Inspection on 22/11/05 for Emily Court

This inspection was carried out on 22nd November 2005.

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

Emily Court 04/01/07

Emily Court 22/02/06

Emily Court 29/11/04

Emily Court 28/04/04

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

CARE HOMES FOR OLDER PEOPLE Emily Court Oakwell Close Bradford West Yorkshire BD7 3PU Lead Inspector Pamela Cunningham Unannounced Inspection 22 & 24 November 2005 10.45 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 Emily Court DS0000001242.V258277.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. Emily Court DS0000001242.V258277.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Emily Court Address Oakwell Close Bradford West Yorkshire BD7 3PU 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) 01274 521733 01274 522607 smithr@brunerhousing.org.uk Brunel and Family Housing Mrs Ruth Smith Care Home 38 Category(ies) of Dementia - over 65 years of age (12), Old age, registration, with number not falling within any other category (38), of places Physical disability over 65 years of age (11) Emily Court DS0000001242.V258277.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th November 2004 Brief Description of the Service: Emily Court was originally opened as a sheltered housing scheme by Brunel Housing Association and has individual flats and communal spaces for the service users. It was later registered as a home for older people. It is situated off the main road leading into Bradford City centre and is well served by public transport. There are shops, banks and other amenities close by. The home has a car park to the front and other parking is available close by. The home provides accommodation for 34 older people both male and female aged over 65. There is provision for people suffering from dementia and physical disabilities. Accommodation is provided over two floors with disabled access into the home and a shaft lift available to access the first floor. All rooms have en-suite facilities and there are specialised bathrooms around the home. Service users bring their own furniture when they move into the home. The home has a large open plan lounge and dining area on the ground floor and there is an additional lounge on the first floor. Emily Court DS0000001242.V258277.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection has to carry out at least two inspections of care homes every year. The inspection year runs from April to March and this was the first inspection visit for 2005/2006. Copies of previous inspection reports are available at the home or on the Internet at www.csci.org.uk. The last inspection of the home was on 29 November 2005. This was an unannounced inspection carried out by one inspector who was at the home over two days, and for a total of six and a quarter hours. The main purpose of this inspection was to make sure that the home provides a good standard of care for the service users and to assess progress on meeting any requirements or recommendations made at the last visit. District nurse spoken to at the time of the visit said they had no concerns whatsoever about either the standard of care delivered, or the expertise of the senior staff. The methods used at this inspection included looking at care records; observing working practices, talking to staff, service users relatives and to the manager, a tour of the premises, and speaking with other healthcare professionals visiting the home. The inspector dined with the service users, and had the opportunity to meet many of the residents and speak to some of them and their relatives. One lady resident said she loved living at the home, that the care was excellent and the staff had “patience next to none”. Another lady visitor said if she needed to be cared for, Emily Court is where she would like to be cared for. Comment cards were taken to the home on the first day of the visit. Certain ones returned to The Commission identified that there were no problems with the care provided. What the service does well: The home provides a welcoming atmosphere and prospective residents are encouraged to visit the home, if at all possible, before moving in. Emily Court DS0000001242.V258277.R01.S.doc Version 5.0 Page 6 In addition to completing accident and incident report forms, the home completes a monthly audit. Information in care plans continues to improve and offer more information regarding the needs of the service users and how these are to be met. The senior care staff present a very professional front, when dealing with other healthcare professionals visiting the home. The food provided to the residents is of a good quality, well cooked and attractively presented. What has improved since the last inspection? 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. Emily Court DS0000001242.V258277.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 Emily Court DS0000001242.V258277.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 and 5, standard 6 is not applicable All residents have their needs fully assessed before moving into the home and can therefore be assured that their needs will be met. Prospective residents have the opportunity to visit the home to help them make an informed choice about the home. Intermediate managed care is not provided at Emily Court. EVIDENCE: The standard of pre-admission information provided by the funding authority varied considerably, depending on who had undertaken the initial assessment and completed the Easy Care document. However evidence in the care plan documentation, showed that all prospective residents were assessed by the manager prior to being admitted into the home. Emily Court DS0000001242.V258277.R01.S.doc Version 5.0 Page 9 Residents and relatives spoken to said they had had the opportunity to visit the home prior to admission, and that alone had been the deciding factor when deciding to come to live at Emily Court. One visitor said when she was no longer able to care for herself, Emily Court is where she would like to come and live. Emily Court DS0000001242.V258277.R01.S.doc Version 5.0 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): All standards were assessed. The health Care needs of residents are fully met. Evidence of visits to the home by other healthcare professionals was seen in the care documentation. EVIDENCE: Care plans chosen for inspection and case tracking were very informative, and contained evidence of pre-admission assessments, and all relevant risk assessments. Risk assessments were present, where risk was identified following a special need of a resident being identified. Lifestyle histories were also documented. The manager recognises the importance for the staff to have an understanding of each person’s past history in order to give care which centres on the person. The care files seen showed evidence that health care was satisfactory. Correction fluid was seen to have been used in one set of care documentation reviewed. Contact with GP’s and district nurses was well documented. The home operates a safe system of medication control that is in line with the Royal Pharmaceutical Guidelines, and all staff administering medication have had training on safe handling of medicine. The home has a self-medication Emily Court DS0000001242.V258277.R01.S.doc Version 5.0 Page 11 policy, however, at this time