Inspection on 12/12/05 for Northleach Court Care Centre

This inspection was carried out on 12th December 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 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

Northleach Court Care Centre 08/03/09

Northleach Court Care Centre 13/10/08

Northleach Court Care Centre 31/03/08

Northleach Court Care Centre 30/10/07

Northleach Court Care Centre 12/06/07

Northleach Court Care Centre 22/06/06

Northleach Court Care Centre 16/12/04

Northleach Court Care Centre 12/05/04

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

CARE HOMES FOR OLDER PEOPLE Northleach Court Care Centre High Street Northleach Cheltenham Glos GL54 3PQ Lead Inspector Mr Adam Parker Unannounced Inspection 12th December 2005 10:25 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 Northleach Court Care Centre DS0000016515.V280501.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. Northleach Court Care Centre DS0000016515.V280501.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Northleach Court Care Centre Address High Street Northleach Cheltenham Glos GL54 3PQ 08453 455746 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) Mrs Sally Roberts Mr Jeremy Walsh To be appointed Care Home 64 Category(ies) of Dementia - over 65 years of age (64) registration, with number of places Northleach Court Care Centre DS0000016515.V280501.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Temporary variation to client categories OP (Old Age) for 1 (one) named service user. The Home will revert to the original client categories when this service user no longer resides at the home. To accommodate one named service user under 65 years of age with Dementia 6th June 2005 2. Date of last inspection Brief Description of the Service: Northleach Court is situated close to the centre of Northleach, which is about 12 miles from Cheltenham and 10 miles from Cirencester.The Home is a registered Care Home with nursing and has 64 beds in the category of dementia care for persons over 65 years of age. Accommodation is on two floors; on the ground floor there are a number of communal rooms including a conservatory, dining areas and lounges.The home has grounds comprising of a number of enclosed courtyard areas and small lawns. Northleach Court Care Centre DS0000016515.V280501.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out on one day in December 2005 by three inspectors. Due to previous concerns a thorough check was made of the environment. A number of service users were spoken to as well as the nurse in charge and the activities coordinator. What the service does well: What has improved since the last inspection? What they could do better: Northleach Court Care Centre DS0000016515.V280501.R01.S.doc Version 5.1 Page 6 The home should carry out needs assessments of service users prior to admission. The regular maintenance of the home needs to be improved. The home needs to be cleaner and free of unpleasant odours with enough cleaning staff deployed to achieve this. The home needs to appoint a manager and ensure that staff are appropriately supervised. 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. Northleach Court Care Centre DS0000016515.V280501.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 Northleach Court Care Centre DS0000016515.V280501.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): 3. There are arrangements to ensure that all service users are admitted following a full assessment of their needs although needs assessments carried out by the home are not always completed prior to admission. EVIDENCE: Service users are usually admitted to the home following a comprehensive assessment of their needs. Copies of Health and Social Services assessments are obtained and then the home carries out its own assessment prior to admission. One example however had been carried out on the day following admission despite a recommendation made at the last inspection that the home should carry out its own assessments prior to admission. Assessments are used to formulate care plans based on activities of daily living. Northleach Court Care Centre DS0000016515.V280501.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8,9 & 10 Systems are in place to ensure that service users health needs are met. Care is given in such a way as to promote the privacy and dignity of service users. The home has made progress with regard to medication storage to ensure that service users are not placed at risk. EVIDENCE: At the previous inspection a requirement was issued for pressure sore risk assessments to be kept under review this was checked and was being done. An immediate requirement notice was issued on the day of the inspection regarding the security of medicines. The provider has reported that this has now been actioned. Requirements issued at the previous inspection about medication storage have been complied with. Requirements issued at the previous inspection for issues around privacy and dignity have also been complied with. Northleach Court Care Centre DS0000016515.V280501.R01.S.doc Version 5.1 Page 10 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): 12,14 & 15 The activities coordinator organises a programme of activities suited to service users needs that offers opportunity for varied and regular social activity. Service users are able to exercise some limited choice over their lives within the limits of their abilities. Service users dietary needs are well catered for with the home offering a balanced and varied selection of food. EVIDENCE: The home has an activities coordinator who maintains a programme of regular activities suited to service users needs. At the time of the inspection there were seasonal activities planned including trips out of the home, a Christmas fair and a visit to the home from a local choir. In addition there is a musical entertainer who visits the home. The activities coordinator confirmed that the ‘Snoezelan’ was working. This provides a multi-sensory experience suitable for service users with Dementia. A minister from a local church visits the home on a regular basis. One response from a quality assurance questionnaire praised the activities in the home. Northleach Court Care Centre DS0000016515.V280501.R01.S.doc Version 5.1 Page 11 The home has information on how to contact external advocates who may act in service users interests. Evidence was seen of service users having brought personal possessions into the home. Following a requirement made at the previous inspection the home has reviewed the practice of providing late breakfasts to service users. Northleach Court Care Centre DS0000016515.V280501.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 The homes policies and procedures ensure that service users are protected from abuse. EVIDENCE: The home has robust procedures for responding to suspicion or evidence of abuse. In addition staff receive training on abuse and challenging behaviour on a biannual mandatory basis. Northleach Court Care Centre DS0000016515.V280501.