Inspection on 11/05/06 for Geel And Hitchen Court

This inspection was carried out on 11th May 2006.

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

Geel And Hitchen Court 27/06/07

Geel And Hitchen Court 13/02/06

Geel And Hitchen Court 10/11/05

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 Key Unannounced Inspection 11th May 2006 09:30 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.V288587.R01.S.doc Version 5.1 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.V288587.R01.S.doc Version 5.1 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.V288587.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th February 2006 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.V288587.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over 5 hours. During the inspection a tour was made of the home, documentation including resident’s files, certificates relating to Health and Safety and fire were examined. Additional documentation was monitored including policies and procedures as well as complaints records. What the service does well: What has improved since the last inspection? There have been some improvements since the last inspection. The complaints documentation has been improved and staff have received training in complaints management. Staff training has also improved to ensure most staff since the last inspection have received POVA (Protection of Vulnerable Adults), with plans of all staff to have completed the training in the next 2 months. Many staff have also received training in Dementia care. The morale within the home has also improved since the last inspection; there has been additional managerial support to both residents and staff whilst the appointment of a new manager is being sort. This action has aided in providing continuity and an improvement of care. Geel And Hitchen Court DS0000025103.V288587.R01.S.doc Version 5.1 Page 6 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. Geel And Hitchen Court DS0000025103.V288587.R01.S.doc Version 5.1 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.V288587.R01.S.doc Version 5.1 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, 4, 5, 6 All residents’ are assessed prior to admission; this ensures their needs can be met. However, all documentation must be signed to ensure all records are appropriate. EVIDENCE: The Statement of Purpose and the Service User Guide contains all the necessary information to enable residents and their families to make an informed choice about the home. Residents’ prior to admission are assessed to ensure their needs can be met. A trained member of staff completes the pre-admission assessment. There has been some improvement to the detail being recorded in the pre-admission assessment, however, the pre-admission assessment forms are still not being signed and dated. All documentation must be signed and dated to ensure both residents’ and staff safety is maintained. The home encourages all potential residents’ to visit the home prior to moving in. A resident can visit the home and stay for a few hours or a meal at no extra cost. The home does not provide intermediate care. Geel And Hitchen Court DS0000025103.V288587.R01.S.doc Version 5.1 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 Medication administration is adequate; however, to ensure residents’ safety is maintained all medication administration must be recorded correctly to protect them effectively. EVIDENCE: Since the last inspection there has been a full review of care plan documentation and risk assessments. There has been a start in moving all residents care files to the new documentation. The Service manager along with the assistant Head of home identified all files will be transferred by the beginning of June 2006. It was noted during the tour of the home that staff had a good rapport with the residents’. Residents who where able to, stated that staff treated them well and they enjoyed living in the home. It was seen that staff treated the residents’ with respect giving residents the opportunity to make choices within their capabilities. The homes policy on care of the dying is appropriate; some staff are due to attend training on care of the dying in June 2006. The homes medication system has improved greatly since the last inspection, however, it was noted that several drug sheets lacked signatures where Geel And Hitchen Court DS0000025103.V288587.R01.S.doc Version 5.1 Page 10 medication appeared to be dispensed. During the discussion at the inspection action to be taken by the home to rectify the issues relating to medication. Geel And Hitchen Court DS0000025103.V288587.R01.S.doc Version 5.1 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 provided on a daily basis, this enables residents’ to lead a balanced and fulfilling life. EVIDENCE: The home is currently awaiting for an activity organiser to join the team. It is envisaged that the person will take up post in June 2006 for 25hours per week. There has been some improvement to the delivery of activities since the last inspection. A programme has been devised and is on display in the entrance area. Daily activities are written on the notice board in the main dining area. The home has recently employed 5 volunteers who have all been CRB checked. These volunteers assist to support residents in leading a varied and fulfilling life. Records are now being maintained of all social activities undertaken by each resident. The home operates an open visiting policy. Residents are able to receive their visitors in private if they choose. The lunchtime meal was observed being served. The home has two sittings so all residents are able to receive the assistance they need. The food was noted to be appetising and nutritious. Geel And Hitchen Court DS0000025103.V288587.R01.S.doc Version 5.1 Page 12 Residents are able to have an alternative to the daily menu by request. A recommendation has been repeated to record a second option to assist residents with making choices. Geel And Hitchen Court DS0000025103.V288587.R01.S.doc Version 5.1 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, 18 Complaints records have been developed to ensure all residents and families know their concerns are listened too and acted upon. EVIDENCE: There has been new documentation relating to complaints developed since the last inspection. Staff have received training in all aspects of complaints management. The home has displayed a complaints procedure that is easy to follow however; it did not contain the contact details of the Commission for Social Care Inspection. Since the last inspection there has been one incident of Adult Protection, this is currently being investigated by the home and correspondence to the Commission for Social Care Inspection is due to be delivered on completion of the investigation. Most staff have received training in Adult Protection. There are further training dates for the remaining staff planned in the near future. The home has an adequate Adult Protection policy in place to promote residents’ safety. Geel And Hitchen Court DS0000025103.V288587.R01.S.doc Version 5.1 