Inspection on 27/09/05 for Fives Court

This inspection was carried out on 27th September 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

Fives Court 12/05/06

Fives Court 06/04/05

Fives Court 12/01/05

Fives Court 26/08/04

Fives Court 19/02/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Fives Court Angel Lane Mere Warminster Wiltshire, BA12 6DF Lead Inspector Karen Mandle 27 TH Unannounced September 2005 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. Fives Court D51_D01_S28276_FivesCourt_V247180_270905_Stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Fives Court Address Angel Lane Mere Warminster Wiltshire BA12 6DF 01747 860707 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) The Orders of St John Care Trust Mrs Diane Bowden Mr Richard Dyer Care Home 31 Category(ies) of DE(E) Dementia - over 65 (11) registration, with number OP Old Age (31) of places Fives Court D51_D01_S28276_FivesCourt_V247180_270905_Stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. No more than 31 service users with Old Age at any one time 2. No more than 11 service users with Dementia, over 65 years of age at any one time. Date of last inspection 6th April 2005 Brief Description of the Service: Fives Court is registered to provide personal care only for 31 older people aged 65 years and older, 11 of which may be suffering from Dementia. The home is located in the village of Mere within walking distance of the village shops and local facilities. Mere is situated on the A303 London to the west trunk road. Fives Court is a purpose built home offering comfortable single room accommodation but without en-suite facilitites. The home offers various communal areas. All bedrooms and communal rooms are located on the ground floor. The home has a large patio area to the rear of the building and surrounding gardens. Fives Court D51_D01_S28276_FivesCourt_V247180_270905_Stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection commenced at 9.40am and was completed at 1.50pm. The Manager was available to assist the inspector. The inspector was able to freely tour the home, visiting various communal areas and many bedrooms. The inspector did not visit the kitchen on this occasion. The inspector spoke with many Service Users and two members of staff. The care records were reviewed as were the medication procedure. What the service does well: What has improved since the last inspection? What they could do better: Fives Court D51_D01_S28276_FivesCourt_V247180_270905_Stage4.doc Version 1.40 Page 6 The care plans do not provide a detailed account of care provided and manual handling risk assessments and pressure risk assessments are not completed. The long-term care needs assessments are not detailed this may be due to this document being used as a pre admission assessment document. The activities programme is limited without an activities co-ordinator in post. 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. Fives Court D51_D01_S28276_FivesCourt_V247180_270905_Stage4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Fives Court D51_D01_S28276_FivesCourt_V247180_270905_Stage4.doc Version 1.40 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 standard(s) 3 A clear admission procedure is in place and care needs assessed. The pre admission assessment document presents as complex and may not readily be understood by Service Users. EVIDENCE: The Registered Manager conducts a pre admission assessment for each Service User prior to admission to ensure the home is able to meet the personal care needs and social care needs of the Service Users. The home continues to use the long-term assessment document from the care plan system, which is not suitable for the pre admission assessment process. The document should be used to identify long term care needs once the Service User has been admitted to the home following which the document should be retained in the care records and reviewed regularly, ensuring that all care needs are being fully addressed and met. Fives Court D51_D01_S28276_FivesCourt_V247180_270905_Stage4.doc Version 1.40 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 standard(s) 7, 8 and 9 The care plans do not fully address all aspects of care and information is limited. Evidence is not available to support that all health care needs are being met. The medication procedure is safe and the Staff have a clear understanding of the responsibility they have to the Service Users when administering medication. EVIDENCE: Each Service User is provided with a care plan. However the information in the care records is limited and relevant documents relating to care issues are no longer used such as the pressure area risk assessment. This document should be used to ensure that all Service Users have been fully assessed regarding the risk of pressure breakdown with the aim to reduce the risk. The Key worker document is no longer used. This document should be used to gain information from Service Users relating to expectations of personal care needs and social needs. All Service Users are registered with a GP. The home is not registered to provide nursing care, therefore nursing needs are attended to by the Community Nursing Team. Service Users confirmed that they could see a doctor on request, which the care staff would arrange. A GP was seen visiting Fives Court D51_D01_S28276_FivesCourt_V247180_270905_Stage4.doc Version 1.40 Page 10 during the inspection. The documentation in the care records does not provide enough evidence to support that all health care needs are being met. Care Staff are responsible for administering medication. The method of administration was safe. All medication was stored and recorded correctly. Fives Court D51_D01_S28276_FivesCourt_V247180_270905_Stage4.doc Version 1.40 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 standard(s) 12 and 13 Social activities are limited and do not fully meet the social needs of the Service Users. Service Users are supported to maintain links with family and friends. EVIDENCE: The activities programme has become limited due to staffing issues. The home had previously assigned a member of the care team to provide a daily activities programme, however due to recruitment problems of staff the home is unable to provide this designated person. The home does not employ a designated activities person. Service Users were observed spending time together in the communal areas of the home or in their bedrooms watching TV or reading. Service Users confirmed that they are supported to retain links with family and friends who can visit at any time. The visitors signing in book provided evidence of