Inspection on 10/05/06 for James Hince Court

This inspection was carried out on 10th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

James Hince Court 11/12/09

James Hince Court 05/07/07

James Hince Court 23/11/05

James Hince Court 22/06/05

James Hince Court 22/03/05

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE James Hince Court Windsor Gardens Carlton-in-Lindrick Worksop Nottinghamshire S81 9BL Lead Inspector Richard Ramsden Unannounced Inspection 10th May 2006 09.45 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 James Hince Court DS0000035527.V291375.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. James Hince Court DS0000035527.V291375.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service James Hince Court Address Windsor Gardens Carlton-in-Lindrick Worksop Nottinghamshire S81 9BL 01909 733821 01909 541108 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) Nottinghamshire County Council Vacant Care Home 45 Category(ies) of Dementia (35), Dementia - over 65 years of age registration, with number (35), Old age, not falling within any other of places category (10), Physical disability (5) James Hince Court DS0000035527.V291375.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 35 DE - 55 years and over (to include 35 DE(E) to be accommodated in either Rufford, Carburton, Clumber or Welbeck. 10 OP to include up to 5 PD 55 years and over to be accommodated in Thoresby. The total number of residents must not exceed 45 Date of last inspection 23rd November 2005 Brief Description of the Service: James Hince Court is a purpose-built, single storey care home, providing personal care and accommodation for 45 residents. It is owned and operated by Nottinghamshire County Council Social Services. The home was opened in 1986 and is located in the middle of a housing estate in the village of Carlton in Lindrick, 3 miles north of Worksop. A day centre is attached to the home and is jointly used by social services and the local health authority as a specialist dementia assessment unit. The home is separated into five units each with its own kitchenette, dining and sitting areas, bathroom and toilet facilities. One of the units is designated to provide respite care. The home is surrounded by gardens, which are fully enclosed by fencing and provide a safe area for people to wander freely. At the time of inspection the senior staff was unclear what the homes monthly accommodation charges would be for those residents who are self funding. The inspector has been informed that the fee would be £1508 per calendar month. A copy of the most recent inspection report is available in the home. James Hince Court DS0000035527.V291375.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector completed this unannounced visit over one-day it took approximately 8 hours. It included the inspection of care and other records, a discussion with two team leaders and two members of care staff. The inspector spoke with two residents and two visitors to the home. A partial tour of the building was also completed. Prior to completing this visit the inspector assessed the homes previous inspection reports and service history. What the service does well: Staff are ensuring that they can meet the assessed needs of prospective residents prior to their admission to the home. This would include any issues in relation to diversity. Individual care plan show the residents health care needs are being adequately met, the residents and relatives spoken with during the inspection confirmed this. The care plans provide appropriate information to ensure that staff are always aware of what support and assistance each resident requires. They are being reviewed on a monthly basis in consultation with the resident and where appropriate their representatives. The food provided for residents appears wholesome and nutritious with plenty of variety and choice. The residents spoken with confirmed that they enjoyed the food provided by the home. One relative said that he has lunch, in the home, with his wife every Sunday. Residents said that they are generally very satisfied with their bedrooms and confirmed that they had been encouraged to personalise them with small items of furniture photographs and ornaments. The home is generally well maintained and comfortably furnished. The gardens are fully enclosed to provide a safe environment for the residents who appeared to be enjoying the sunshine on the day of this visit. The residents and the visitors describe the staff as caring and considerate and said that they ensure that residents privacy and dignity is respected at all times. James Hince Court DS0000035527.V291375.R01.S.doc Version 5.1 Page 6 Staff are being provided with a good level of training and supervision which helps equip them to meet the needs of the residents. A high percentage of staff have completed their NVQ training. 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. James Hince Court DS0000035527.V291375.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 James Hince Court DS0000035527.V291375.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): 1,3,6. Prospective residents are provided with sufficient information to make an informed choice as to whether the home will meet their assessed needs. The homes staff ensure that they can meet the needs of prospective residents by obtaining full written assessments prior to their admission to the home. The home does not provide intermediate care. “Quality in this outcome area is good. This judgment has been made using available evidence including a visits to the service” EVIDENCE: The literature supplied to prospective residents now contain sufficient information to enable them to make an informed choice, as to whether the home will meet their assessed needs. The senior staff was reminded that there must be additional copies of this literature so that it can be given to all prospective residents. James Hince Court DS0000035527.V291375.R01.S.doc Version 5.1 Page 9 All of the residents records which were assessed as part of this visit contained pre-admission assessments that had been completed by either social workers or health care professionals. The senior staff on duty confirmed that residents are never admitted to the home and unless staff feel confident that they can meet their assessed needs. The home does not provide intermediate care. James Hince Court DS0000035527.V291375.