Inspection on 22/02/06 for Greta Cottage

This inspection was carried out on 22nd February 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

Greta Cottage 25/11/08

Greta Cottage 30/11/07

Greta Cottage 29/08/06

Greta Cottage 25/07/05

Greta Cottage 08/11/04

Greta Cottage 27/08/04

Greta Cottage 06/01/04

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

CARE HOMES FOR OLDER PEOPLE Greta Cottage Greta Street Saltburn-by-Sea TS12 1LS Lead Inspector Katherine Acheson Unannounced Inspection 22nd February 2006 10:00 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 Greta Cottage DS0000000087.V272348.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. Greta Cottage DS0000000087.V272348.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Greta Cottage Address Greta Street Saltburn-by-Sea TS12 1LS 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) 01287 622498 01287 626400 Greta Cottage Limited Mrs Heather Yvonne Russi Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Greta Cottage DS0000000087.V272348.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th July 2005 Brief Description of the Service: Greta Cottage is a converted Victorian House in a residential area of Saltburn. The home is registered to provide personal care for up to 19 older people. There are fifteen single rooms and two double rooms one of which has en-suite facilities comprising of a toilet and hand washbasin. Bedrooms in the home environment meet with size requirements of National Minimum Standards. A stair lift enables residents to access the first floor. Greta Cottage is managed by the provider and supported by a team of staff. There are two lounges, one dining room and a conservatory. There is an enclosed garden area for resident use. Greta Cottage DS0000000087.V272348.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection started at 10:00am and lasted for six hours. Seven residents, two relatives, two staff and Management of the home were spoken to during the inspection. Numerous records including care plans, medication, personal allowance, and policies/procedures were examined. What the service does well: What has improved since the last inspection? What they could do better: Care plans would benefit from further development to ensure that each resident has a plan of care for each problem identified. The home’s medication policy and associated medication systems require further development. Any resident who is to self medicate must be provided with appropriate lockable storage. The home’s adult protection policy/procedure requires further development to bring in line with local adult protection procedures/protocols. Greta Cottage DS0000000087.V272348.R01.S.doc Version 5.1 Page 6 The Registered Person must continue with the refurbishment of the laundry to ensure that it meets with National Minimum Standards. Immediate action is required in respect of recruitment of staff. Staff must not be appointed until the home is in receipt of a satisfactory POVA/Criminal Record Bureau check. 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. Greta Cottage DS0000000087.V272348.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 Greta Cottage DS0000000087.V272348.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): The above standards were not inspected. EVIDENCE: Greta Cottage DS0000000087.V272348.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): 9, 10 Resident’s privacy and dignity are respected at all times. The home’s medication policy, recording of medication coming into the home and recording of controlled medication are not sufficiently robust to safeguard residents. EVIDENCE: Standard 7, Care Planning was not inspected in full, however, it was highlighted at the last inspection that care plans required further development and as such two plans of care were examined during this inspection. Plans of care examined were observed to be well presented, informative and individual to the resident. It is evident that the Manager and staff have worked extremely hard since last inspection to improve the standard of care planning in the home environment. Greta Cottage DS0000000087.V272348.R01.S.doc Version 5.1 Page 10 Although care plans examined were informative, resident’s problems and assistance required were grouped together in one individual plan of care. Care plans would benefit from further development to ensure that each resident has a plan of care for each individual problem that they have, this will ensure that staff are clear of the care/assistance required to manage the problem. A discussion took place with the management of the home in respect of this. Care plans examined had been evaluated on monthly basis, however evaluations examined did not give a baseline of capabilities or limitations of the resident nor did they include any deteriorations or progress made. Care plans examined were not signed by the resident or their representative to confirm that they had been involved in drawing up the plan of care. Seven residents and two relatives were spoken to during the inspection all of who spoke positively of life in the home. One resident said, “It’s very nice here, staff are very nice and helpful” another said, “Staff are very nice and kind, I couldn’t ask for better” another said, “Staff help us in anyway that they can, they are good to us they don’t make us feel a nuisance”. The home has a medication policy/procedure, however this is not sufficiently detailed, a discussion took place with the manager in respect of this. Records examined identified that the home have an appropriate system in place for the recording of medication returned to pharmacy at the end of each month, however the home are not keeping a record of any medication coming into the home. The Manager said that a number of staff have completed accredited medication training