Inspection on 11/07/05 for Fosse Court

This inspection was carried out on 11th July 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

Fosse Court 12/07/06

Fosse Court 17/11/05

Fosse Court 18/11/04

Fosse Court 15/07/04

Similar services:

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Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

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

CARE HOMES FOR OLDER PEOPLE Fosse Court 207-211 Fosse Road North Leicester Leicestershire LE3 2FU Lead Inspector Keith Williamson Unannounced 11 July 2005 at 9.15am 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. Fosse Court C51 C01 S53757 Fosse Court V237601 110705 Stage 2.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Fosse Court Address 207-211 Fosse Road North Leicester Leicestershire LE3 2FU 0116 2518822 0116 2518822 None Eastern Care Ltd 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) Ms Sadhna Patel Care Home 22 Category(ies) of PD(E) - Physical Disability over 65 - 11 registration, with number MD - Mental Disability - 11 of places PD - Physical Disability - 11 MD(E) - Mental Disability over 65 - 11 OP - Old Age - 22 Fosse Court C51 C01 S53757 Fosse Court V237601 110705 Stage 2.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: To admit up to 11 service users with a mental disorder, excluding learning disability or dementia. Physical disability (11), Physical disability over 65 years of age (11). To admit up to 11 service users with a mental disorder, excluding learning disability or dementia - over 65 years of age. To admit up to 11 service users with a physical disability and up to 11 service users with a physical disability over 65 years of age. Date of last inspection 18-11-04 Brief Description of the Service: Fosse Court is part of Eastern Care Ltd group of care homes. Fosse Court is a large care home made up of three large terraced houses, which is situated in the West End of Leicester. The home is on a main road, close to shops, parks, local amenities and places of worship. The home is on a bus route and ten minute bus journey to the city centre. Fosse Court is registered to accommodate service users requiring an Asian Lifestyle within the category of older people, physical disabled, mental health and the elderly. The home is registered to accommodate up to 22 service users, of which up to 11 with a physical disability or mental disorder. The service users have their own daily routine, choosing how they wish to spend the day. There are three separate lounges and to the rear of the home, a large dining room which overlooks the small flat garden. Bedrooms are located on the upper floors, which can be accessed via stairs or the passenger lift located at the centre of the home. The home provides Asian style meals that are culturally appropriate for the service users. Meals are prepared at another home close by and snacks and beverages are prepared within the home. The Registered Manager oversees the day-to-day management of the care home and has completed the National Vocational Qualification – level 4, Registered Managers Award. There is a stable staff group with language skills appropriate to the service users who receive a programme of induction and on-going training. Fosse Court C51 C01 S53757 Fosse Court V237601 110705 Stage 2.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over one day and commenced at 9.15am and took six and one quarter hours. An opportunity was taken to look around the home, view records and policies, speak to residents, and to staff; an interpreter was used in this process. The manager and senior care assistant assisted throughout the inspection process. No questionnaires were returned to the Inspector prior to the Inspection process, these shall be collated and responses studied for the next inspection of this service later in 2005/06. What the service does well: What has improved since the last inspection? What they could do better: The responsible individual visits the home on a regular basis, however the visits are not recorded, nor copies sent to the CSCI. The Statement of Purpose should be on display with a copy of the last inspection report enclosed; the Service User Guide should also be available. Fosse Court C51 C01 S53757 Fosse Court V237601 110705 Stage 2.doc Version 1.40 Page 6 Care plans could be far more detailed, be made available to staff and those staff encouraged to read them; they could be shared at staff supervision sessions, signed by the resident or a representative and include details on the last wishes of the resident. An assessment of daily need could be introduced into all the plans of care, and be included in the “key worker” tasks. Training should be made available for staff administering insulin and monitoring blood tests. Furniture in the home could be added to the replacement programme and included in the routine maintenance plan of the home. 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. Fosse Court C51 C01 S53757 Fosse Court V237601 110705 Stage 2.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 Fosse Court C51 C01 S53757 Fosse Court V237601 110705 Stage 2.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) 1, 2, 4 & 6. The admission procedure is good. Detailed information is provided for residents and their relatives about the services provided in the home. This home does not provide intermediate (rehabilitation) care. EVIDENCE: A detailed examination of the Statement of Purpose indicated that the document gives an accurate description of the services provided in the home, though does not currently include all the appropriate information. No residents spoken with could indicate that they were given copies of this document. Two residents’ files were inspected and subsequent conversation held with those residents indicated that the content of their assessments confirmed accurately their care needs, copies of the residents’ terms and conditions or contracts were also enclosed. The manager stated the residents or a representative receives a copy of the statement of purpose, service user guide and contract, though this could not be confirmed on the day. Fosse Court C51 C01 S53757 Fosse Court V237601 110705 Stage 2.