Inspection on 08/02/06 for Housman Court

This inspection was carried out on 8th 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

Housman Court 01/09/09

Housman Court 08/08/07

Housman Court 11/08/06

Housman Court 09/08/05

Housman Court 11/01/05

Housman Court 28/06/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Housman Court School Drive Bromsgrove Worcestershire B60 1AZ Lead Inspector Andrew Spearing-Brown Unannounced Inspection 8th February 2006 11:50 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 Housman Court DS0000018484.V282189.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. Housman Court DS0000018484.V282189.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Housman Court Address School Drive Bromsgrove Worcestershire B60 1AZ 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) 01527 575440 01527 577439 Somerset Redstone Trust Caroline Ann Onley Care Home 30 Category(ies) of Dementia - over 65 years of age (14), Old age, registration, with number not falling within any other category (30), of places Physical disability over 65 years of age (30) Housman Court DS0000018484.V282189.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home to accommodate one named person under 65. Date of last inspection 9th August 2005 Brief Description of the Service: Housman Court is an established care home for older people, purpose built in 1988. It is situated in the centre of Bromsgrove within easy reach of shops, post office, library and swimming pool. Housman Court provides accommodation and care for up to thirty older people some of whom may have a physical disability or dementia type illness. The home is in the centre of a sheltered housing complex with landscaped gardens. Somerset Redstone Trust runs both Housman Court and the sheltered housing complex of five separate units. Caroline Onley is the registered manager of the home. Maureen Price, director of operations, carries out the monthly visits on behalf of the Trust. Housman Court DS0000018484.V282189.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over a period of one day lasting a total of 3 hours. The last inspection at Housman Court, which was also unannounced, took place during August 2005 making this inspection the second statutory visit during the 2005 – 2006 inspection year. At the time of this inspection Housman Court had no vacancies Part of this inspection was to assess the progress made in relation to the requirements from previous inspection. In addition some of the key standards were inspected. A number of standards have not been inspected during the current inspection year but will be as part of future inspections. Discussion with residents was very limited on this occasion. A greater emphasis on residents’ comments will therefore take place as part of future inspections. Some parts of the home were seen. These areas included communal areas as well as a small representative number of bedrooms. The care records regarding a sample number of residents were viewed. Other documents seen during the inspection included medication records, staff rotas and staffing information including training records. What the service does well: What has improved since the last inspection? Although some improvements were noted regarding care plans and medication since the last inspection further improvement is necessary. The new registered manager demonstrated a commitment to improve the range of activities available to residents. Housman Court DS0000018484.V282189.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Housman Court DS0000018484.V282189.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 Housman Court DS0000018484.V282189.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): None of the standards in this section were assessed in any great detail as part of this inspection. As a result these standards will be assessed as part of a forthcoming inspection at Housman Court. EVIDENCE: As previously noted a range of information about the home and services offered was on display in the reception area for prospective residents and or their relatives. None of this information was read during this inspection. Residents and or their representatives are able to visit the home prior to admission. A trail period takes place before residents become long term. Housman Court DS0000018484.V282189.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): Standards 7, 8 and 9 Some progress has been made on improving care plans; further improvement is necessary to ensure that they are suitably detailed to ensure safe working practices and safeguard residents. In addition progress has been made regarding to the administering and recording of medication however shortfalls remain which could leave residents at risk. EVIDENCE: A small random sample of care plans were viewed. One was in relation to a recently admitted resident. A number of shortfalls were identified whereby gaps in the information available to carers were evident. It was noted that care needs recorded upon the daily notes did not always have a suitable care plan. Risk assessments did not exist or where incomplete in matters such as nutrition and falls. A care plan of another resident was clear however it was not reviewed or up dated during December 2005. Housman Court DS0000018484.V282189.R01.S.doc Version 5.1 Page 10 As part of the inspection the management, administration and recording of medication was assessed. The Medication Administration Record (MAR) sheets in use had only just commenced and therefore only contained staff signatures for the last couple of days. Despite the short period of time these sheets were operating a number of shortfalls were identified. A small number of gaps were in evidence on the MAR sheets whereby no signature or code was entered. The vast majority of these gaps were in relation to items such as eye drops and inhalers. The use of coding on the MAR sheets was drawn to the attention of the manager as anomalies or errors were noted. On one occasion a signature was in place and then over scored by the code ‘F’ with an explanation that the drug could not be found. As the MAR sheet should be signed following administration this evidenced that policies and procedures are not always followed. As previously identified handwritten amendments to MAR sheets did not have two signatures as required. Some medication was not receipted into the home as required. Furthermore when medication was prescribed on a variable dose it was not always evident what dosage was administered. It was noted that the date of opening is recorded on boxed medication; this assists in carrying out a full audit of medication. A returns book was available and appeared to be in order although no audit was carried out against these records. Standards around the up holding of privacy and dignity were not assessed during this inspection however it was noted that staff were affording residents appropriate respect. The registered manager has recently introduced a keyworker system. Housman Court DS0000018484.V282189.