with a number of other care staff working towards achieving the qualification. Any staff who are to administer medication to residents must be appropriately trained in safe handling of medication prior to administering any medication to residents. The Manager said that those residents who are able are encouraged to self medicate; a risk assessment is carried out on the resident to determine ability and safety. One resident spoken to during the inspection said that she was supported by staff to self medicate, however did not have a lockable storage in which to keep the medication. The home’ s controlled medication record was not sufficiently detailed, a discussion took place with the Management of the home during the inspection who said that they would take immediate action to address the situation. Greta Cottage DS0000000087.V272348.R01.S.doc Version 5.1 Page 11 Following a discussion with the resident’s they all confirmed they were treated well and with dignity. Residents said that staff were polite and kind towards them and would assist them with anything they required them to do. Privacy was maintained and respected at all times. Greta Cottage DS0000000087.V272348.R01.S.doc Version 5.1 Page 12 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 Resident’s daily lives are enhanced by the social activities provided by the home and the welcome it extends to residents visitors. Residents are supported and encouraged to lead active lifestyles based on their preferences and choice. EVIDENCE: Residents said that activities, entertainment and outings are in plentiful supply and included bingo, quizzes, dominoes, exercises and trips out. Residents spoken to during the inspection said that they go to the local shops, town centre and in the summer listen to the band playing at Saltburn Spa. The home benefits from visits from the mobile library. One resident said, “I like joining in the morning exercises, they are really good and we all do them together” another said, “I like to listen to music”, another said, “Sometimes we play bingo, sometimes dominoes, but I also like to watch television”. One resident said that they regularly used Dial a Ride independently to go to arts and crafts club on a Monday and swimming on a Tuesday. Greta Cottage DS0000000087.V272348.R01.S.doc Version 5.1 Page 13 The Manager said that the home support residents to practice their religion and that visits from clergy are available to the home, residents spoken to confirmed that this was the case. Residents interviewed said that contact with family and friends is encouraged and that visiting is at any time. One relative spoken to during the inspection said, “We are made to feel welcome every time, staff make us a cup of tea. Staff are very nice they never change”. Residents interviewed spoke of flexibility in routine. One resident said, “I like it here I can do what I want whenever”. Management of the home said that residents are involved in the running of the home. Residents meetings are held on a regular basis enabling residents to voice their opinions. Greta Cottage DS0000000087.V272348.R01.S.doc Version 5.1 Page 14 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 The home has an effective complaints procedure, which enables residents to make any complaints they feel necessary. Procedures are in place to help protect residents from abuse, minor amendments are required to be made to the home’s adult protection policy/procedure to bring in line with local adult protection protocols/ procedures. EVIDENCE: The home has a clear complaints procedure. Residents spoken to during the inspection said that the Manager and staff at the home are approachable and if they felt the need to complain then they would do so. The home since last inspection have developed an adult protection policy/procedure that informs of action to take if abuse is suspected, a few minor amendments are required to be made to this policy to ensure that is in line with local adult protection protocols. Management of the home were informed of this during the inspection. Management of the home said that they had attended adult protection training and that they are now in the process of cascading the training to other staff working at the home. Residents spoken to during the inspection said that they felt safe. Greta Cottage DS0000000087.V272348.R01.S.doc Version 5.1 Page 15 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): Standard 19 was not inspected in full, however a requirement highlighted at the last inspection in respect of the laundry was re-visited. Management of the home advised that work is well underway to complete the laundry, however there are a few jobs remaining. EVIDENCE: Greta Cottage DS0000000087.V272348.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): 29 The home’s recruitment procedures are not robust and as such do not provide protection for residents living at the home. EVIDENCE: Staff files examined during this inspection were observed to contain a photograph of the staff member and two references, one being from the last employer. It was observed that the home’s reference request did not ask the referee to confirm dates of employment, which would enable the home to explore any gaps in employment. There was no proof of identity on file for the staff member. Following discussion with the Manager and examination of records it became evident that the home have recruited staff from July 2004 prior to the receipt of satisfactory POVA first/Criminal Record Bureau Check. Management of the home were informed that this was not acceptable practice and must take immediate action to address the situation. This will be followed up as a separate issue by the Commission for Social Care inspection. Greta Cottage DS0000000087.V272348.