Inspection on 25/07/05 for Greta Cottage

This inspection was carried out on 25th July 2005.

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 22/02/06

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 Lyn Burrell Unannounced 25 July 2005 10:00 am 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. Greta Cottage B51 B01 S87 Greta Cottage V240745 250705 Stage 4 .doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Greta Cottage Address Greta Street Saltburn-by-Sea TS12 1LS 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) 01287 622498 01287 626400 Greta Cottage Limited Mrs H Russi Care Home (CRH) 19 Category(ies) of Old Age (OP) registration, with number of places Greta Cottage B51 B01 S87 Greta Cottage V240745 250705 Stage 4 .doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 8 November 2004 Brief Description of the Service: Greta Cottage is converted Victorian House in a residential area of Saltburn. The home is registered to provide personal care for up to 19 older people over the age of 65 years. There are 15 single rooms and 2 double rooms one of which has en-suite facilities. Greta Cottage is managed by the provider supported by a team of staff. There are two lounges, one dining room and a conservatory for the residents to use. The garden area from the conservatory is not level and therefore not suitable for people with limited mobility. There is a stair lift to allow residents to access the first floor. Greta Cottage B51 B01 S87 Greta Cottage V240745 250705 Stage 4 .doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over four hours and 2 inspectors were present. It was difficult to access most of the information required for inspection. The Responsible Individual was unavailable for the inspection, however the comanager was present throughout. What the service does well: What has improved since the last inspection? What they could do better: • • • • • The newly installed laundry in the basement needs to be completed. Care records viewed at the time of the inspection were inadequate and do not reflect the care the resident requires. Policies looked at were out of date. Some maintenance records were not up to date. Fire precautions are inadequate. Greta Cottage B51 B01 S87 Greta Cottage V240745 250705 Stage 4 .doc Version 1.40 Page 6 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 B51 B01 S87 Greta Cottage V240745 250705 Stage 4 .doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Greta Cottage B51 B01 S87 Greta Cottage V240745 250705 Stage 4 .doc Version 1.40 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 standard(s) 2,3 Each service user has a statement of terms and conditions of residency in their care file. Each service user’s needs are assessed prior to their move to the home and periodically thereafter. This will help ensure that each service user’s needs are met at the home and inappropriate admissions avoided. EVIDENCE: The manager is currently changing the residents care records therefore some information was kept in an old file as it had not been transferred into the new format. It was not easy to access much of the information due to the comanager being unable to locate it in the absence of the manager. The care records that were viewed had the pre-admission information available; a care manager prior to admission completed this. The home manager also visited the residents at their home to gather medical and social information to ensure the home could meet the residents’ needs. Greta Cottage B51 B01 S87 Greta Cottage V240745 250705 Stage 4 .doc Version 1.40 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 standard(s) 7,8 The health and personal care needs recorded in the care plans do not fully reflect the residents’ current level of need. As such the resident’s welfare is not fully promoted and safeguarded. Residents’ care plans are not in place, and do not reflect their observed needs. This cannot offer the guidance for staff regarding care practices and consistency. EVIDENCE: There were no care plans in the four care records that were viewed. The records were incomplete and there was no other health care professional input seen. The Responsible Individual has advised me that the staff are currently learning the new care plan documentation. This will be completed in the near future. It was noted in one resident’s records that a carer had selected a dressing for a wound on a resident’s leg. This practise must cease and the carers must contact the GP or nurse for professional advice. Greta Cottage B51 B01 S87 Greta Cottage V240745 250705 Stage 4 .doc Version 1.40 Page 10 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) 15 Residents’ are offered and receive a varied, wholesome, nutritious and wellpresented menu. EVIDENCE: Each day the cook informs the residents’ what is available for the lunch the following day and alternatives are discussed at that time. The cook will then cook what the resident wants. There is no breakfast menu available however we were told that residents could