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 &11. Residents’ care plans are not written in detail to give staff members clear instructions about the tasks they must carry out to meet residents’ care needs; information for residents having access to health care provisions is included in the plan. EVIDENCE: A detailed inspection of three residents’ care plans indicated that most aspects of personal and health care needs are being met, though risk assessments have yet to be added and developed in some plans. One resident indicated that the staff assisted access to health care, and when well enough was taken to visit his General Practitioner. The daily care records were inspected, the manager and inspector discussed ways to increase the detail in the plans of care and report writing by the care staff. It was noted in the care plans that were seen, the final wishes of residents have not been recorded. Fosse Court C51 C01 S53757 Fosse Court V237601 110705 Stage 2.doc Version 1.40 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 & 15. Residents experience a homely lifestyle and visitors are welcome at any time, resulting in an open and honest relationship between staff and residents relatives. EVIDENCE: A culturally appropriate environment is provided. A resident confirmed that visitors were free to come and go as they please, however the current policy is to lock the front door for the protection of residents due to the home being sited next to the main road. Residents’ choice and quality of food is of a very high standard, residents’ commented on this, confirming three choices of main course at times for the main meal with additional dhals and breads. Fosse Court C51 C01 S53757 Fosse Court V237601 110705 Stage 2.doc Version 1.40 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18. Robust processes are in place so that residents or their relatives can make a complaint if required. There is an adult protection procedure in place to respond to suspicion or allegation of abuse for residents’ protection. EVIDENCE: Detailed inspection of the written complaint process indicated that adequate guidance is given to residents and their relatives on how to make a complaint. The complaints logbook seen indicated that there have been four complaints since the last inspection, which appear to have been resolved with positive outcomes. The adult protection process was inspected. Two staff members spoken with gave good verbal responses regarding their understanding concerning reducing the risk of elder abuse and what actions to take in the event of suspicion or allegation of abuse. One resident spoken to indicated that he felt safe residing in the home. Fosse Court C51 C01 S53757 Fosse Court V237601 110705 Stage 2.doc Version 1.40 Page 12 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) none No standards were assessed on this particular occasion. EVIDENCE: No standards were assessed on this particular occasion. Fosse Court C51 C01 S53757 Fosse Court V237601 110705 Stage 2.doc Version 1.40 Page 13 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 & 29. A good skill mix of staff is provided, some being trained professionals, giving Residents the benefit of an experienced workforce. Staff recruitment records in the home are not of a sufficient accuracy to ensure safety of Residents in the home. EVIDENCE: Staffing levels at the time of the Inspection were adequate to meet the needs of the Residents in the home, however the staff “multi task” and have to attend all of the tasks in the home, these include domestic and catering duties. Of the staff files viewed, evidence of a detailed induction programme was seen to be in place, foundation training was also seen to be in place. Of the staff files in the home, not all have the appropriate proofs of identification required prior to commencing employment. Two references are in place in most staff files, and some of these are marked “to whom it may concern”; overall this does not provide a safe environment for Residents. Fosse Court C51 C01 S53757 Fosse Court V237601 110705 Stage 2.doc Version 1.40 Page 14 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) 37 & 38. Residents’ rights and safety are not safeguarded by policies and procedures and health and safety practices. EVIDENCE: A number of policies were viewed within the Inspection process none of which had been reviewed recently. Some temperature monitoring records for hot food and cold areas in the kitchen and hot water were also viewed these were up-to-date, but action had no been taken on the information. The health, safety and welfare of residents is not promoted or protected, due to the practices of staff in the home, the manager must ensure staff adhere to specific training with this frail elderly group. Fosse Court C51 C01 S53757 Fosse Court V237601 110705 Stage 2.doc Version 1.40 Page 15 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 3 3 x 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x x STAFFING Standard No Score 27 3 28 x 29 3 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 x x x x x x 3 2 Fosse Court C51 C01 S53757 Fosse Court V237601 110705 Stage 2.doc Version 1.40 Page 16 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 Regulation Requirement Timescale for action 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. 2. 3. 4. 5. 6. 7. Refer to Standard 1 7 7 8 11 15 24 Good Practice Recommendations It is recommended that the Statement of Purpose includes a copy of the last inspection report and results from any resident questionaires. It is recommended that all details of the care plan are made individually descriptive, and the residents abilities are also reflected. It is recommended that the assessment of daily need seen in some plans of care, be extended to all residents in the home, and those assessments be updated periodically. It is recommended that staff be trained to perform blood tests and insulin injections, by a person medically qualified to do so. It is recommended that the final wishes of residents is entered in to the plan of care. It is recommended that residents be encouraged not to eat in the kitchen of the home. It is recommended that the any furniture in the home be added to the list for replacement in the routine maintainance plan of the home. C51 C01 S53757 Fosse Court V237601 110705 Stage 2.doc Version 1.40 Page 17 Fosse Court 8. 9. 33 38 It is recommended that the quality assurance questionnaires be given or sent out regularly to residents, their relatives or advocates who visit the home. It strongly recommended that action is taken to promote the safety and well-being of residents in relation to hot water temperatures and fire safety Fosse Court C51 C01 S53757 Fosse Court V237601 110705 Stage 2.doc Version 1.40 Page 18 Commission for Social Care Inspection The Pavilions, 5 Smith Way Grove Park Enderby Leicestershire 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 Fosse Court C51 C01 S53757 Fosse Court V237601 110705 Stage 2.doc Version 1.40 Page 19 - 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. 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