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12 and 13 Activities within the home need improving to provide stimulation and interest for people living in the home. Contact with family members is open and well maintained. EVIDENCE: Although activities are in place at Housman Court recent consultations has shown that improvement in the activities on offer are requested. The registered manager is currently exploring how these can be implemented. Due to the undertaking given to improve this standard it was not assessed in any detail upon this occasion. It is however proposed that a social care plan is located within each resident’s bedroom with the intention that carers, residents and their representatives collectively compile these records as well as complete a communication page. In addition it is proposed to have a calendar available for each resident so that carers can marked down events in the home while residents and carers can highlight other events such as family birthdays and anniversaries. A greater empathise will be placed on this standards during a forthcoming inspection. Lunch was being served during this inspection. A choice of two main meals was available to residents with a choice of four alternatives for the sweet. Housman Court DS0000018484.V282189.R01.S.doc Version 5.1 Page 12 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): Standard 16 Complaints are listened to and taken seriously. EVIDENCE: The registered manager maintains good records of any concerns raised and how they were resolved in any attempt to prevent more formal or serious complaints occurring. A recent questionnaire to relatives showed that many individuals were not aware of the homes complaints procedure. A recent relatives meeting clarified the procedure. Housman Court DS0000018484.V282189.R01.S.doc Version 5.1 Page 13 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): Standards 19 and 26 The home overall is comfortable, clean and hygienic however carpeting and décor in some areas need renewing to further improve appearance and homeliness. EVIDENCE: Communal facilities seen were spacious, varied, comfortable and attractive. The carpet in the lounge remains stained as noted within the previous report. Despite the registered manager making attempts to clean carpets those along corridors are marked and stained in places; this is particular so along the top floor. The walls along each of the upstairs corridors need decorating as the wall covering was recently removed. The corridors look ‘tired and fatigued’ due to the appearance of the walls, bedroom doors and ceiling lights The home was clean and there were no malodours in the communal areas or any bedrooms seen. Only a small representative sample of bedrooms were viewed as part of this visit however all those seen were personalised and Housman Court DS0000018484.V282189.R01.S.doc Version 5.1 Page 14 provided the appropriative furnishings. It was noted that freestanding wardrobes were not secured to the wall. Originally the top floor was used as staff living in accommodation although now registered to accommodate residents this floor is not ideal in that the corridor is narrow. A number of bedrooms seen on the top floor have restricted headroom in places and therefore require specific risk assessments to be in place. None of these risk assessments were sought during this visit. The majority of communal bathing and toilet facilities within the home possessed liquid soap and paper towels in line with infection control policies provided by Herefordshire and Worcestershire Health Authority. Disposable gloves were plentiful throughout the home in areas where staff may need access to such items. Housman Court DS0000018484.V282189.R01.S.doc Version 5.1 Page 15 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): Standards 27, 28, 29 and 30 Procedures for the recruitment of staff are not sufficiently robust to ensure the protection of residents however the number of staff available is sufficient to meet the needs of residents. Records failed to demonstrate that staff are suitably up to date with mandatory training. EVIDENCE: Staff rotas are on display. Due to a misunderstanding in interpreting some of the colour coding the home was operating with one less carer on duty at the time of this inspection from the normal ratio. During the morning shift the home usually has a care supervisor and three carers on duty, in addition another member of staff is employed during the busiest period of time. The afternoon has one less carer on duty although an addition person working over the peak period of time operates. Additional staff are employed in ancillary roles such as housekeeping, cook and kitchen assistant. The documentation of a newly appointed member of staff was viewed. The required Criminal Records Bureau disclosure was obtained prior to the individual commencing employment as required. The application form was viewed which gave details of two persons to be contacted in order to obtain written references. An alternative name was given in place of one of these references. It was however of concern to note that only one reference was on file. Housman Court DS0000018484.V282189.R01.S.doc Version 5.1 Page 16 Training records were available including staff individual records and a matrix showing staff against specific training. These records were not totally up to date. Records suggested that one person only received three hours of training during 2005. The registered manager is aware of the shortfalls as well as gaps in the training undertaken by some staff. In order to develop an action plan the registered manager has started work on assessing training needs for the current year. In addition to mandatory training shortfalls more specialist training in areas such as dementia care must be provided. The actual percentage of staff qualified to level 2 NVQ (National Vocational Qualification) was not collected however it was believed to be over the required 50 of carers. Housman Court DS0000018484.V282189.