Inspection on 04/10/05 for Good Companions

This inspection was carried out on 4th October 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Good Companions 01/10/08

Good Companions 30/10/06

Good Companions 01/03/06

Good Companions 09/12/04

Good Companions 23/06/04

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

CARE HOMES FOR OLDER PEOPLE Good Companions 113 Roe Lane Southport Merseyside PR9 7PG Lead Inspector Elaine White Unannounced 4 October 2005 th 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. 20051004 Good Companions X10015 UN Stage 4 S5324 V231700 F53.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Good Compaions Address 113 Roe Lane Southport Merseyside PR9 7PG 01704 220450 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) Mrs Jenifer Moffatt Mrs Jenifer Moffatt Care Home 23 Category(ies) of (OP) Old age registration, with number of places 20051004 Good Companions X10015 UN Stage 4 S5324 V231700 F53.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 23 OP 2.The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection Service users to include up to 23 (OP) Old age. Date of last inspection 9th Dec 2004 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 17 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 1 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. 20051004 Good Companions X10015 UN Stage 4 S5324 V231700 F53.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one day, a total of 5 hours. 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 December 2004. 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 owners, managers, care staff and residents. What the service does well: Good Companions has a very pleasant relaxed atmosphere and residents interviewed commented that staff provide a good standard of care. Relatives and visitors are encouraged to visit when they like. Residents interviewed commented, “The staff are all very good”, “I only came here for two weeks and I want to stay”. The home is clean, odour free and well maintained. A varied and wholesome menu is available to suit dietary needs and likes and dislikes. The cook regularly speaks to the residents individually to obtain their views on the food provided. Residents’ needs are assessed to ensure the home can care for them. The manager commented, “I won’t take residents who’s needs I cannot meet”. Following admission a plan of care is drawn up and this records key areas including general welfare and social care. The documentation is subject to regular review thus ensuring records are up to date. Care files evidenced hospital appointment and medical referrals at the appropriate time. An activity programme is in place and includes, boat trips, dominoes and entertainers. The home also has it’s own mini bus for transporting residents. One resident said, “We recently went to Blackpool and I enjoyed it very much”. 20051004 Good Companions X10015 UN Stage 4 S5324 V231700 F53.doc Version 1.30 Page 6 The home provides an ongoing training programme. Many courses are run ‘in house’ in their own training room. Both the deputy managers are qualified trainers. What has improved since the last inspection? What they could do better: Low temperature radiators are in place in some areas. Those without should be replaced or a risk assessment in place to eliminate risk to the residents. The manager is to confirm that a Legionella risk assessment has been completed. The medication policies and procedures are in place, however it was noted that a new medication sheet is required for 1 resident. Medication sheets must be in place for prescribed medication, kept up to date and signatures in place for all administrations made. Any written changes must be countersigned pending a new MAR sheet being produced. The home must provide more robust recruitment and selection procedures and ensure that 2 written references are obtained prior to employment. A statement of purpose is in place and this needs to be displayed in the home, along with the last inspection report, for access by prospective service users, residents and visitors. 20051004 Good Companions X10015 UN Stage 4 S5324 V231700 F53.doc Version 1.30 Page 7 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. 20051004 Good Companions X10015 UN Stage 4 S5324 V231700 F53.doc Version 1.30 Page 8 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 20051004 Good Companions X10015 UN Stage 4 S5324 V231700 F53.doc Version 1.30 Page 9 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) 1,3,6. Information is in place but is not on display for prospective service users, residents and visitors to access. Pre admission assessments carried out by the manager are detailed and help ensure that the home can meet the needs of the residents. EVIDENCE: 20051004 Good Companions X10015 UN Stage 4 S5324 V231700 F53.doc Version 1.30 Page 10 All residents have an individual care file. Assessment documentation for 4 residents was seen and this had been completed in good detail. Information recorded included general health areas, nutrition and relevant background information. The manager expressed that she “won’t take residents who’s needs we cannot meet”. Observation, viewing of records and discussion with the management, staff and residents demonstrated the home was able to meet the needs of those accommodated. Comments received form residents included, “The staff are all very good”, “You couldn’t find a better home”. 20051004 Good Companions X10015 UN Stage 4 S5324 V231700 F53.doc Version 1.30 Page 11 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) 7,8,9,10. 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 generally well recorded. Staff were observed providing care and assistance to residents in a polite and sensitive manner. EVIDENCE: Discussion with residents and staff confirmed that care needs are being met. Care plans and records are kept up to date and reviewed regularly to reflect changing need. The inspector recommends that the care plan format be reviewed to demonstrate assessed need/action required to meet the needs/desired outcome. Medication policies and procedures are in place, however the medication records for one resident was not up to date and recorded in the correct format. Discussion with the manager confirmed that this will be brought up to date immediately and corrected. This is highlighted in the recommendations of this report. 20051004 Good Companions X10015 UN Stage 4 S5324 V231700 F53.doc Version 1.30 Page 12 Access is available to other health care services when required. One resident received a visit from her district nurse during the inspection to provide nursing care. Residents spoken with were complimentary regarding the supportive and caring approach by staff. One resident interviewed commented, “They help me to get dressed. They do not rush me and are very gentle”. 