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Residents individual care plans appear to contain sufficient information to ensure that staff are always aware of what support and assistance each resident requires. Residents’ health care needs are being met. The homes medication administration systems require minor amendments to ensure that the system protects the health and safety of the residents. Residents are treated with respect and their rights to privacy are upheld. “Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service”. James Hince Court DS0000035527.V291375.R01.S.doc Version 5.1 Page 11 EVIDENCE: Three residents care plans were viewed as part of this inspection, the care plans appear to address the issues highlighted in the residents assessment process. All of the care plans had been reviewed on a monthly basis and where possible the residents or their representatives had been involved in the review process. (This is good practice). The records showed that residents’ health care needs are being appropriately met; this was confirmed by one of the residents spoken with during the visit. The homes medication systems were generally well managed. As the majority of people who live at James Hince Court have poor short-term memories none had been assessed as safe to administer their own medication. The records of receipt and disposal of medication and the homes controlled medication had all been well maintained. It was noted that some people who had only been recently admitted to the home or who were receiving respite care did not have photographs attached to their medication Administration records. The senior staff was informed that photographs must be provided with all medication Administration records. This is particularly important for new residents who staff may not immediately recognise. The majority of medication was stored safely however it was noted that the refrigerator in which medication is stored was not locked at the time of this inspection. The senior staff was reminded that this must be kept locked at all times. Both of the residents spoken with during the inspection said that the staff are always friendly and respectful and that they ensure that their privacy and dignity is maintained at all times. This was also confirmed by one of the relatives spoken with during the visit. The observed interaction between staff and residents was of a very good standard. James Hince Court DS0000035527.V291375.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Residents are satisfied with the frequency and variety of activities and entertainment provided by the home. People are encouraged main contact with family and friends. Where possible residents are encouraged to make decisions about their individual lifestyles. The diet provided for the residents is varied, wholesome and nutritious. “Quality in this outcome area is good. This judgment has been made using available evidence including a visits to the service” EVIDENCE: The program of activities and entertainment to be provided each week are prominently displayed in the main reception area. The two residents spoken with during the inspection said that they are very satisfied with the level of activities and entertainment provided by the home. There was evidence of craftwork etc displayed in each unit. James Hince Court DS0000035527.V291375.R01.S.doc Version 5.1 Page 13 The care plans viewed as part of this inspection contain brief details of residents’ past and present interests. Residents and their relatives confirmed that visitors are made welcome at any time. One visitor said that he visits his wife every day and that he is always made to feel very welcome. One resident said that she could see visitors in her bedroom or use one of the communal areas if she wishes to speak to them in private but does not wish to use her bedroom. Access to records policies as well as leaflets giving details of how to contact local advocates have been made available to every resident. (This is good practice). Both of the staff spoken with during the inspection were clear about the process they would need to follow if residents or relatives asked to view their personal records. Both of the residents spoken with said that they are satisfied with the meals provided by the home. They confirm that there is always a choice of meal and if they do not want the food suggested on the menu an alternative will always be provided. One of the visitors spoken with said that he always has his Sunday lunch with his wife in the home he confirmed that the meals of a very good standard. The lunch on the day of inspection looked appetising and nutritious. Some residents require a soft diet, each element of the meal is liquidised individually to preserve flavour and appearance. (This is good practice). The rotating menus are displayed in each unit, however the print is very small and it is almost impossible to ascertain which week is actually in use. It is recommended that the records of food to be provided be displayed in a userfriendly format. The refrigerator, freezer and food temperature records were checked and they had all been well maintained. James Hince Court DS0000035527.V291375.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Residents and their relatives believe that their complaints would be taken seriously and that appropriate action would be taken. However the staff are not keeping appropriate records of all informal complaints and consequently the home does not have an overview of the nature and frequency of complaints received. The registered person has take appropriate action to protect residents from abuse. “Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service”. EVIDENCE: The home has an appropriate complaints procedure, which is displayed in various areas throughout the home. The homes complaints records show that only one complaint has been received this year. This had been dealt with in an appropriate manner. The residents and their relatives believe that their complaints would be taken seriously and that appropriate action would be taken. James Hince Court DS0000035527.V291375.R01.S.doc Version 5.1 Page 15 The senior staff stated that ‘informal’ complaints would be recorded in the ‘managers log’. The inspector stated that these should have been recorded in the complaints records to provide an overview of the nature and frequency of complaints received. The complaints must be able to be viewed in a confidential format and records must show what action, if any, has been taken to investigate and resolve the complaints. The inspector was informed that there have been no incidents of abuse in the home in the last 12 months. The home has an appropriate Whistle Blowing Procedure, which is displayed, in the staff room. The staff spoken with had a clear understanding of this procedure. The senior staff were clear, about the procedures they must follow if any incidents relating to adult protection occurred within the home. James Hince Court DS0000035527.V291375.R01.S.doc Version 5.1 Page 16 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): 19,22,26. The premises are generally well maintained and comfortably furnished. The premises were clean, however a commode containing urine had been left in the dining room. The homes call system was not fully operational at the time of this inspection, and one resident could not access assistance from staff in an emergency situation. “Quality in this outcome area is acceptable. This judgment has been made using available evidence including a visit to the service.” James Hince Court DS0000035527.V291375.R01.S.doc Version 5.1 Page 17 