CARE HOMES FOR OLDER PEOPLE
Good Companions 113 Roe Lane Southport Merseyside PR9 7PG Lead Inspector
Mrs Elaine White Unannounced Inspection 1st March 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 Good Companions DS0000005324.V285672.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. Good Companions DS0000005324.V285672.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Good Companions Address 113 Roe Lane Southport Merseyside PR9 7PG 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) 01704 220450 Mrs Jennifer Moffatt Mr David Michael Moffatt Mrs Jennifer Moffatt Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Good Companions DS0000005324.V285672.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Service users to include up to 23 OP One named service user, under pensionable age with a physical disability may be accommodated at the home for a period of 4 to 6 weeks. Once the named service user leaves the home; the variation will cease to apply. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 4th October 2005 3. Date of last inspection Brief Description of the Service: Good Companions is a Registered Care Home providing personal care and accommodation for up to 23 older people. At the time of the inspection there were 19 service users in residence. The home is owned and managed by Mr and Mrs Moffatt. The two deputy managers Ruth Watson and Mhairi Cairns are also actively involved with the day-to-day running of the home. The home is a large, converted Victorian property with an added extension to the rear and side of the building. The home is serviced by a passenger lift and access is available to all floors. All but one of the bedrooms has en-suite facilities. Communal facilities include two lounges, a large pleasant dining area and a hairdressing room. There are two bathrooms that provide assisted baths and one shower unit. There is a large well-maintained rear garden, which the home uses for garden parties and activities. The garden also provides a pleasant area for the service users to sit in the summer months. The front entrance provides an attractive approach to the home and parking for visitors. The home has a minibus, which is used frequently for day trips. Good Companions DS0000005324.V285672.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over one day. It was an unannounced visit and was carried out as part of the regulatory requirement for care homes to be inspected at least twice a year. There has been no cause to visit the home since the last inspection in October 2005. For this inspection a partial tour of the home was conducted and care records and other home records were viewed. Discussion took place with the deputy managers, care staff, relatives and residents. 9 of the 38 National Minimum Standards were assessed on this occasion. What the service does well:
Good Companions has a very pleasant relaxed atmosphere and residents and relatives interviewed commented that staff provide a good standard of care. Relatives and visitors are encouraged to visit when they like. Visiting relative said, “I looked at many homes and this was the best”. “You can write in your report that this is a good one”. Residents interviewed commented, “I am very happy here ”, “I feel very safe”. The home is clean, odour free and well maintained. A varied and wholesome menu is available to suit dietary needs and likes and dislikes. Residents provided positive comments on the food provided. “There is lots of choice. I am always asked what I want and can have cereal, toast or porridge for breakfast”. Residents’ needs are assessed to ensure the home can care for them. Following admission a plan of care is drawn up and this forms the basis for the plan of care. Care files are reviewed regularly to reflect changing need. An activity programme is in place and includes concerts, dominoes, bingo and entertainers. The home also has it’s own mini bus to provide trips out for residents to quiz nights and barge trips. Good Companions DS0000005324.V285672.R01.S.doc Version 5.1 Page 6 The home aims to meet the individual needs of each resident and has provided transport and support to enable residents to attend aromatherapy sessions and religious festivals of their choice. A training programme is in place, which extends to additional areas of training other than the statutory training required i.e. dementia and stroke care. Staff interviewed commented that they have a good training programme, are encouraged to develop their skills and qualifications and receive a lot of support from the management. A training room is provided for staff. Policies and procedures are reviewed annually to keep up to date with current legislation. 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. Good Companions DS0000005324.V285672.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 Good Companions DS0000005324.V285672.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): 3 Pre admission assessments carried out by the manager ensure that the home can meet the needs of the residents. EVIDENCE: Assessment documentation for four residents was viewed, which contained detailed information on general health areas, nutrition and background information. Observation, viewing of records and discussion with the management, staff, relatives and residents demonstrated the home was able to meet the needs of those accommodated. Comments received form residents included, “I love it here. The staff are brilliant”. “Always very caring”. Visiting relatives commented, “This is the best home we have looked at. There are no smells and it is very clean and homely”. Good Companions DS0000005324.V285672.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): 7,9. Residents health, personal and social care needs are addressed in care plans and care needs are met effectively. A good overall standard of care is in place. Medication administration records are recorded and policies and procedures in place. EVIDENCE: Discussion with residents, staff and viewing of records confirmed that care needs are being met. Care plans and records are kept up to date and reviewed regularly to reflect changing need. A ‘residents individual requirements’ record is maintained and regularly updated to reflect changing needs. Staff interviewed demonstrated a clear understanding of the care needs of the residents and felt that there is sufficient information in place to ensure they provide the correct care. Medication policies and procedures are in place and records kept of all administrations made. Residents spoken with were complimentary regarding the support and care provided. “They always ask me what I want”. “They are always very caring”.
