Inspection on 05/09/07 for Ingersley Court

This inspection was carried out on 5th September 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ingersley Court 12/12/06

Ingersley Court 21/09/05

Ingersley Court 18/04/05

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 Mr Val Flannery Unannounced Inspection 5 September 2007 09:50 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 Ingersley Court DS0000006668.V347631.R01.S.doc Version 5.2 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. Ingersley Court DS0000006668.V347631.R01.S.doc Version 5.2 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 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) www.clsgroup.org.uk CLS Care Services Limited Sharon Strain Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Ingersley Court DS0000006668.V347631.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 34 service users in the category of OP (old age, not falling within any other category) 3rd July 2007 Date of last inspection Brief Description of the Service: Ingersley Court is a purpose-built care home for older people. It is run by the CLS Group, a not for profit organisation based in Cheshire and Wigan. The home is located in the village of Bollington and within reach of local facilities such as shops, churches and other community amenities. Macclesfield town centre is approximately five miles away. Ingersley Court is a three- storey building (basement, ground and first floor). Residents live on the ground and first floors only. Access between floors is via a passenger lift or the stairs. There are 33 bedrooms in the home, with one being used as a double room. 18 bedrooms have en-suite facilities and the remaining bedrooms have wash hand basins fitted. There is generous communal space of 4 lounges, 2 dining rooms and a sitting area in the reception. Ingersley Court has a number of separate toilets and bathrooms. Various aids and adaptations have been provided for service users who need help to move around. There are a number of flats attached to the home. These are occupied by tenants who sometimes come into the home during the day for a meal or company. Fees range from £450 to £490 per week, depending on the accommodation provided. Ingersley Court DS0000006668.V347631.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit took place on 5 September 2007 and lasted seven hours. The visit was carried out by Val Flannery, Regulatory Inspector. This visit was just one part of the inspection. Before the visit the manager was asked to complete an Annual Quality Assurance Assessment to provide up to date information about services in the home. Questionnaires were also made available for residents, families and health and social care professionals to find out their views. Other information received since the last key inspection was also reviewed. During the visit various records and the premises were looked at. A number of residents and relatives were also spoken with and they gave their views about the service. What the service does well: The home promotes equality by treating people as individuals to make sure their diverse needs are appropriately met. Prospective residents’ needs are assessed before they move into the home and they are provided with written information about the home and can visit or stay on a trial basis. This ensures they have all the information necessary to decide whether the home can meet their individual needs. Residents’ care plans identify their health and personal care needs and include information on what staff need to do to meet those needs so that people receive the care they need in the way they prefer. Relatives and friends are able to visit the home as they wish so the people who live there are able to keep in touch with their families. The people who live in the home said the food offered is usually good so they enjoy a varied diet. People who live in the home are asked for their views about the home and there is a thorough complaints procedure, so they know their concerns will be listened to and acted upon. The home is well maintained with good standards of décor and furnishings so that the people who live there live in safe, comfortable surroundings. Ingersley Court DS0000006668.V347631.R01.S.doc Version 5.2 Page 6 Thorough recruitment checks are carried out before staff start work at the home to make sure they are suitable to work with the people who live in the home. 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. The summary of this inspection report can be made available in other formats on request. Ingersley Court DS0000006668.V347631.R01.S.doc Version 5.2 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 Ingersley Court DS0000006668.V347631.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of the people are assessed before they come to live in the home to check that their needs can be met there. EVIDENCE: The relative spoken with during the visit said information about the service offered by the home had been made available when she had visited on behalf of her mother. A copy of the statement of purpose and service user guide for the home is kept in each bedroom. People spoken with who live in the home said they knew about the home because they lived in Bollington and ‘would not go in any other home’. The care records for four the people who live in the home were seen during the visit. These showed that assessments of need were carried out by staff from the home before each person moved in. Copies of assessments from the Ingersley Court DS0000006668.V347631.R01.S.doc Version 5.2 Page 9 local authority were also seen on a number of files. Care plans were in place that showed how the needs of the people that live in the home were to be met. The manager said that a senior care team leader from CLS is working the home two days a week to support care staff improve the care planning process. A number of people that live in the home said that although their care needs were being met the quality of the care offered is dependent on the staff on duty. They said ‘things are not as good when there are agency staff on duty’. They also commented on the changes of personnel within the staff team. They said the new staff ‘are getting better’. Copies of the contract of residency were seen during the visit. The home service manager said a copy is given to the person or their relative. Ingersley Court DS0000006668.V347631.