Inspection on 18/04/05 for Ingersley Court

This inspection was carried out on 18th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ingersley Court 05/09/07

Ingersley Court 12/12/06

Ingersley Court 21/09/05

Ingersley Court 15/09/04

Ingersley Court 20/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Ingersley Court Lowther Street Off Church Street Bollington, Cheshire SK10 5QA Lead Inspector June Shimmin Unannounced 18th April 2005 09:30 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. Ingersley Court Version 1.10 Page 3 SERVICE INFORMATION Name of service Ingersley Court Address Lowther Street Off Church Street Bollington Cheshire SK10 5QA 01625 574233 01625 573196 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) CLS Care Services Hilary Jane Young Care Home 34 Category(ies) of OP (Old age, not falling within any other registration, with number category) 34 of places Ingersley Court Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: This home is registered for a maximum of 34 service users to include: up to 34 service users in the category of OP (old age not falling within any other category) requiring personal care only. The registered provider must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Date of last inspection 15th September, 2004 Brief Description of the Service: Ingersley Court is a purpose-built care home for older people. It forms part of the CLS group which is a not for profit organisation based in Cheshire and Wigan. The home is located in the village of Bollington.and has access to local facilities such as shops, churches and other community amenities. The large town of Macclesfield is aproximately five miles from the home. Ingersley Court is a three-storey building (basement, ground and first floor). Service users are accommodated on the ground and first floor only. Access between floors is via a passenger lift or the stairs. Service users` accommodation currently consists of 33 single bedrooms, with one bedroom being used as a double. 18 bedrooms have en-suite facilities and the remaining bedrooms have wash hand basins fitted. There is generous communal space and this comprises 4 lounges, 2 dining rooms and a receoption area with seating. There are a number of sitting areas and walkways in the gardens. Ingersley Court has an adequate number of separate toilets and bathrooms. Various aids and adaptations have been provided for residents requiring assistance. There are a number of flats attached to the home. These are occupied by tenants who come into the home during the day for a meal or company. Ingersley Court Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 8 hours. A tour of the care home was carried out took place and conversations took place with 9 residents, 5 staff, a visiting health professional and the manager. What the service does well: What has improved since the last inspection? What they could do better: Although a new system of care planning was introduced some time ago this has not yet become fully operational. There was no care plan or risk assessment in place for one resident who moved into the home some time ago. An incident was identified during the inspection and, other than daily records, there was no indication of what should be done to follow up this incident. Enhanced disclosures for staff from the Criminal Records Bureau are not being kept available for inspection in the home. There was no record that the hot water temperatures were being checked. Ingersley Court Version 1.10 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ingersley Court Version 1.10 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 Ingersley Court Version 1.10 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 The process of moving new residents in is well managed to ensure that their needs can be met at the home. When the needs of residents change advice is sought from appropriate care professionals such as social workers, doctors and nurses so that residents health and well-being is maintained. EVIDENCE: The manager of the home assesses new residents before they move in to ensure their needs can be met at the home. The assessment is based on written information provided by social care and sometimes health professionals. If the needs of a resident change, the manager and other staff seek the advice of health and social care professionals to assess whether the care home can continue to meet the resident’s needs. During this process the resident and their family are kept informed and a review of care needs will take place. The home does not provide intermediate care. Ingersley Court Version 1.10 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 Although there has been some improvement in care planning and review, more work needs to be undertaken to ensure consistency. The staff make sure that residents receive appropriate health care and medication at the home is generally well managed. The care staff make sure that the residents’ privacy and dignity is respected. EVIDENCE: Three residents’ files were checked and two contained well written care plans but, generally, these had not been reviewed. There was no care plan for a third resident, although the manager said that it was being re-written. An incident relating to this resident had been recorded but no risk assessment had been undertaken as a result of the incident. The care plan of a resident who was insulin dependent did not include information to guide staff to manage the residents’ diabetes. Ingersley Court Version 1.10 Page 10 Since the last inspection, the medication room had been moved to a cooler environment. The medication administration records were accurately completed. Risk assessments were in place for residents who wished to administer their own medication and suitable lockable storage for this medication was provided in their bedrooms. Additional instructions were provided where necessary. The district nurse had provided a week’s supply of insulin for 3 residents and this was labelled and stored appropriately. A small number of minor problems were noted in relation to medication. There was no record kept of the temperature of the medication fridge and room, and there was some excess stock of several medications. Residents said they were very happy with the care they received. They said that care staff treated them in a courteous manner and understood their needs. Staff knocked on doors before entering residents’ rooms. See Requirements 1 & 2 and Recommendations 1 & 2 Ingersley Court Version 1.10 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, 13, 14 and 15 Activities were provided to stimulate and interest the residents. They can make choices about how they spend their daily lives. The standard of catering at the home is good and service users ate well. EVIDENCE: An activities coordinator works at the home for 20 hours a week and the following activities were taking place: reading with residents, reminiscence, exercise, musical bingo, quiz, crosswords, one to one with residents, shopping with a resident in Macclesfield, bingo and a film (Calamity