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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): 14. The residents are helped to exercise choice and control over their lives. EVIDENCE: A varied menu is provided with alternatives, which enables the residents to have a choice in the food they eat. The cook spends time with the residents to discuss their ‘likes and dislikes’. Residents spoken with commented that they are able to have their meals in the lounge or within the privacy of their own rooms if they wish. Residents were observed to receive this service during the inspection. One resident said, “there is lots of choice of food and you can have cereal, toast or porridge for breakfast”. An activity programme is in place and the residents have the choice if they wish to take part or attend the trips out. A mini bus is available and residents attend quiz nights with other homes in the Southport area. One resident who had attended the recent quiz night said, “We had a lovely time”. Residents have access to attend services of their religious beliefs and the residents spoken with confirmed this. Relatives and friends are encouraged to call at any time and have a choice of where they meet with the residents i.e. two lounges, dining room or bedroom.
Good Companions DS0000005324.V285672.R01.S.doc Version 5.1 Page 12 Relatives spoken to were very satisfied with the care and support provided. “I am more than happy”. “It gives us peace of mind”. “The staff are lovely”. . Good Companions DS0000005324.V285672.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): 18. Residents are protected from abuse by the policies, procedures and staff training in place. EVIDENCE: Abuse policies and procedures in place are available for staff reference. Staff spoken to demonstrated their awareness of abuse and the action to take. Discussion with the deputy managers confirmed the abuse policy and procedure should be reviewed in line with the new guidance from Liverpool and Sefton. ‘Safeguarding adults’. Both deputy managers have demonstrated in recent incidents their commitment to safeguarding residents and ensuring that policies and procedures are followed. All staff are employed following a satisfactory POVA (Protection of Vulnerable Adults) check and two written references. Staff sign to confirm their understanding of all policies and procedures in place. Finance policies and procedures are in place and receipts and signatures obtained for all transactions made. A number of minor adjustments were recommended within the recording of residents’ personal finances. These were agreed with the deputy managers during the inspection. The home is not appointee for any residents monies. Residents and families are encouraged to control their own financial affairs were possible.
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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. The home offers very comfortable, ‘homely’ accommodation and all areas are well maintained. This contributes to a good quality of life for the residents. EVIDENCE: All communal areas and a number of private rooms were viewed. The home provides a pleasant, comfortable and homely setting for residents and is well maintained. The home is a large, three storey converted building. A passenger lift provides access to all three floors and the home is accessible via steps and a ramp. There are car-parking facilities at the front of the building and a large garden at the rear, which is used in the summer months. Two communal lounges provide areas for the residents to sit, meet their visitors, read, watch TV or take part in activities. All areas of the home were found to be clean and odour free. Residents commented on their satisfaction with the standard of the home. “I love it here and I am not moving from here”, “I feel safe here”. Visiting relatives said, “It is clean and homely with no smells”.
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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): 28,29. Qualified, trained staff care for residents. The correct recruitment and selection process is followed to protect residents. EVIDENCE: Staff are employed following the correct recruitment and selection procedures, which include a satisfactory POVA check and two written references. A training plan is in place and covers all statutory training required, i.e. manual handling and first aid. Additional training is also provided in areas relating to the care of the elderly i.e. stroke care, dementia. Staff are encouraged to obtain National Vocational Qualifications. Staff interviewed confirmed that the training is good and kept up to date. The home has a training room to conduct ‘in house’ training and they are hoping to become an NVQ accredited centre. Good Companions DS0000005324.V285672.R01.S.doc Version 5.1 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): 35. Residents’ finances are safeguarded by the home’s policies and procedures. EVIDENCE: The home has policies and procedures in place for handling residents’ finances. The home is not appointee for any resident. All financial transactions are recorded and receipts and signatures obtained. All finances are securely stored. A number of minor recommendations were discussed with the deputy managers during the inspection and action agreed. Good Companions DS0000005324.V285672.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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 X X X X X X X STAFFING Standard No Score 27 X 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X X Good Companions DS0000005324.V285672.R01.S.doc Version 5.1 Page 20 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. 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. Refer to Standard Good Practice Recommendations Good Companions DS0000005324.V285672.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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