Inspection on 23/01/06 for Pool Cottage Care Home

This inspection was carried out on 23rd January 2006.

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

Pool Cottage Care Home 06/01/09

Pool Cottage Care Home 21/07/08

Pool Cottage Care Home 30/05/07

Pool Cottage Care Home 30/06/06

Pool Cottage Care Home 26/09/05

Pool Cottage Care Home 09/03/05

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 Pool Cottage Care Home Pool Road Melbourne Derbyshire DE73 1AA Lead Inspector Jo Wright Unannounced Inspection 23rd January 2006 09:00 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 Pool Cottage Care Home DS0000061459.V279879.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. Pool Cottage Care Home DS0000061459.V279879.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Pool Cottage Care Home Address Pool Road Melbourne Derbyshire DE73 1AA 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) 01332 863715 Mutebi Blessious Kalemeera Jennifer Susan Williams Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Pool Cottage Care Home DS0000061459.V279879.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th September 2005 Brief Description of the Service: Pool Cottage is a detached property, which has been adapted and extended to provide personal care for up for up to 17 persons aged 65 years and over, and day care for up to 3 persons. The home overlooks Melbourne lake and is close to the town centre, local shops and a bus route. The home has 11 single and 3 double bedrooms located on the ground and first floor, 7 bedrooms have ensuite facilities. Access to the first floor is by stairs and a stair lift. There are 2 lounges, a conservatory and a dining room on the ground floor. The Home has a garden. Pool Cottage Care Home DS0000061459.V279879.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and the duration of the visit was approximately 5 hours. Time was spent speaking with the manager and residents, and observing the daily routine. Records such as care plans (as part of the case tracking process, which is used to help determine how the home meets the needs of individual residents) were not examined in depth during this inspection. Other records such as medication records, staff files, and financial records were examined. An assessment was made with respect to the requirements made at the last inspection of this service. The manager was present at the inspection, and the findings the inspection were discussed with her. What the service does well: What has improved since the last inspection? The manager has addressed the issues raised in the last inspection report around staff practice and best use of staff skills and knowledge. The staff rota is organised so that an experienced member of staff in on duty each shift to guide and support less experienced members of the staff team. Staff continue to improve their practice around the administration of medication, although a number of issues were noted during this inspection. Pool Cottage Care Home DS0000061459.V279879.R01.S.doc Version 5.1 Page 6 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. Pool Cottage Care Home DS0000061459.V279879.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 Pool Cottage Care Home DS0000061459.V279879.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): EVIDENCE: These standards were not inspected during this inspection. Pool Cottage Care Home DS0000061459.V279879.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 and 10 People living the home were treated as individuals and made decisions about their daily lives. Inconsistent record keeping around medication places residents at risk of not having their health care needs fully met. EVIDENCE: A number of residents were spoken with during this inspection. People spoke positively about the staff team, and commented that ‘they felt well cared for’ and ‘happy living at the home’. Residents commented that staff were attentive to their needs, and this was supported by observation. Staff respected each resident as an individual, and supported people to organise their day as they wished. Personal clothing was laundered to a good standard and both residents and staff took care over people’s appearance. Residents’ files were not looked at in depth during this inspection. However, they were checked to see if the requirement to carry out pressure area care and nutritional assessments had been complied with. The files looked at contained these assessments. However, staff were not always reviewing these assessment in accordance with the guidelines. Pool Cottage Care Home DS0000061459.V279879.R01.S.doc Version 5.1 Page 10 Discussion with the manager indicated that following the last inspection a referral through the GP for a physiotherapy assessment had been made for one particular resident. Following this assessment, appropriate equipment had been provided for this resident, which had greatly improved their ability to transfer and move about. A number of requirements relating to medication were made in the last inspection report, and a review of medication practice was undertaken. The manager reported that the local pharmacist provides a good service to the home, and good working relationships have been established. Staff responsible for administering medication had received training. The medication records were checked and against the monitored dosage system. It was noted on several occasions that medication had not been signed for, so it was unclear whether the resident had received their medication as prescribed. Staff no longer shared prescribed medication between residents and supplies were available as required. The manager was advised to record on the medication chart when residents were self administering their medication and creams. A lock has still not been fitted to the medication refrigerator. Pool Cottage Care Home DS0000061459.V279879.