Inspection on 10/11/05 for Geel And Hitchen Court

This inspection was carried out on 10th 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

Geel And Hitchen Court 27/06/07

Geel And Hitchen Court 11/05/06

Geel And Hitchen Court 13/02/06

Geel And Hitchen Court 09/02/05

Geel And Hitchen Court 29/07/04

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

CARE HOMES FOR OLDER PEOPLE Geel And Hitchen Court Woodlands Road Aigburth Liverpool Merseyside L17 Lead Inspector Andrea Morris Unannounced Inspection 10th November 2005 08:30 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 Geel And Hitchen Court DS0000025103.V264712.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. Geel And Hitchen Court DS0000025103.V264712.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Geel And Hitchen Court Address Woodlands Road Aigburth Liverpool Merseyside L17 0151 261 2000 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) Nugent Care Care Home 24 Category(ies) of Dementia - over 65 years of age (24) registration, with number of places Geel And Hitchen Court DS0000025103.V264712.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th February 2005 Brief Description of the Service: The Geel and Hitchen Care Home is part of the Nugent Care Society and is a purpose built nursing home that offers single accommodation on a ground floor level. All bedrooms have hand wash facilities and there are several assisted baths, showers, and toilets. There is a large lounge, quiet room and a separate dining room. There are long corridors for residents to wander in. There is access to a patio area and secure garden. The interior and exterior of the home is well maintained. The home is set in grounds shared with another home owned by the Nugent Care Society, however, both homes have separate amenities and staff. Geel And Hitchen Court DS0000025103.V264712.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out over 6hrs. The inspector spoke to the person in charge, staff relatives and residents. A tour was made of the home and documentation was examined including residents’ files, accident book, incident book, certificates’ relating to Health and Safety and fire records. What the service does well: What has improved since the last inspection? What they could do better: Not all care plans are reviewed monthly. One resident had no care plan documentation at all. There is no evidence of pre-admission assessments being carried out. Not all complaints are documented, and no evidence of follow-up action available. Not all certificates relating to matters of Health and Safety were available at time of inspection. Geel And Hitchen Court DS0000025103.V264712.R01.S.doc Version 5.0 Page 6 No evidence of any fire drills recorded since November 2004. 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. Geel And Hitchen Court DS0000025103.V264712.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 Geel And Hitchen Court DS0000025103.V264712.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): 1, 2, 3, 5, 6 There is no pre-admission assessment documentation to identify the needs of an individual prior to admission have been noted. Residents therefore are at risk of care needs not being met. EVIDENCE: The Statement of Purpose was seen but it did not reflect that there was no manager of the home at present. The Statement of Purpose did not reflect the change from National Care Standards Commission to Commission for Social Care Inspection. Each resident admitted to the home is given a contract identifying their terms and conditions. There was no evidence that residents have a pre-admission assessment prior to being admitted to the home. Any person wishing to move into the home is offered the chance to visit the home. They are able to stay for a period of time to try out the facilities. The home does not provide intermediate care. Geel And Hitchen Court DS0000025103.V264712.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, 9, 10, 11 All drug sheets have an up to date photograph and this helps safeguard residents. However not all medication is signed for, this can compromise residents’ care EVIDENCE: Individualised care plans were in place for all residents except one resident who had recently been admitted to the home. Not all care plans are reviewed on a monthly basis. The accident book was available, evidence of accidents being recorded was noted. The home has an incident file which records all incidences not considered to be an accident. There was no evidence of specialist nurse input for those residents’ with a diagnosis of Diabetes, these residents are being managed by the GP and staff in the home. The treatment room was not ventilated and found to be very warm. Fridge temperatures are recorded on a daily basis. Return medication is recorded in the returns book, no out of date stock was noted. Some residents’ drug sheets had gaps and this makes it unclear as to whether medication has been administered or not. Geel And Hitchen Court DS0000025103.V264712.R01.S.doc Version 5.0 Page 10 There was a photograph on all drug sheets of residents. All policies and procedures for the home were examined and found to be appropriate. The home has an adequate death and dying policy. Geel And Hitchen Court DS0000025103.V264712.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 Activities are appropriately organised to provide stimulation to the residents’. Meals are well balanced but liquidised meals are not presented appropriately thus preventing residents’ making a choice. EVIDENCE: The home operates an open visiting policy. There is a relatives committee that meet on a regular basis. The home has a weekly visit from the local church. The Home shares a mini bus with the other home on site, they use this to take residents on outings. Due to residents not having the capacity to make informed decisions, the home encourages relatives to take an active role in the residents care. The home completes with the residents’ relatives a life history which aids in meeting residents preferences. The kitchen is appropriately staffed. Menus are on a three weekly basis. They are well balanced. The daily menu is displayed in the dining room on a board. The lunchtime meal was observed being served, staff did not rush residents’ and a system is in place for two sittings to be available. It was noted liquidised meals were not presented appropriately, all contents where mixed together and not served as separate options. Geel