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): Standards 31, 33, 36, 37 and 38 Quality assurance and monitoring systems assist in provided a service which safeguards residents interests however shortfalls in staff supervision and some health and safety matters could place residents at potential risk. EVIDENCE: The newly registered manager has extensive experience of working with older people and holds both the Registered Managers Award and a NVQ level 4. During the recent managers fit person interview at the local office of the CSCI it was apparent that up date training in some areas was necessary; some of this has now taken place. As indicated elsewhere within this report a recent questionnaire was sent out to residents’ relatives. In addition staff comments are also sought into how the quality of service provision can be improved. The owners representative Housman Court DS0000018484.V282189.R01.S.doc Version 5.1 Page 18 visits the home on at least a monthly basis and completes a report as required under regulation 26 of the Care Homes Regulations. A copy of this report is forwarded to the local office of the CSCI. The registered manager has commenced a staff supervision timetable in order to see all carers in the near future. Despite these efforts the number of supervision sessions undertaken by each carer over a twelve-month period will not be achieved. The majority of health and safety records were not viewed on this occasion. However the fire log was seen and found to be generally in good order with the weekly fire test taking place in sequential order. The registered manger needs to ensure that alternative persons have the necessary skills to test the alarm and carry out other tests in the event of the handyperson being away from the home. Although records indicated that fire extinguishers were serviced as required one carbon dioxide did not have an up to date label upon it. The registered manager needs to ensure that this piece of equipment was suitably tested and that it is fit for purpose. Accident records were in good order with a regular audit of accidents taking place. Currently a number of problems exist with dead ends in the water system. These shortfalls are to be addressed as a means to reduce the risk of legionella. Housman Court DS0000018484.V282189.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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 2 2 2 Housman Court DS0000018484.V282189.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 OP7 Regulation 15 (1) (2) Requirement The registered manager must ensure that care plans are reviewed at least monthly to take into account changing care needs and significant events. (Previous timescale of 31/08/05 not met. New timescale given) 2. OP8 17 (1) sch. 3 (o) The registered manager must ensure that residents care plans contain information regarding all identified care needs such as nutritional care needs. (Previous timescale of 31/08/05 part met. New timescale given) 3. OP8 12 (1) The registered manager must ensure that appropriate and suitable risk assessments are carried out and regularly reviewed. 08/02/06 08/02/06 Timescale for action 28/02/06 Housman Court DS0000018484.V282189.R01.S.doc Version 5.1 Page 21 4. OP9 13 (2) Handwritten MAR charts must be checked and signed by two members of staff. (Previous time scale of immediate and on going following the inspection on 09/08/05 not met. This requirement must be met without delay) 08/02/06 5. OP9 13 (2) The registered manager must ensure that all MAR (Medication Administration Record) sheets must possess a signature each time prescribed medication is administered. When medication is not administered, the responsible staff member must enter a recognised code defining the reason(s) for non – administration. The registered manager must ensure when a variable dosages is prescribed the actual dose given is recorded. The registered manager must ensure that all medication is receipted into the care home. The registered manager must ensure that suitable and varied activities are available to meet the needs, expectations and capacities of residents. 08/02/06 6. OP9 13 (2) 08/02/06 7. OP9 13 (2) 08/02/06 8. OP12 16 (2) 31/03/06 9. OP19 23 (2) (b) The registered provider must 31/05/06 ensure that all areas of the home are in good order and well maintained. Housman Court DS0000018484.V282189.R01.S.doc Version 5.1 Page 22 10. OP19 13 (4) The registered manager must 28/02/06 ensure that freestanding wardrobes are safe and not likely to fall over. The registered manager must ensure that references are obtained from the most recent employer and from suitably relevant persons. (Previous time scale of immediate and on going following the inspection on 09/08/05 not met. This requirement must be met without delay) 08/02/06 11. OP29 19 (1) 12. OP30 18 (1) (c) The registered manager must ensure that training records are up to date. All members of staff must receive formal supervision that includes all aspects of practice, philosophy of care in the home and career development needs at least 6 times a year. The registered manager must ensure that all records are accurate and up dated. (Previous timescale of 31/08/05 not met. New timescale given) 31/03/06 13. OP36 18 31/03/06 14. OP37 17 (1) 17 (2) 31/03/06 15. OP38 23 (4) (c) The registered manager must ensure that all fire extinguishers are serviced. The registered manager must ensure that suitable persons are available to ensure the weekly and month fire safety checks can be carried out. 08/02/06 16. OP38 23 (4) (c) 08/02/06 Housman Court DS0000018484.V282189.R01.S.doc Version 5.1 Page 23 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 Housman Court DS0000018484.V282189.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Housman Court DS0000018484.V282189.R01.S.doc Version 5.1 Page 25 - 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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