Jane). Three residents said that there were all kinds of entertainment at the home including films, singing and outings. Several residents confirmed that they did not have to join in activities if they did not want to. There are a number of shared living areas in the home where residents could read or chat quietly. There were bookshelves at various points around the home with some books in large print. Residents said that a Methodist minister visits the home every third Wednesday of the month and a Church of England minister on the first Thursday of every month. Ingersley Court Version 1.10 Page 12 The residents were complimentary about the standard of catering at the home. The menu was displayed on boards on each floor and alternatives were provided at each meal. The lunch on the day of inspection was corned beef hash with peas followed by apple crumble and custard. There was a hot or cold evening meal available. Ingersley Court Version 1.10 Page 13 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 The system for managing complaints is satisfactory to ensure that residents know who they can complain to if necessary. Staff understand the need to make sure that residents are protected from harm and appropriate policies and procedures were in place. EVIDENCE: The care home had not received any complaints since the last inspection. There are leaflets on how to complaint in the home’s reception area. Information about the complaints procedure is included in the service user guide for the home. Residents said that if they were unhappy they would speak to a member of staff or the home manager. There is a policy and procedure on the protection of vulnerable adults. Staff were aware of the actions to be taken in the case of alleged abuse. Ingersley Court Version 1.10 Page 14 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 and 26 The home provides a pleasant, comfortable environment for residents and high standards of cleanliness and hygiene continue to be maintained. However, there is no record to show that the temperature of hot water is being monitored. EVIDENCE: Since the last inspection the main dining room has been redecorated and has new lighting. Rooms are usually redecorated when there is a change of resident. Residents said that they were happy with their rooms and the standard of decoration. The home was very clean, as it has been at previous inspections. A laundry assistant confirmed that suitable protective clothing was provided. The maintenance man employed at the home and care staff said that they checked the temperature of hot water outlets there was no record of this. Ingersley Court Version 1.10 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, 28 and 30 More permanent staff had been employed at the home and this provided better continuity of care for residents. Certain checks, which were part of the recruitment process, have not been followed up, putting residents at potential risk. The care staff are supported to undertake training to enable them to provide better care for residents. EVIDENCE: The manager has successfully filled a number of staffing vacancies although several remained for weekend care staff. Residents said they were happier when the home’s own staff were on duty as they were more aware of their needs. They said agency staff were “not used to us and we’re not used to them”. The staff thought the calibre of agency staff varied and this could present problems. Staff said that they were able to undertake training and were receiving regular supervision with senior staff. Care staff were still doing some laundry duties but these had decreased in volume. Recruitment records for two new members of staff were inspected. All relevant information was on file other than an enhanced disclosure from the Criminal Records Bureau. The disclosure for one member of staff was not held at the home and although a disclosure for another member of staff who had been in post since September 2004 had been sought, it had not been received. See Requirement 4 and Recommendation 3 Ingersley Court Version 1.10 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 38 The home is well managed and the manager is well regarded by residents and their families. Appropriate measures are taken to make sure the residents are safe. EVIDENCE: Residents and staff spoke highly of the manager who has held the post at this home for twenty-seven years. The manager was observed interacting in a caring and sensitive manner with residents and relatives. A representative of the registered provider visits the home every month to check on the way the home is run and a written report is provided on their findings. The manager said that the care home was working towards Investors in People and expected to achieve this by December 2005. Staff said they had undergone fire safety training and further training was due to take place in the near future. They had also taken part in fire drills. Ingersley Court Version 1.10 Page 17 Records showed that fire safety equipment in the home was tested and serviced regularly. The fire officer visited the home in February 2005 and made several recommendations in relation to fire safety. The kitchen was clean and tidy and steps had been taken to ensure food safety. Eight care staff had done training in first aid in the last year. Ingersley Court Version 1.10 Page 18 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. Where there is no score against a standard it has not been looked at during this inspection. 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 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 x x x x x 2 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x x x 2 Ingersley Court Version 1.10 Page 19 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 Requirement Care plans, to cover all care needs, and appropriate risk assessments must be provided for all service users. Care plans must be regularly reviewed. (Timescale of 15/11/04 not met) Records of the tests of the temperatures of hot water from outlets to which service users have access must be kept to show that the safety of service users has been ensured. An enhanced disclosure must be applied for from the Criminal Records Bureau before a new member of staff takes up post and a record of the received disclosure must be kept at the home. Timescale for action 18/06/05 2. 3. 7 25 15 13, 23 18/06/05 18/06/05 4. 29 19 18/06/05 5. 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 Ingersley Court Version 1.10 Page 20 1. 2. 3. 9 9 27 The temperature of the medication room and fridge should be recorded every day. Excess medication should be returned to the pharmacist. The number of hours that care staff are required to perform laundry duties should be monitored and additional laundry staff recruited if necessary. Ingersley Court Version 1.10 Page 21 Commission for Social Care Inspection Unit D, Off Rudheath Way Gadbrook Park Northwich Cheshire, CW9 7LT 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 Ingersley Court Version 1.10 Page 22 - 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!