Inspection on 09/08/05 for Housman Court

This inspection was carried out on 9th August 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

Housman Court 01/09/09

Housman Court 08/08/07

Housman Court 11/08/06

Housman Court 08/02/06

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 9 August 2005 12:55 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. HOUSMAN COURT E52 S18484 Housman Court V243708 090805.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Housman Court Address School Drive Bromsgrove Wordestershire B60 1AZ 01527 575440 01527 577439 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) Somerset Redstone Trust Angela Mary Till Care Home 30 Category(ies) of DE(E) Dementia (over 65) - 14 registration, with number OP Old Age - 30 of places PD(E) Physical Disability (over 65) - 30 HOUSMAN COURT E52 S18484 Housman Court V243708 090805.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home to accommodate a named female of 64. Date of last inspection 11 January 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. Housman Court and the sheltered housing complex of five separate units are both run by Somerset Redstone Trust. The home is managed by Angela Till. The monthly visits on behalf of the Trust are carried out by Maureen Price, director of operations. HOUSMAN COURT E52 S18484 Housman Court V243708 090805.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and undertaken by an inspector from the Worcester office of the Commission for Social Care Inspection (CSCI). The visit lasted just under 3 ½ hours. The last inspection took place during January 2005. Following the previous inspection a small number of requirements were made. Part of this inspection was to assess the progress made in relation to these requirements. On the day of this inspection the registered manager was on duty as well as a shift leader and a number of carers and auxiliary members of staff. The manager, the shift leader and a small number of residents were consulted as part of this inspection. Many areas of the home were seen including some bedrooms and all communal rooms. The care records of a small sample of residents were seen. Other documents seen included medication records, fire records, some staff files and service records. What the service does well: The home was clean, tidy and comfortably furnished. All bedrooms seen were personalised by the resident residing within that room. The grounds were well maintained, and tidy. Residents consulted spoke favourably about both the care provided and staff employed. Confidence in the manager was also expressed. Potential residents are able to visit the home prior to admission. Routines in the home were relaxed and there are a variety of activities to choose from, including outings and cookery. Information including a suitable and clear complaints procedure was on display within the entrance hall of the home. HOUSMAN COURT E52 S18484 Housman Court V243708 090805.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. HOUSMAN COURT E52 S18484 Housman Court V243708 090805.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 HOUSMAN COURT E52 S18484 Housman Court V243708 090805.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) 3 and 5. Standard 6 is not applicable to Housman Court Potential residents are able to visit the home and have their care needs assessed prior to their admission to ensure that individual needs can be appropriately met. EVIDENCE: A range of information about the home and services offered was on display in the reception area for prospective residents and or their relatives. The file of a recently admitted resident evidenced that an assessment is carried out prior to individuals moving into the home. Potential residents are furthermore able to visit the home prior to admission, which is initially on a trail basis. HOUSMAN COURT E52 S18484 Housman Court V243708 090805.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, 9 and 10 Some improvement is needed with regard to the administering and recording of medication, however significant improvement is necessary to improve the up dating of care plans and risk assessments to fully safeguard residents as they currently fail to do this. EVIDENCE: Individual plans of care are available; a small representative sample was viewed as part of this inspection. The care plans seen were not reviewed as required on at least a monthly basis or to reflect the changing care needs of an individual. The care plan of one resident highlighted nutritional intake as an identified care, a care plan was started in May 2005 but had not details upon it whatsoever. Other documents such as risk assessments were incomplete or out of date. From the information upon care plans it would not be possible to fulfil the current care needs of residents and therefore placing an over reliance on staff knowledge and memory. HOUSMAN COURT E52 S18484 Housman Court V243708 090805.doc Version 1.40 Page 10 The home uses the Monitored Dosage Systems (MDS) supplied by a high street pharmacist. Staff who administer medication have received training from a different major high street pharmacy as well as the current supplier. All medication was held securely. The Medication Administration Record (MAR) sheets indicated that some residents administer some or all of their own medication. The MAR sheets examined had the time and dose marked by a highlighting pen to assist staff administer correctly, only one gap was noted upon the sheets viewed. It was however noted that one resident had run out of his medication over the previous weekend. The section on the MAR sheets for record allergies was blank, if no allergies are known the sheets must stipulate this fact. The opening dates on inhalers had not been recorded as required. Controlled medication was fully in order and well maintained. It was noted that attention was given to ensuring that any risk of residents becoming dehydrated or over hot during a period of warm weather was minimised. Fans were in operation around the home including communal sitting areas and corridors furthermore jugs of water were available as well as taken to individuals’ bedrooms. A visiting professional was noted to be carrying out some treatment in the lounge; although this could be the wish of persons not wanting to move from the lounge it could be off putting to other residents within the home. This matters therefore needs to be satisfactorily resolved for all concerned. HOUSMAN COURT E52 S18484 Housman Court V243708 090805.doc Version 1.40 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 standard(s) 12 Social activities are organised, creative and provide some areas of stimulation and interest for residents EVIDENCE: One of the lead carers is also contracted to provide 15 hours per week leading and organising a range of activities. A calendar of events on display was out of date in that it was for the month of July. Another notice displayed was also dated incorrectly however it formed a general rolling programme for activities. Activities include bingo, quizzes, visits to a pub, musical movement and cookery. The cookery activity consists of mixing ingredients and making cakes, which are later eaten with a cup of tea. In describing the home one resident said ‘Its the best’. The main mid day meal was coming to its end at the start of this inspection. It was noted however that some residents were receiving assistance. The dining room was later well set out for tea. HOUSMAN COURT E52 S18484 Housman Court V243708 090805.doc Version 1.40 