And Hitchen Court DS0000025103.V264712.R01.S.doc Version 5.0 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 the following standard(s): 16, 17, 18 Not all staff are trained in Adult Protection thus putting residents’ at potential risk of harm. EVIDENCE: The home does not display the complaints procedure in the main entrance area; there are no contact details for the Commission for Social Care Inspection. However, the home does provide an internal complaints form. A recent complaint made to the home was not documented and no evidence was available to what action had been taken. Any resident wishing to vote is offered the postal vote system, relatives are encouraged where appropriate to assist the resident so their legal rights are protected. The home has provided POVA (Protection of Vulnerable Adults) training to some staff. Other staff members are waiting further dates. Geel And Hitchen Court DS0000025103.V264712.R01.S.doc Version 5.0 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 the following standard(s): 19, 21, 22, 23, 24, 25, 26 The home is well maintained. Decoration is ongoing to ensure the environment is safe and comfortable for residents’ living in it. EVIDENCE: The home is well maintained. The lock on the back gate has been replaced. There are plans for one of the bathrooms to be replaced. The conservatory is being used for residents’ who prefer quiet time. A snoozelum has been created in the quiet room for residents’ who are anxious or unsettled. The home has adequate number of baths and showers, however, it was seen during the tour of the home one shower room is being used as a storage room, no application has been made to the Commission for Social Care inspection to decommission the room. Some of the pipe work has been covered as required in the last inspection but there is some that still requires covering. Geel And Hitchen Court DS0000025103.V264712.R01.S.doc Version 5.0 Page 14 There was evidence that residents’ where personalised. The home had no malodours evident. Cupboards containing cleaning materials were not locked. Geel And Hitchen Court DS0000025103.V264712.R01.S.doc Version 5.0 Page 15 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, 30 Regular training is given to staff to ensure the safety of the residents’ is maintained. EVIDENCE: Rotas were examined, the home is staffed appropriately, agency staff is currently being used to maintain staffing levels. Two staff hold an NVQ2 certificate, this is below the recommended 50 as detailed in the National Minimum Standards. The inspector was advised that the NVQ programme had just been re-introduced. Staff personal files were not available at the home for inspection, there is currently no record in the home of nurses being checked against the national register. Supervision is carried out on a 6 weekly basis. Records were maintained appropriately. There was evidence that staff were in receipt of mandatory training, this is done through the Companies internal training team. There was no evidence of any specialist training for Dementia being carried out. Geel And Hitchen Court DS0000025103.V264712.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 37, 38 Fire safety procedures are not robust enough to protect the residents’ from harm. EVIDENCE: There is currently no Registered Manager; staff are being supported by the Regional Manager. The home has an internal quality assurance system that monitors all aspects of care. It was noted that most of certificates’ in relation to Health and Safety were in date. Gas installation certificate had expired but arrangements were made during the inspection for a visit to occur the next day to renew the certificate. There was no up to date certificate for fire panel and smoke detectors available. There was also no evidence of staff file drills being undertaken since November 2004. Geel And Hitchen Court DS0000025103.V264712.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 2 N/a 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 3 N/a 2 3 3 3 3 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 2 N/a 3 N/a N/a N/a 3 2 Geel And Hitchen Court DS0000025103.V264712.R01.S.doc Version 5.0 Page 18 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 OP1 Regulation 4 Requirement The Registered Person shall compile a Statement of Purpose which consists of a statement as to the matters listed in Schedule 1 The Registered Person shall not provide accommodation unless the needs of the resident have been assessed by a suitably qualified person. The Registered person shall, after consultation with the resident or a representative prepare a written plan of needs. The Registered person shall make arrangements for the recording, handling, safeguarding, safe administration and disposal of medicines received into the care home. The Registered Person shall ensure any complaint made under the complaints procedure is fully investigated The Registered Person shall having regard to the number and needs of the residents’ ensure that there are sufficient number DS0000025103.V264712.R01.S.doc Timescale for action 01/12/05 2 OP3 14 01/12/05 3 OP7 15 01/12/05 4 OP9 13 30/11/05 5 OP16 22 01/12/05 6 OP21 23 01/12/05 Geel And Hitchen Court Version 5.0 Page 19 7 OP29 17 8 9 OP31 OP38 8 23 of baths and showers. The Registered Person shall ensure that the records referred to in paragraphs (1) and (2) are at all times available for inspection in the care home by any person authorised by the Commission to enter and inspect the care home. The Registered provider shall appoint an individual to manage the care home. The Registered Person shall ensure by means of fire drills and practices at suitable intervals, that the persons working at the care home are aware of the procedure to be followed in the case of fire, including the procedure for saving life. 30/11/03 05/01/06 15/11/05 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 Refer to Standard OP18 OP15 Good Practice Recommendations It is strongly recommended that all staff receive training in POVA including ancillary staff. It is strongly recommended that the current practice of serving liquidised meals is changed to ensure it reflects a well presented meal. Geel And Hitchen Court DS0000025103.V264712.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Geel And Hitchen Court DS0000025103.V264712.R01.S.doc Version 5.0 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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