this taking place and visits were observed taking place. Fives Court D51_D01_S28276_FivesCourt_V247180_270905_Stage4.doc Version 1.40 Page 12 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 and 18 There is a complaints policy and procedure in place. A vulnerable adults procedure is also in place and staff are fully aware of the local procedures and how to use it. EVIDENCE: There is an organisational complaints procedure in place, a copy of which is situated in the entrance hall to the home for anyone to see. All Service Users are provided with a copy of the complaints procedure. The home has not recently received any formal complaints. The home has copies of the “No Secrets” document available to all staff. Care Leaders understand their role and responsibility in how to report any incident of abuse. An “Abuse” organisational policy and procedure is in place as is a “Whistle Blowing” policy. Fives Court D51_D01_S28276_FivesCourt_V247180_270905_Stage4.doc Version 1.40 Page 13 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, 24 and 26 The home is well maintained providing a safe environment for Service Users to live in. All bedrooms are single which are personalised and homely. The home is clean to a good standard throughout. EVIDENCE: Fives Court is well maintained throughout. The furnishings of the home are domestic and homely as is the décor. The Manager has worked hard to individualise the décor of the bedrooms and tries to involve the Service User when their bedroom is due to be redecorated to provide the Service User with choice. Many of the bedrooms were visited which were personalised and clean and Service Users expressed they were happy with the accommodation provided apart from not having an en-suite facility. The home was clean to a very good standard throughout including the toilets and bathrooms. Infection control measures were in place and clinical waste is being dealt with appropriately. Hand washing facilities are available for the staff ensuring cross infection is reduced between Service Users. Fives Court D51_D01_S28276_FivesCourt_V247180_270905_Stage4.doc Version 1.40 Page 14 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 The current staffing levels in the home do not meet the needs of the Service Users group. EVIDENCE: Recruitment of staff has recently been a problem for the home and an increasing amount of agency staff have been used. However the rotas did provide evidence of the same agency staff working repeatedly at the home providing some continuity of care to Service Users. Apart from the Manager, a Care Leader and two carers are responsible to the Service Users for providing all personal care. Other duties include the medication round by the Care Leader, making contacts to other health care professionals and setting up appointments for Service Users and conducting care reviews. The laundry service and activities programme are also provided by the Team Leader and two carers on duty. Whilst these duties are being performed Service Users may not be receiving adequate support or supervision from the care staff. A support worker is employed 25 hours per week to assist with duties such as bed making and providing drinks. The home is providing care for 11 Service Users who are suffering with Dementia these Service Users require more assistance and support by the care staff with daily activities and personal care. Fives Court D51_D01_S28276_FivesCourt_V247180_270905_Stage4.doc Version 1.40 Page 15 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) 31 and 38 The Manager understands the responsibility of the management role and provides leadership to the home. Health and safety of Service Users and staff is well provided for. EVIDENCE: The Registered Manager has been in post approximately 2 years and has now completed the Registered Managers Award. The Manager is supported by, a Care Leader on each shift and two carers. The Manager provides regular supervision to staff and is currently working towards recruiting more care staff for the home. Fire records indicated that weekly testing of the fire alarm system was taking place and staff had received fire training. Emergency lighting was tested monthly and all fire exits were accessible. The accident records were detailed and the number of falls has reduced during recent months. The home is very Fives Court D51_D01_S28276_FivesCourt_V247180_270905_Stage4.doc Version 1.40 Page 16 well maintained ensuring Service Users and Staff are provided with a safe living and working environment. Fives Court D51_D01_S28276_FivesCourt_V247180_270905_Stage4.doc Version 1.40 Page 17 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 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x 3 x 3 STAFFING Standard No Score 27 2 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x x x x x x 3 Fives Court D51_D01_S28276_FivesCourt_V247180_270905_Stage4.doc Version 1.40 Page 18 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 OP7 Regulation 15(2,B) Requirement The Registered Manager will ensure all Service Users who have pressure damage or are at risk of pressure damage will have a risk assessment in place which is reviewed monthly. The Registered Manager will ensure more detail is recorded on the long term care needs assessment document. Service Users will be given the opportunity to particpate in the care planning process and sign the care plan when agreed. The Registered person will ensure that each Service User has a manual handling assessment in place. The Registered Manager will ensure the staffing levels provided fully meet the needs of the Service Users at all times. Timescale for action By 14th November 2005 2. OP7 15 By 14th November 2005 By 14th November 2005 By 14th November 2005 3. OP7 15 4. OP7 15 5. 6. OP27 18 By 14th November 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Fives Court D51_D01_S28276_FivesCourt_V247180_270905_Stage4.doc Version 1.40 Page 19 No. 1. 2. 3. Refer to Standard OP3 OP7 OP12 Good Practice Recommendations The Registered Manager should consider a more Service User friendly pre assessment tool. The Registered Manager should audit care plans monthly. The Registered Manager should consider providing an activities person. Fives Court D51_D01_S28276_FivesCourt_V247180_270905_Stage4.doc Version 1.40 Page 20 Commission for Social Care Inspection Avonbridge House Bath Road Chippenham Wiltshire, SN15 2BB 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 Fives Court D51_D01_S28276_FivesCourt_V247180_270905_Stage4.doc Version 1.40 Page 21 - 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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