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, 33, 35, 38 The owner who is also the Manager offers clear leadership and direction to staff. Residents are well cared for and happy. The home ensures that the health and safety of residents is promoted and protected by operating a rolling programme of servicing of appliances and equipment. Fire practices, including evacuation of residents have not taken place and as such does not ensure that safety of residents is promoted and protected. Systems are in place to ensure resident’s money is managed appropriately. The results of the home’s quality assurance process do not justify the hard work of staff and the happiness of residents. Greta Cottage DS0000000087.V272348.R01.S.doc Version 5.1 Page 18 EVIDENCE: The owner/Manager of the home, Heather Russi has many years of experience of working with older people in a social care environment. Heather is in the process of working towards achieving her NVQ level 4 in Management and Care. There is also a Co-manager, Sue Tate who assists with the day-to-day running of the home. Sue also has many years of experience of working in a care home environment. Residents and relatives spoken to during the inspection spoke highly of the management, staff team and care that is provided. One resident said, “The staff are great we can have a laugh and a joke with them”. The home has a quality assurance system in place based on seeking the views of residents and their representatives. Completed questionnaires were available for inspection, however were not dated. The Manager advised that staff had assisted the residents to complete the questionnaires. Questionnaires examined did not contain all of the positive comments that the Inspector had heard from residents during the inspection process. It was felt that if residents and relatives completed the questionnaires themselves the quality assurance Process would have been much more informative and complimentary. Management of the home were informed that the results of the quality assurance survey should be published and made available to residents and their representatives. The home operates an effective system in which they look after the personal allowance of a number of residents. Accurate records of transactions and receipts were available for examination. The home operates a rolling programme of servicing appliances and equipment. Records examined at random confirmed that the homes hoists, fire extinguishers, fire alarm, gas boilers and emergency lighting are serviced on a regular basis. Records were available to confirm that the fire alarm system is tested on a regular basis. It was observed that fire drills in the home environment do not include evacuation of residents. This was pointed out to the Manager at the time of the inspection to take action to address this. The Manager said that she would speak to the local Fire Safety Officer to seek guidance in respect of this. The manager said that the home operate a rolling programme of mandatory training for staff. Greta Cottage DS0000000087.V272348.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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X X STAFFING Standard No Score 27 X 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Greta Cottage DS0000000087.V272348.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 OP19 Regulation 4,23 Requirement The laundry must meet with National Minimum Standards. (Previous timescale for action of 12/10/05 not met) • Care plans must be developed further to ensure that each resident has a care plan for each individual problem • Evaluations of resident’s plans of care must include a base line of capabilities, limitations and assistance required. Evaluations must include deterioration or improvements made • Care plans must be drawn up with the resident or their representative. Care plans must be signed by the resident or their representative wherever possible • The home must develop a system in which to record medication coming into the home • The home’s medication policy requires further development DS0000000087.V272348.R01.S.doc Timescale for action 30/04/06 2 OP7 15 30/05/06 3 OP9 13 31/05/06 Greta Cottage Version 5.1 Page 21 4 OP9 13 5 OP9 13 6 7 OP18 OP29 13 13, 17 8 OP29 13, 17 All staff must be appropriately trained in Safe Handling of Medication prior to administering medication to residents • Residents who self medicate must be provided with lockable storage The Registered Person must ensure that the home has a controlled medication register that includes all of the required information The home’s adult protection policy/procedure requires further development The Registered Person must ensure that the home are in receipt of a satisfactory POVA first/Criminal Record Bureau Check prior to the commencement of employment • The home’s reference request must be updated to confirm dates of employment • Staff files must be updated to contain proof of identity The homes quality assurance system must be developed further • The results of the yearly quality assurance survey must be published and made available to residents. The Manager must consult with the homes Fire Safety Officer, following this carry out, as agreed with the Fire officer a fire practice that includes an evacuation of residents • • 22/02/06 30/03/06 30/03/06 22/02/06 30/03/06 9 OP33 24 30/06/06 10 OP38 23 22/02/06 Greta Cottage DS0000000087.V272348.R01.S.doc Version 5.1 Page 22 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 OP31 Good Practice Recommendations The Manager should continue working towards achieving her NVQ level 4 in Management and Care Greta Cottage DS0000000087.V272348.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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 Greta Cottage DS0000000087.V272348.R01.S.doc Version 5.1 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!