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 standard(s) 16 and 18 There is a clear and accessible complaints procedure in place in addition staff training has taken place in relation to adult protection together these areas assist in safeguarding residents. EVIDENCE: The home has a clear complaints procedure, which was displayed in the entrance hall. The home has received no complaints since the last inspection. The one member of staff spoken to was aware of adult protection issues. Staff have received adult protection training, which was recently reinforced by watching a video. The homes policy was not viewed on this occasion having been assessed as meeting the necessary standard as part of previous inspections. The registered manager was aware of her responsibilities regarding the reporting of allegations of abuse to relevant persons as well as to the Protection of Vulnerable Adults Scheme. Information was on display for staff including a photocopy of guidance to staff recently issued by Worcestershire Social Services. HOUSMAN COURT E52 S18484 Housman Court V243708 090805.doc Version 1.40 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 standard(s) 19, 20, 21, 23, 24, 25 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 is however stained. In addition the carpeting along corridors is marked and stained in places. The home needs to address the scuffed décor in some areas especially the top floor corridor. 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 provided the appropriative furnishings. 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 and at least one bedroom seen has restricted headroom in places. HOUSMAN COURT E52 S18484 Housman Court V243708 090805.doc Version 1.40 Page 14 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. A patio and grassed area can be reached via the dining and sitting areas providing residents the opportunity to sit outside during the warmer weather. HOUSMAN COURT E52 S18484 Housman Court V243708 090805.doc Version 1.40 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 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 and 29 The procedures for recruiting new members of staff were not sufficiently robust to fully ensure that residents are safeguarded however a sufficient number of staff were on duty. EVIDENCE: Staff rotas were on display near to the staff room. These clearly showed the role of each employee. Amendments to the rota were evident covering absences such as holidays however the rota indicated that one person was within the home when she was not. An information board giving the names of those on duty for the attention of residents and visitors also showed this persons name. In addition to care staff are other staff including kitchen and domestic staff. The laundry is staffed seven days per week. Having ancillary staff enables carers more time to attended to the personal, social and health care needs of residents. Residents made very positive comments about the staff and the care provided. The documentation of an individual due to commence work at the home in the near future was viewed. An application made to the Criminal Records Bureau for the required check was evident; in the meantime a suitable POVA (Protection of Vulnerable Adults) first check had been obtained. Although two written references were in place the suitability of one was discussed, as it was HOUSMAN COURT E52 S18484 Housman Court V243708 090805.doc Version 1.40 Page 16 not from the manager or the employer of either the current or recent place of work HOUSMAN COURT E52 S18484 Housman Court V243708 090805.doc Version 1.40 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 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, 35, 37 and 38 Areas such as residents finances show that the home is well managed in addition staff are supported by the registered manager to assist them to provide the care the residents need. However records need to be kept up to date to ensure care is carried out consistently. The manager was aware of a sole fire safety shortfall EVIDENCE: The registered manager stated that she has completed her National Vocational Qualification (NVQ) in both care and management. The responsible individual recently informed the CSCI that the manager would shortly be leaving Housman Court to take up the manager’s post at another care home managed by the organisation. HOUSMAN COURT E52 S18484 Housman Court V243708 090805.doc Version 1.40 Page 18 The balance of a small random sample of residents’ money and valuables held in safekeeping were checked and found to be correct. A number of records such as care plans were not up dated on a regular basis as required. Furthermore the staff rota and information available to residents about staff on duty and activities to be held was not accurate. Health and safety was not assessed in full as part of this inspection. However all servicing records requested including hoists and gas equipment were in order. Fire records were examined and in order including records of any faults found, the action taken and when they were resolved. A chair blocked one fire extinguisher in the television lounge, which could potential hinder access to this piece of equipment. This matter needs to be resolved without undue delay. All windows above ground floor level have restrictors in place. HOUSMAN COURT E52 S18484 Housman Court V243708 090805.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 x COMPLAINTS AND PROTECTION 2 3 3 x 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x x x 3 x 2 2 HOUSMAN COURT E52 S18484 Housman Court V243708 090805.doc Version 1.40 Page 20 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 7 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. The registered manager must ensure that residents’ care plans contain information regarding all identifed care needs such as nutritional care needs. The registered manager must ensure that a risk assessment is carried out in respect of every resident, regarding all aspects of their lives. Handwritten MAR charts must be checked and signed by two members of staff. The registered manager must ensure that the date of opening is recorded on medication not within the monitored doseage sysytem including inhallers. Timescale for action 31/08/05 2. 7 15 (1) 31/08/05 3. 8 14 (2) 17 (1) (a) Schedule 3 (o) 13 (2) 31/08/05 4. 9 immediate and on going immediate and on going 5. 9 13 (2) HOUSMAN COURT E52 S18484 Housman Court V243708 090805.doc Version 1.40 Page 21 6. 9 13 (2) The registered manager must ensure that all Medication Administration Record (MAR) sheets show all known allergies. In the event of ‘none known’ the MAR sheet must reflect this information. The registered provider must commence a programme of carpet replacement and redecoration in corridor areas of the home. The registered manager must ensure that references are obtained from the most recent employer and from suitably relevant persons. The registered manager must ensure that all records are acurate and up dated. The registered manager must make suitable arrangements to ensure that all fire fighting equipment is easily accessable. immediate and on going 7. 19 23 (2) (b) 31/12/05 8. 29 19 (1) immediate and on going 9. 37 17 (1) 17 (2) 23 (4) (c) (i) 31/08/05 10. 38 immediate and on going 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 10 Good Practice Recommendations The registered manager should review the present practice of certain procedures or treatments taking place within the lounge. 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