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,24,25 & 26 Lack of maintenance and cleaning mean that service users do not live in a safe well maintained or clean environment. EVIDENCE: Based on previous concerns a thorough inspection of the environment was undertaken. It was noted that a painter was working on the interior of the home on the day of the inspection. Two issues were identified that needed immediate action these being a lack of lighting in some rooms due to defective light bulbs and a lack of toilet paper and soap in toilets and en-suite facilities. The provider has confirmed that these have now been actioned. There was an improvement in the general cleanliness of the environment. However some issues were noted, these being • Dirty pillows and pillowcases in bedrooms • Dirty toilet brushes in ensuite toilets • Odours in rooms 1,24,29,36,40, the ensuite to Room 6 and one of the toilets in the ‘EMI unit’ Northleach Court Care Centre DS0000016515.V280501.R01.S.doc Version 5.1 Page 14 Dirty carpets in the’EMI dining room’, the main entrance and ground floor corridors and room 3. • Light fittings in need of cleaning. • Stained toilets in rooms 14,19,37,40 • Stained armchairs in rooms 24 and 36 Some maintenance issues were noted these being • Knobs missing from chests of drawers • Broken toilet seat in room 33 • A cracked mirror in room 18 • Towel rail hanging off wall in room 19 • Loose window fittings in Room 9 One toilet in the ‘EMI unit’ was locked and had apparently not been in use for some time. In some rooms it was noted that radiators were set on full although very little heat was coming from them. • Northleach Court Care Centre DS0000016515.V280501.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 Although a system is in place to ensure sufficient care staff there are times when the numbers of cleaning staff are not enough to ensure that service users live in a clean, pleasant and hygienic home. EVIDENCE: On the day of the inspection there was only one member of cleaning staff on duty. The nurse in charge stated that there were normally three cleaning staff on duty. A requirement was made at the previous inspection regarding the number of cleaning staff working in the home. The home has confirmed that staffing levels for care staff are reviewed weekly taking account of the layout of the home and the dependencies of residents. Northleach Court Care Centre DS0000016515.V280501.R01.S.doc Version 5.1 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 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): 31,33,35,36,37 & 38 Service users have not had the benefit of living in a home with an appointed manager. Quality assurance systems are in operation to ensure that the home is run in the interests of service users. Service users financial interests are safeguarded through systems in place at the home. Staff have not been appropriately supervised in meeting service users needs. Service users’ interests are safeguarded through secure storage of records. Some monthly maintenance checks are not being carried out potentially failing to safeguard the health and safety of service users. EVIDENCE: Northleach Court Care Centre DS0000016515.V280501.R01.S.doc Version 5.1 Page 17 At the previous inspection a requirement was issued regarding the appointment of a manager for the home. This has not been complied with. On the day of the inspection a registered nurse from an agency was in charge of the home. The home operates a quality assurance system based on questionnaires sent out to relatives of service users. The last survey had been completed in March 2005. Out of 55 questionnaires sent out 32 had come back. An action plan is drawn up in respect of any issues raised. The home provides secure facilities and keeps accurate records of any money or valuables kept on behalf of service users. An inspection of staff supervision records showed that little has been done in the way of staff supervision sessions although annual staff appraisals had been completed. The lack of a manager in the home has no doubt contributed to this. Following a requirement issued at the previous inspection regarding storage of records it was noted that these are now being held securely. Although standard 38 was not inspected in full it was noted that there was no record of some monthly maintenance checks being carried out. Checks on water temperatures were being carried out. Northleach Court Care Centre DS0000016515.V280501.R01.S.doc Version 5.1 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. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 2 X 2 X X 2 2 1 STAFFING Standard No Score 27 1 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X 3 1 3 2 Northleach Court Care Centre DS0000016515.V280501.R01.S.doc Version 5.1 Page 19 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 OP19 Regulation 23 (2) (b) Requirement The registered person must ensure that all maintenance issues detailed in the text of this report are attended to. The registered person must ensure that toilet in the ‘EMI unit’ is brought back into use. The registered person must ensure that the cleanliness and condition of all pillows and pillowcases in use in the home is reviewed and any remedial action taken. The registered person must ensure that all radiators are checked to ensure they are in working order. The registered person must ensure the cleaning and disinfection of all toilet brushes. The registered person must eliminate the odours in the areas detailed in the text of this report. The registered person must ensure that the areas detailed in this report in respect of toilets, light fittings, carpets and chairs are cleaned. The registered person must DS0000016515.V280501.R01.S.doc Timescale for action 31/03/06 2 3 OP21 OP24 23 (2) (j) 16 (2) (c) & (e) 31/03/06 31/03/06 4 OP25 23 (2) (p) 31/03/06 5 6 7 OP26 OP26 OP26 13 (3) 16(2) (k) 23 (2) (d) 31/03/06 31/03/06 31/03/06 8 OP27 18 (1) (a) 31/03/06 Page 20 Northleach Court Care Centre Version 5.1 9 OP31 8 (1) (a) 10 OP36 18 (2) 11 OP38 23 (2) (c) ensure that at all times there are sufficient cleaning staff working to maintain the home in a clean and hygienic state (previous timescale of 30/9/05 not met). The registered person must ensure that a manager is appointed to run the home (previous timescale of 30/9/05 not met). The registered person must ensure that staff supervision sessions take place and that a record of these is kept. The registered person must ensure that all monthly maintenance checks are carried out. 30/04/06 30/04/06 31/03/06 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 OP3 Good Practice Recommendations All pre admission assessments carried out by the home should be completed prior to the service user’s admission. Northleach Court Care Centre DS0000016515.V280501.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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. 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