20051004 Good Companions X10015 UN Stage 4 S5324 V231700 F53.doc Version 1.30 Page 13 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. The atmosphere in the home was pleasant. Social activities are in place and visitors are made welcome. The home offers a well-balanced choice of nutritious meals. EVIDENCE: Residents interviewed said they enjoyed living at Good Companions. Comments included, “I am very comfortable”, “I like my room very much”, “I decide whether I want to go to the lounge or stay in my room, the staff do not mind” and “Whatever I want they get”. Activities are arranged ‘in house’ and residents also recently enjoyed an excursion to Blackpool in the mini-bus. Fund raising events and musical entertainment are also arranged. One resident attends a local organised club each week. “This enables me to mix with others”. While another resident said, “I like to sit in my own room and listen to music”. The staff were observed playing dominoes in the lounge with a couple of the residents. Visitors are made welcome and were seen popping in at different times and meeting with residents in the lounge or in their bedroom. 20051004 Good Companions X10015 UN Stage 4 S5324 V231700 F53.doc Version 1.30 Page 14 Discussion with a number of residents confirmed that the food was good, always served hot and on time. One resident commented,” The food is very good and if I don’t like it they will get me something else”. The cook has a certificate in Intermediate Food Hygiene and caters for special diets where appropriate. The cook conducts regular surveys with the residents to obtain comments on the food. Satisfactory records were seen for environmental checks for food, fridge and freezer temperatures and the home had a good supply of fresh produce. Staff were observed helping residents with their meal in a sensitive a manner. One resident said, “I have breakfast in my room”, whilst another resident commented that “I would like to have my lunch in my room more often”. The care needs of this resident were discussed with the manager during the inspection. 20051004 Good Companions X10015 UN Stage 4 S5324 V231700 F53.doc Version 1.30 Page 15 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. The home has a complaint procedure and residents were confident that their concerns would be listened to and acted upon. EVIDENCE: Good Companions had a complaints policy and procedure in place, which contained an assurance that complaints would be responded to within 10 working days. Records showed that the home had received no formal complaints since the last inspection. Residents spoken to confirmed that should they have a complaint they would inform the manager and are confident their complaint would be listened to. 20051004 Good Companions X10015 UN Stage 4 S5324 V231700 F53.doc Version 1.30 Page 16 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) 19,20,23,24,25,26. 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: 20051004 Good Companions X10015 UN Stage 4 S5324 V231700 F53.doc Version 1.30 Page 17 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 am very happy with my room”, “I am very comfortable and have everything I need”. Low temperature radiators are in place in some areas. A risk assessment should be completed to eliminate risks to the residents in areas where there are no radiator covers. 20051004 Good Companions X10015 UN Stage 4 S5324 V231700 F53.doc Version 1.30 Page 18 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) 27,29,30. Sufficient numbers of staff were on duty to care for the residents however procedures for the recruitment of staff need to be more robust. Staff receive the necessary training to ensure competency in their role. EVIDENCE: The managers live on the premises and are available at all times when resident. 3 care staff, (including a senior), cook, domestic and the 2 managers were on duty at the time of the inspection. Residents were pleased with staffing arrangements and felt there are enough staff about to help them. “The staff are all very good”. 20051004 Good Companions X10015 UN Stage 4 S5324 V231700 F53.doc Version 1.30 Page 19 2 staff files were viewed and contained application forms, criminal record checks and health declarations. The home must ensure that 2 written references are obtained prior to employment. This was brought to the manager’s attention during the inspection. A training plan and induction programme is in place. The deputy managers are qualified trainers and conduct some training on the premises. Certificates are on display in the home. A number of staff interviewed provided positive comments on the training and supervision provided. “I love it here. I get on well with the staff and the residents are wonderful. I have done all the training and get lots of support”. 20051004 Good Companions X10015 UN Stage 4 S5324 V231700 F53.doc Version 1.30 Page 20 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) 33,38. An external consultant to ensure that the home is run in the best interests of residents conducts annual monitoring reports. General safety certificates for equipment and services to the home including the fire log book were in date. This promotes the health and safety of the residents. EVIDENCE: An external consultant completes an annual written report following a visit to the home to inspect the building and meet with residents, relatives and staff. An up to date record was seen for the safety checks of the gas, electric, lift, manual handling equipment and fire prevention equipment. The manager is to confirm legionella compliance has been met. The fire alarms are tested weekly 20051004 Good Companions X10015 UN Stage 4 S5324 V231700 F53.doc Version 1.30 Page 21 ‘in house’ by the staff. A training programme is in place to ensure the staff are equipped to carry out their roles. 20051004 Good Companions X10015 UN Stage 4 S5324 V231700 F53.doc Version 1.30 Page 22 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 x 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 x x 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x 3 x x x x 3 20051004 Good Companions X10015 UN Stage 4 S5324 V231700 F53.doc Version 1.30 Page 23 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 OP29 Regulation 19 Requirement The registered person must ensure that 2 written references are obtained prior to employment. Timescale for action 31st Oct 2005. 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. Refer to Standard OP9 OP7 OP25 OP38 OP1 Good Practice Recommendations Medication should be clearly recorded for all residents. A second member of staff should witness all hand written annotations on Medication Administration Record charts. The care plan format could be reveiwed to demonstrate assessed need/action required to meet that need/desired outcome. Radiator covers to be fitted or a risk assessment in place to eliminate risk to residents. The registered manager to confirm legionella compliance. Information and the last inspection report should be made available to residents, prospective residents and visitors. 20051004 Good Companions X10015 UN Stage 4 S5324 V231700 F53.doc Version 1.30 Page 24 Commission for Social Care Inspection Burlington House, South Wing 2nd Floor, Crosby Road North Waterloo Liverpool L22 OLG 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 20051004 Good Companions X10015 UN Stage 4 S5324 V231700 F53.doc Version 1.30 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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