar visits and Jewish service users have their cultural needs respected. Service users spoken to said that they were very satisfied with the activities provided and that they also enjoy pursuing their own interests individually, for example, reading and watching television. One service user reads to another, who is partially sighted. Service users stated that their relatives and friends could visit them. A friend who was visiting said that she was always made to feel very welcome at the home and could visit at any time. Courtlands DS0000010402.V271083.R01.S.doc Version 5.0 Page 12 Two service users share a room. The inspector spoke to them as they socialised there. They both said that they were very happy with the arrangement and that they enjoyed each other’s company. The bedroom was very homely and was nicely personalised by these service users. The kitchen and meal arrangements were examined and staff spoken over the lunch period. A nourishing and interesting home cooked lunch was provided. Menus were varied and service users said they had good input into meal planning. Daily fridge and freezer temperatures were recorded and were satisfactory. The menu was varied and balanced. The Deputy Manager showed the inspector the garden. There is a large vegetable plot, which she said provides all the home’s vegetables and some fruit during the spring and summer. It is managed by a gardener. There was evidence of plentiful fresh food. Courtlands DS0000010402.V271083.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Service users’ rights are protected. There is an adequate complaints policy and procedure and adult protection procedures are in place. EVIDENCE: The complaints record was examined. There have been two minor complaints since the last inspection and these have been appropriately investigated and dealt with. Staff had an understanding of adult protection procedures and have been trained in this area. Service users are also protected by the home’s independent advocacy process, described under Standard Thirty Three. All service users spoken to said that they had been well treated. Courtlands DS0000010402.V271083.R01.S.doc Version 5.0 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 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 home was clean and well maintained, providing a pleasant environment for service users to live in. Further improvements are still needed to ensure the safety of service users. EVIDENCE: The premises were very clean and well maintained. The communal areas were well decorated, furnished to a high standard and cosy. The inspector spoke to three service users in their bedrooms, which were highly personalised and a very good standard. Since the last inspection, the home has made several improvements. A new stair lift has been purchased, along with a new washing machine and dryer. One bedroom has been completed redecorated. A call bell system is in place to protect the service users’ health and safety. Water temperatures were within the safe range. Health and safety certificates were up to date and in order, including new certificates for the assisted baths, hoists and gas installations which were not available at the last inspection. Courtlands DS0000010402.V271083.R01.S.doc Version 5.0 Page 15 At the last inspection, the inspector noted that some bedrooms did not have a lockable facility and made a requirement. The Registered Person said that the all service users had been asked if they want a facility to lock away valuables in their rooms. All refused and signed a form stating this. The home has not yet completed a requirement to either guard exisiting radiators in all bedrooms and communal areas or indicate by risk assessment that this is not needed. The requirement is restated. Courtlands DS0000010402.V271083.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 The recruitment process in place generally ensures that service users’ needs are met by an appropriate group of staff. Staffing levels have been reviewed and were found to be adequate to care for the service users. EVIDENCE: Staff on duty were knowledgeable about their roles and responsibilities and service users said that all staff were respectful and caring towards them. At the last inspection, a concern about staffing levels was raised and requirement made to review these levels and report to CSCI. This was done and the staffing was found to be adequate. Service users and staff spoken to also said they were happy with the numbers of staff available. The training records were examined. Staff have received training in adult protection, fire safety, falls prevention, hearing impairment, manual handling, food hygiene, first aid and infection control. All staff have either completed or are due to complete NVQ2. The Deputy Manager and the prospective manager have both completed the Registered Manager’s Award. Staff records were examined. Recruitment procedures are good and preemployment checks are done. However, one newly employed staff member requires an up to date CRB specific to Courtlands. Courtlands DS0000010402.V271083.R01.S.doc Version 5.0 Page 17 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): 32, 33, 36, 38 Good systems are in place to ensure that the rights and interests of service users are safeguarded and staff well supported to provide quality care. Improvements are still needed in the home’s health and safety arrangements to ensure that service users live in a safe environment. EVIDENCE: Prospective management changes were discussed with the Registered Person and Deputy Manager. An application for a new manager will be submitted to the CSCI in the near future. A long serving staff member will be put forward for this position. This staff member has already completed the RMA. Good planning for the change is clearly in place. Staff and service users spoken to expressed confidence in the way the home was managed. The home has a quality assurance system in place. A volunteer independent advocate visits the home monthly and speaks to the service users, giving them a regular opportunity to raise concerns. She then reports any concerns to the home. Courtlands DS0000010402.V271083.R01.S.doc Version 5.0 Page 18 Staff are provided with regular, formal supervision sessions and these are appropriately recorded. Weekly fire alarms checks are carried out and recorded. Fire drills still need to be carried out at least four times per year, including one after dusk. This was discussed with the Registered Person. Staff have been provided with fire training and the emergency lighting is checked weekly. Window restrictors have not been fitted to all bedrooms. These are required for safety and security reasons unless a written risk assessment indicates otherwise. Courtlands DS0000010402.V271083.R01.S.doc Version 5.0 Page 19 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 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 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 3 X X 3 X 2 Courtlands DS0000010402.V271083.R01.S.doc Version 5.0 Page 20 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 OP25 Regulation Requirement Timescale for action 15/05/06 2. OP29 3. OP38 4. OP38 13(4(a,c,2 The Registered Person is 3(2(p) required to ensure that radiator guards or 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. Previous timescales of 31/1/05 and 12/09/06 not met. 18(1) The Registered Person must 30/04/06 ensure that an up to date Criminal Records Bureau check is obtained for recently employed staff member. 23(4) The Registered Person is 31/05/06 required to arrange fire drills for the home (at least 4 times a year. One of these must be after dusk). Previous timescale of 12/09/06 not met). 13(4) The Registered Person must 15/05/06 ensure that window restrictors are fitted to all windows unless a written risk assessments indicates otherwise. Previous timescale of 13/09/06 not DS0000010402.V271083.R01.S.doc Version 5.0 Courtlands Page 21 met). 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.V271083.R01.S.doc Version 5.0 Page 22 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. 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