have what they wanted. The residents said that they enjoyed the meals. The teatime menu is repetitive and offers sandwiches, pastries and cakes most days. However the choice is up to the residents and the cook discusses the teatime options with each resident on a daily basis. Meals are mainly eaten in the dining room and conservatory, which is pleasantly furnished, and the tables are set with the appropriate crockery and cutlery. Greta Cottage B51 B01 S87 Greta Cottage V240745 250705 Stage 4 .doc Version 1.40 Page 11 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) 16,18 A complaints procedure is available, but is not fully implemented. This can affect service users’, and their relatives, confidence in the process, and the ability of the management team to improve the service provided. Robust procedures are not in place; therefore the residents are not protected from abuse. EVIDENCE: The complaints policy was not up to date, however it was in compliance with the National Minimum Standards. A record of any complaints made to the home was not available. Only one member of staff had signed the policy to confirm they had read it. There was no policy or procedure available for the Protection of Vulnerable Adults. Staff have not received training in Adult Protection therefore the residents could be seen as at risk. Greta Cottage B51 B01 S87 Greta Cottage V240745 250705 Stage 4 .doc Version 1.40 Page 12 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, 26 The home is clean, well decorated and maintained. This can help promote a positive image for service users, and ensure they remain safe. Improvements have been to the building, which ensures that service users needs are met. However the laundry room needs to be fully decorated and refurbished, as it does not offer staff appropriate facilities in which to carry out their work. EVIDENCE: Whilst touring the building it was noted that the home was clean and tidy throughout. The hairdresser was using a residents’ bedroom as a salon, this is not acceptable and other measures must be sought. The laundry has recently been installed however the floor and walls need to be impermeable and readily cleanable. The pipe work needs boxing in and an obsolete boiler should be removed. A wash hand basin must also be in place to reduce the risk of cross infection. Greta Cottage B51 B01 S87 Greta Cottage V240745 250705 Stage 4 .doc Version 1.40 Page 13 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, 30 Staffing levels are sufficient to effectively meet the needs of service users living in the home. Staff have received training in relation to the care needs of service users, to ensure they have a good understanding of these needs and how they can be met. EVIDENCE: There are sufficient waking night staff on duty to provide adequate care to 19 residents. There is currently one active carer and one sleeping carer on duty. A domestic person is currently employed 20 hours per week. All staff receives 3 days paid training per year and have an individual training and development file. Training includes health and safety, fire safety, risk assessment and other mandatory training. Care practises and NVQ training is also obtained. Greta Cottage B51 B01 S87 Greta Cottage V240745 250705 Stage 4 .doc Version 1.40 Page 14 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) 31,38 There is no registered manager in post at this time. There are some areas of potential risk to resident’s safety that need to be addressed. EVIDENCE: The homeowner is currently being processed with the CSCI to be the registered manager. Fire precautions and risk assessments were not available in the home. Greta Cottage B51 B01 S87 Greta Cottage V240745 250705 Stage 4 .doc Version 1.40 Page 15 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 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 1 3 x x x x x x 2 Greta Cottage B51 B01 S87 Greta Cottage V240745 250705 Stage 4 .doc Version 1.40 Page 16 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. 2. 3. 4. 5. 6. 7. 8. 9. Standard 7 8 16 18 19 Regulation 13,15,17 12,13,15, 17,18 4,23 4,17,19,2 1 4,23 Requirement Each resident must have care records that will reflect their needs. Each resident must have a care plan that is clearly written and evaluated. A record of all complaints made to the home must be kept and available for inspection. All residents must be safeguarded and protected from abuse The laundry must meet the National Minimum Standards. Timescale for action 12 Oct 2005 12 Oct 2005 12 Oct 2005 12 Oct 2005 12 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. Greta Cottage B51 B01 S87 Greta Cottage V240745 250705 Stage 4 .doc Version 1.40 Page 17 Refer to Standard Good Practice Recommendations Commission for Social Care Inspection Unit B, 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 B51 B01 S87 Greta Cottage V240745 250705 Stage 4 .doc Version 1.40 Page 18 - 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. 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