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 Residents’ rooms are personalised to promote the feeling of belonging for residents’. EVIDENCE: Since the last inspection there has been an improvement to the homes standard of tidiness. All bathrooms are clear and hazard free. However, it was noted in many bedrooms there were a number of items stored on top of wardrobes this is a potential hazard that could lead to a person sustaining injury if the items were to fall. There are plans to improve the gardens, a volunteer group have agreed to undertake the work and plans have been drawn. Including a plan to include a sensory garden to promote stimulus to residents. The home has adequate specialist equipment such as hoists and a multisensory room. Residents are able to access their rooms as they choose. All residents’ rooms were noted to contain their personal effects and made to be homely to the individual. Geel And Hitchen Court DS0000025103.V288587.R01.S.doc Version 5.1 Page 15 However, it was identified that several chairs in the lounge area are in need of repair or replacement. There was no unpleasant odours noted at the time of the inspection. Geel And Hitchen Court DS0000025103.V288587.R01.S.doc Version 5.1 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 Staff training has developed; this assists in promoting resident safety and standards of care for residents’. EVIDENCE: The homes rotas were examined and found to be appropriately staffed. 50 of current care staff hold the NVQ2 in Care. It was noted that the home is needing to use a large number of agency staff to ensure safe numbers of staff are available. The home does use certain agency staff to assist with maintaining continuity of care. The home is actively recruiting staff and there are several staff waiting to commence employment on receipt of a cleared CRB. The home does not hold staff personnel files as they are maintained at head office. However, evidence was seen that all staff are CRB checked prior to employment. The training plan has been developed since the last inspection to ensure all staff are appropriately trained. Training received by staff since the last inspection include food hygiene, dementia, Basic Health and Safety and First Aid. Geel And Hitchen Court DS0000025103.V288587.R01.S.doc Version 5.1 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): 31, 32, 33, 34, 35, 36, 37, 38 The home needs to appoint a full time manager to ensure continuity and development of care for all residents’ within the home. EVIDENCE: There has been no application made to register a permanent manager, the Service Manager who visits the home two days per week and a manager from a local home within the company are currently supporting the home on a weekly basis. The need for a permanent manager is a priority to ensure the smooth and consistent running of the home. The home provides a more positive atmosphere since the last inspection, staff appear to be more settled and thus ensures residents are cared for effectively. The home operates adequate financial procedures that provide residents with a safe system that ensures their personal finances are protected. Geel And Hitchen Court DS0000025103.V288587.R01.S.doc Version 5.1 Page 18 All monies received into the home are recorded appropriately with receipts and records maintained to a good standard. Currently no staff members are receiving formal supervision. Plans are in place to implement supervision. All care staff must receive supervision on a 6 times a year basis to ensure the National Minimum Standards are adhered too. The home reviews its policies and procedures on a regular basis and as required. Certificates relating to Health and Safety were viewed and all found to be in date and accurate. The homes public liability Certificate is in date, and all certificates relating to registration where displayed accordingly. There has been a great improvement in fire safety within the home since the last inspection; staff are now receiving regular fire drills to promote safety of all persons in the home. Records as required by the Fire regulations are being maintained and this must continue to ensure safety of residents’. Geel And Hitchen Court DS0000025103.V288587.R01.S.doc Version 5.1 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 3 3 2 3 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 3 17 N/a 18 3 2 3 3 3 3 3 2 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 1 2 3 3 3 1 3 3 Geel And Hitchen Court DS0000025103.V288587.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? yes 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 OP3 Regulation 14(1)(a) Requirement Timescale for action 31/05/06 2. OP7 15(2)(a) The registered person shall not provide accommodation to a service user at the care home unless the needs of the service user have been assessed by a suitably qualified or suitably trained person. The preadmission assessment must contain detailed information of the potential clients needs. (previous timescale 28/02/06). The registered person shall make 30/06/06 the service users plan available to the service user. All care plans must be detailed to determine care required. Care plans must be written where a risk assessment has identified a high or very high risk factor. (Previous timescale 28/02/06) The registered person shall keep the service users care plans and risk assessments under monthly reviews to ensure safety is maintained. (Previous timescale 28/02/06) DS0000025103.V288587.R01.S.doc 3. OP7 15(2)(b) 30/06/06 Geel And Hitchen Court Version 5.1 Page 21 4. OP9 13(2) The registered person shall make 31/05/06 arrangement for the recording, safekeeping, safe administration and disposal of medication. All medication dispensed by staff must be signed to prove its been administered. The registered person shall ensure that the external grounds are appropriately maintained. (Previous timescale is 31/03/06) The registered person shall ensure that the equipment provided in the care home for use by service users is maintained in good working order; the lounge furniture needs repairing or replacing to ensure the home remains adequately furnished. The registered provider shall appoint an individual to manage the care home (Previous timescale 31/03/06) The registered person shall ensure that persons working at the care home are appropriately supervised. (Previous timescale 28/02/06) 31/08/06 5. OP19 23(2)(o) 6. OP25 23(2)(c) 20/07/06 7. OP31 8(1) 30/06/06 8. OP36 18(2) 30/06/06 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 OP15 Good Practice Recommendations It is strongly recommended that all kitchen staff receive training on special diets to ensure the well being of all residents. DS0000025103.V288587.R01.S.doc Version 5.1 Page 22 Geel And Hitchen Court 2. OP15 It is strongly recommended that a second meal option is made available and written so that service users are aware of the possible options Geel And Hitchen Court DS0000025103.V288587.R01.S.doc Version 5.1 Page 23 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. 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