there are no residents who have expressed a wish to self medicate. The manager said she and her staff try to address end of life situations sensitively. Emily Court DS0000001242.V258277.R01.S.doc Version 5.0 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 and 15 Residents spoken to said the home suited them, and they were happy with their lifestyle. There are a variety of social activities on offer to residents. Staff give support to keep in contact with people outside of the home. The food provided is in accordance with the choice of residents. EVIDENCE: Activities are provided according to the preferences of the resident. At the present time there is no dedicated person to organise activities, however the manager said a person is shortly to be employed to fulfil this task. The manager also said that all care staff also take part in the planning and working with residents in activities thus using the skill within the staff team. The inspector dined with the residents, and found the meal to be well cooked very tasty and nicely presented. Residents spoken to at the time said there was always a good choice of food, and that they particularly enjoyed the Friday main choice of fish and chips. During the mealtime the inspector observed care staff interacting with residents, and giving help in a sensitive way where needed. Manual handling techniques observed at this time were also seen to be within safe limits. Emily Court DS0000001242.V258277.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 Complaints are dealt with appropriately. Service users are protected from abuse with all the staff having had adult protection training. Residents are aware of the complaints procedure and how to use it. The home has a detailed complaints and adult protection procedure which is robust and protects service users. When talking to the staff, the inspector identified that the level of staff understanding gives assurance that complaints will be taken seriously and service users will be protected from abuse. EVIDENCE: There have been no complaints since the last inspection. The home has a complaint procedure that is prominently displayed on the notice board in the home. The manager said that all complaints received are responded to in writing, and passed to head office. Staff spoken to said they had received adult protection training. Emily Court DS0000001242.V258277.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): All standards were inspected. The home offers a safe, well-maintained environment for the residents and provides appropriate bathing and toilet facilities. Some work on the environment has recently taken place. There are also plans to provide en-suite shower facilities on the top floor. EVIDENCE: The home was seen to be very clean, and with no unpleasant odours. During a tour of the living accommodation it was evident that residents are encouraged to bring items of personal memorabilia with them when they come to live at Emily Court. All rooms are provided with a small refrigerator. The communal areas in the home are well maintained offering residents facilities that would meet their needs. Residents can use sitting areas to meet with their visitors and sit and speak with other residents. Emily Court DS0000001242.V258277.R01.S.doc Version 5.0 Page 15 The area is split into two areas, one use for dining which has the appropriate furniture, and the sitting area, which is furnished with comfortable chairs set out to create a homely environment. The manager said any specialist equipment is provided to make sure that the needs of residents are met. Emily Court DS0000001242.V258277.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): All standards were inspected. The numbers and skill mix of staff were sufficient to meet the needs of the service users. There are good recruitment procedures in place to protect service users. Staff are trained and competent to do their jobs. EVIDENCE: On the day of the visit there were sufficient members of staff on duty to meet the needs of the residents. There are however only two waking night staff on duty at any one time. Due to the layout of the building the inspector expressed some concern regarding this, however, the manager said that current dependency levels did not indicate the need for an additional member of waking night staff, that there was always a manager or senior support worker on call, and that one member of staff starts duty at 6am to cover peak times of activity. She did however say that she was hoping to recruit one extra night duty carer. The manager said that training to NVQ standards was well under way, many staff have completed the training, and that the remainder of the them will have completed by the end of the year. Emily Court DS0000001242.V258277.R01.S.doc Version 5.0 Page 17 The training matrix seen identified that staff are being provided with, and have completed mandatory training. Emily Court DS0000001242.V258277.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36, 37 and 38. The manager has the skills and knowledge to provide effective leadership. Staff are well motivated, residents are consulted and their interests are safeguarded at all times. However she has still to complete the Registered Managers award. EVIDENCE: Staff spoken to confirmed they have regular supervision 6 times per year, either by the manager, or by the senior support workers who have had appropriate training. Performance reviews are also undertaken. Although it was confirmed by residents that they are consulted about their views, some said they had attended resident meetings in the past and that they did not feel the need for them, as they were able to express their views on a day to day basis, and that they felt they were listened to. Emily Court DS0000001242.V258277.R01.S.doc Version 5.0 Page 19 The manager said that the resident meetings did not work out, but that resident satisfaction surveys were carried out. Health and Safety records were checked and found to be up to date with the exception of the testing of hot water at all outlets. The manager said these were tested annually, when the building was checked for safety. However, water discharging from hot water outlets should be checked and documented monthly, to ensure the temperature is in line with health and safety limits of 43ο C. The home is still awaiting the certificate for the testing of the system for legionella. Emily Court DS0000001242.V258277.R01.S.doc Version 5.0 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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 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 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 x x 3 3 3 Emily Court DS0000001242.V258277.R01.S.doc Version 5.0 Page 21 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 OP31 Regulation 9 (2)(i) Requirement The Registered Provider must ensure the manager completes the Registered Managers award. Timescale for action 01/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations Correction fluid should not be used to correct any written mistakes in care documentation. Emily Court DS0000001242.V258277.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Emily Court DS0000001242.V258277.R01.S.doc Version 5.0 Page 23 - 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. 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