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans set out how the people who live in the home are to have their personal and healthcare needs met. This helps ensure their well-being and that their privacy and dignity is respected. EVIDENCE: Four care files for people who live in the home were seen during the visit. These included information about their healthcare needs and how these were to be met. The records also showed that people receive visits from doctors and nurses and that they are supported to attend outpatients appointments at the hospital. A district nurse was seen visiting the home during the visit. A number of the people that live in the home said they are able to ask for visits from doctors as required. During the visit staff were seen providing personal care to a number of people who live in the home. This included help with eating their meal, using the bathroom and moving about the home. Help was given in a caring and Ingersley Court DS0000006668.V347631.R01.S.doc Version 5.2 Page 11 sensitive manner. For example, one of the people needed a lifting aid to use the bathroom. The staff member regularly checked that she was comfortable and also explained to her what she doing. A number of the people spoken with said they only require minimal help with personal care but ‘its reassuring to have staff around if an emergency arises’. A number of staff have received training on first aid. Risk assessments were seen that ensured the safety and well being of the people who live in the home; for example, moving/handling, risk of bedsores and use of bedrails. Since the last visit the procedures for storing medication, particularly controlled drugs, has been reviewed. During the visit the care leader was seen giving medication to people who live in the home. This carried out in a satisfactory manner. A sample of the records of medication administered to people that live in the home was seen during the visit. All records seen were signed and dated. A senior care team leader from CLS Care Services visits the two days a week to provide staff with additional support/training with medication procedures and care planning. Ingersley Court DS0000006668.V347631.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in the home are enabled to choose how they wish to live their daily lives. This helps to ensure they have control over their affairs and are to maintain their independence. EVIDENCE: The previous activities organiser for the home is to become the home service manager and a new activities organiser has been appointed to begin working at the home in September. During the visit a residents’ meeting took place. A relative spoken with said she and her sister are able to visit the home at any time and are made to feel welcome by staff. People spoken with said the food is ‘usually very good’ although some agency cooks are ‘not very interested in doing good food’. People said they can do as they please and most said they prefer a daily routine. People were seen moving freely between their bedrooms and the communal areas. A number Ingersley Court DS0000006668.V347631.R01.S.doc Version 5.2 Page 13 spoken with said they get up and go to bed when they wish, also that they can choose when and where they eat their meals. One person talked about his trip to see Manchester United and also that he went on a boat trip. Because of the absence of an activities co-ordinator over the last few month’s activities have tended to be organised by staff when they have free time. The menus seen during the visit showed that the people that live in the home are offered a choice for each meal. The menu is changed for the winter and summer months. The comments about the menus ranged from ‘food very good, am offered a choice’, quantities offered ‘are plentiful’, to ‘meals not so good when some agency staff are doing the cooking’. During the visit staff were seen helping people with their meal and this was done in a discreet manner. The mealtime observed was unrushed, people where able at eat their meal at their own pace. Ingersley Court DS0000006668.V347631.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a good complaints procedure for people to live in the home to use so their concerns will be acted upon. There is a policy on adult protection and staff have received training so they know what to do to protect people who live at the home from possible harm. EVIDENCE: Ingersley Court had received one complaint from a relative since the last inspection, which had been resolved. The complaints procedure is included in the service user guide in residents’ rooms. Residents said that they would know who to speak to if they were unhappy about any aspect of their care. Ingersley Court has an adult protection policy and procedure in place. The home had followed the correct procedures following recent allegations. A record was seen during the visit to show that staff have received training on the organisation’s adult protection procedures. Ingersley Court DS0000006668.V347631.