EVIDENCE: A partial tour of the premises was completed as part of this inspection. The accommodation is comfortably furnished and acceptably decorated. The two residents spoken with during the inspection said that they are very satisfied with their bedrooms and confirmed that they had been encouraged to personalise them with small items of furniture photographs and ornaments. Residents and visitors confirmed that the home is always kept very clean and tidy. However it was noted that a commode containing urine had been left in the dining room. This is not only extremely unhygienic but could potentially encourage residents with poor short-term memories to use the commode in an inappropriate area. The call bell in one bedroom was tested and was not working; consequently this resident could not have accessed assistance from staff in an emergency situation. The call bell system was not fully functional at the last inspection. The senior staff had been testing the call bells periodically but this had clearly not resolved the issue. The home has pleasant fully enclosed garden areas, which provide a safe area enabling residents to wander freely. Several residents appeared to be enjoying the garden at the time of this inspection. James Hince Court DS0000035527.V291375.R01.S.doc Version 5.1 Page 18 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): 27,28,29,30. The rota provided for the week of this inspection showed that adequate staffing levels are being maintained. The homes recruitment policies and practices are generally supporting and protecting residents however staff criminal records bureau checks must be kept in the home available for inspection at all times. The home is able to demonstrate a commitment to staff training. “Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service”. EVIDENCE: The rota provided for the week of this inspection showed that sufficient staff are being provided to comply with previously agreed staffing levels. The residents and a relative spoken with during the inspection said that although the staff are always very busy they find time for social interaction. James Hince Court DS0000035527.V291375.R01.S.doc Version 5.1 Page 19 The personal records of the two most recently recruited members of staff were assessed as part of this visit; each set of records contained an application form two satisfactory references and proof of identity. However there was no criminal records bureau check available for one of the members of staff. (Although the senior staff had received written confirmation that an acceptable CRB check had been received). CRB guidance states that, for CSCI regulated services, disclosures should be kept for up to 12 months or more to enable CSCI inspectors to see a sample at the next inspection. Out of the total of 34 members of staff 17 had completed NVQ level 2 or above. Six other members of staff were completing the training at the time of this inspection. (This commitment to staff training is good practice). James Hince Court DS0000035527.V291375.R01.S.doc Version 5.1 Page 20 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): 31,33,35,38. There has been no registered manager at the home for several months however the senior staff have ensured that the home is well managed and run in the best interests of the residents. Residents’ financial interests are safeguarded. Efforts are made to protect the health and safety of the residents and staff “Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service”. James Hince Court DS0000035527.V291375.R01.S.doc Version 5.1 Page 21 EVIDENCE: Although there has been no registered manager at the home for some considerable time and there has been a shortage of senior staff, the home remains well managed. CSCI has received an application for the new manager who will have a fit person interview in the next few weeks. Quality monitoring systems are in place which show that the residents have been encouraged to express their views about the services provided by the home. The inspector advised that staff should seek the views of relatives and stakeholders in the community such as District Nurses General Practitioners etc. The home had a copy of the local authority business plan that there was no business plan produced specifically for the home. The records of residents’ finances were checked and had been satisfactorily maintained. The homes Fire records had been well maintained. However the senior staff were not able to locate the date of their last visit by the fire officer or confirm whether there was any work outstanding from that visit. The last visit by the environmental health officer was on the 3rd August 2005 and the records show that there was no work outstanding from that inspection. The home has a Legionella risk assessment water temperatures are being tested on a regular basis. The records show that lifting equipment bath aids etc are all being service on a regular basis. James Hince Court DS0000035527.V291375.R01.S.doc Version 5.1 Page 22 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 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 Standard No Score 16 2 17 X 18 3 3 X X 2 X X X 2 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 James Hince Court DS0000035527.V291375.R01.S.doc Version 5.1 Page 23 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 OP16 Regulation Schedule 4 (11) Requirement It is required that the registered person keep a record of all complaints, detailing the investigation and where appropriate any action taken. It is required that the registered person ensures that the homes call system is fully operational at all times. (This is outstanding from 23/11/05) Some work has been completed to implement this requirement but the work has not been successful. It is required that the registered person ensures that commodes are never stored in the dining room. It is required that all staff personal files contain evidence of CRB checks a specified within the report. It is required that the quality assurance/ quality monitoring system is developed to include all the issues identified in Standard 33. Timescale for action 10/05/06 2. OP22 23.2 (c) 10/05/06 3. OP26 23.2 (d) 10/05/06 4. OP29 7,9,19. 12/06/06 5. OP33 24 10/07/06 James Hince Court DS0000035527.V291375.R01.S.doc Version 5.1 Page 24 6. OP38 23 (4) It is required that the Registered Person informs the Commission for Social Care Inspection of the date of the last visit by the Fire Officer and confirm whether there is any work outstanding from that visit. 12/06/06 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 OP15 Good Practice Recommendations It is Recommended that the menu detailing the food to be provided for the residents, be displayed in the home in a user-friendly format. James Hince Court DS0000035527.V291375.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 James Hince Court DS0000035527.V291375.R01.S.doc Version 5.1 Page 26 - 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. 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