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained so people live in safe, clean, comfortable surroundings that suit their needs. EVIDENCE: The home is Bollington, close to shops and other local amenities. The layout of the home allows the people who live there to be able to move freely between their bedrooms and communal areas. There is a programme of maintenance that includes re-decoration, for example, the manager said the exterior of the home is due to be painted. During the visit a tour of the building was carried out. The areas seen were clean, tidy and free from bad smells. The carpet on one of the stairways and on a section of corridor is showing signs of wear and tear. Ingersley Court DS0000006668.V347631.R01.S.doc Version 5.2 Page 16 A number of bedrooms have en-suite facilities. There are sufficient communal toilet and bathroom facilities for those people that do not have en-suites. Adaptations and equipment were seen in communal areas that would help people with mobility problems. These include hoists, other lifting equipment, wheelchairs, zimmer frames and grab rails. A number of bedrooms were seen during the visit; these contained items of personal possessions and were individually decorated. The people spoken with said the bedrooms suit their needs and that they have a key to their room if they wished. They also said the home is kept clean, warm and comfortable. Ingersley Court DS0000006668.V347631.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are normally sufficient staff on duty to care for the people that live in home However, a number require further training and support to ensure they have the skills to care for the people who live in the home. EVIDENCE: During the visit staffing rotas were seen that showed that there is normally one care team leader and at least three care assistants on duty during the day. There is one care team leader and one care assistant on duty during the night. The rota showed that there are support staff on duty including the home service manager, cook, kitchen assistant, domestic staff and maintenance assistant. A number of people that live in the home were spoken with during the visit. They commented on the changes in the staff team and about the new staff. They said ‘some of the staff are better then others’ and that ‘new staff need time to get to know the job’. The manager said there is still a need for improvement amongst the staff but there are ‘signs that things are getting better’. Two senior staff from CLS visit the home four days a week to offer additional support and training to the care staff. Ingersley Court DS0000006668.V347631.R01.S.doc Version 5.2 Page 18 Individual staff records were seen that showed they had received training in, for example, moving/handling, protection of vulnerable adults, first aid and fire safety. Also seen were records to show which staff have obtained an NVQ. The manager said all staff , including support staff, are expected to do their NVQ training. Three staff personnel files were seen during the visit. These were satisfactory and contained information such as the completed application form, two references and evidence that a Criminal Record Bureau disclosure had been obtained. Staff meetings are held for the individual staff teams in the home. Although there is a commitment to provide staff with individual supervision the records show that this not happening with all staff. Ingersley Court DS0000006668.V347631.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed to make sure that it is run in the best interests of the people that live there. EVIDENCE: The manager has been in post for approximately fifteen months. She has worked in social care for 15 years and has worked for CLS for 11 years. She has an NVQ Level 3 in Care and has completed the Registered Managers Award (NVQ Level 4). She is waiting for her NVQ coursework to be assessed. Staff and residents who were spoken with said that the manager was very approachable and they could go to her with any concerns. They said she consulted them about any issues that concerned them. Ingersley Court DS0000006668.V347631.R01.S.doc Version 5.2 Page 20 Copies of customer satisfaction surveys were seen during the visit. These showed a general satisfaction with the service offered by the home. There was also a quality audit system in place that covered care plans, medication, accidents, health and safety, catering and maintenance. A representative of the company that owns the home visits monthly and completes a written report of their findings. Residents’ meetings are held quarterly. The arrangements for the safekeeping of residents’ monies and valuables were discussed with the home service manager and found to be satisfactory. The system for formal supervision of care staff was that the manager supervised the care team leaders and they in turn were responsible for the other care staff. However, very little formal supervision of care staff had taken place. The manager had identified that there was training need for the care team leaders and had arranged for this to be provided. All equipment was serviced and maintained at the required intervals. Records were seen for the passenger lift, fire system, care call system and baths/hoists. Staff were issued with a health and safety handbook on induction and received regular training in safe working practices. Ingersley Court DS0000006668.V347631.R01.S.doc Version 5.2 Page 21 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 3 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 2 X 3 Ingersley Court DS0000006668.V347631.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No 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 OP36 Regulation 18(2) Requirement Staff working in the home must be appropriately supervised to make sure that they are providing good quality care for the people who live in the home. Timescale for action 31/10/07 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 OP27 Good Practice Recommendations All staff should be supported to develop the skills necessary to meet the assessed needs of the people that live in the home. 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