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 14 & 15 A social and leisure programme, which met the leisure and recreational interests of the residents, was in place. Links with the community were good and support and enrich residents’ social opportunities. Residents were provided with meals that they enjoyed, offering them a balanced and varied diet. EVIDENCE: Pool Cottage has a relaxed atmosphere and residents commented that routines were kept to a minimum. Residents confirmed that they were able to go in the garden or into the village as they wished. There was a good rapport amongst the people living at the home and between the residents and staff. Residents were observed making good use of all areas of the home, and staff respected individual residents wishes to remain in their rooms. Staff were committed to providing a varied social and leisure programme, and supported this through fund raising events. Residents confirmed that they were involved in deciding what activities were organised, and how the money was spent, and this was discussed during residents meetings. Residents commented on how much they had enjoyed the activities over the Christmas period, especially the pantomime that was held at the home. Photographs of Pool Cottage Care Home DS0000061459.V279879.R01.S.doc Version 5.1 Page 12 recent events were on display. A list of weekly events was displayed on the notice board. Several people continue to attend regular social clubs in the village. Residents and staff were also supported by a group of volunteers who organise coffee and cake afternoons each week, and the proceeds go towards the amenities fund. Several residents assist the volunteers with these activities, and commented that they now have regular group of people who visit each week. Residents may attend communion services held in the home, or at any of the churches in the village. Residents had access to hairdressing services each week, and several residents continue to use their own hairdresser. Observation supported that visitors were welcome in the home at any time. Staff were observed routinely asking visitors if they would like refreshments and providing these as required. Residents were able to see visitors either in the main lounge area, the quiet lounge or in the privacy of their own room. Residents were encouraged to remain as independent as possible and supported to manage their own affairs as required. Residents were encouraged to bring in their own belongings to personalise their rooms. Although the current group of residents have a person to advocate on their behalf, the manager was aware of independent advocacy services. Residents commented that the meals provided at the home were very good, they were offered choices and they enjoyed the meals. The mealtime was relaxed, the dining areas well presented, and staff available to provide support and assistance as required. The kitchen area was clean and tidy at the time of this inspection. Required records were available and up to date. The chef reported that Environmental Health visited during January 2006, and no issues were raised at that time. The report had not been received at the time of this inspection. Pool Cottage Care Home DS0000061459.V279879.R01.S.doc Version 5.1 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 the following standard(s): 16 & 18 A satisfactory complaints process was in place with evidence that residents felt their views were listened to and acted upon. Arrangements for protecting residents were satisfactory. EVIDENCE: Residents spoken with were fully aware of how to raise any concerns and commented that they would speak with the manager. People were confident that their concerns would be listened to and acted upon appropriately. The Commission has not received any complaints relating to Pool Cottage since the last inspection. People living in the home were protected from potential risk of harm or abuse through policies and procedures and staff training. All staff were provided with a booklet on Adult Protection and attend in house training. The manager and deputy have attended a two day training course on the Protection of Vulnerable Adults provided by the local authority, and staff also attend a one day training course provided by the local authority. The manager had booked two places on courses arranged for March and May 2006. The home’s policy on the Protection of Vulnerable Adults was accessible to all staff, and made reference to the local authority procedure. Although a copy of the local authority Protection of Vulnerable Adults procedure was available in the home, this was not the most up to date version. No referrals have been made through these procedures since the last inspection. Pool Cottage Care Home DS0000061459.V279879.R01.S.doc Version 5.1 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 the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 The standard of the environment was good providing people living there with an attractive and homely place to live. EVIDENCE: Pool Cottage was maintained and decorated to a good standard. All areas of the home were clean and tidy, and free from odours. Residents had been supported to personalise their rooms with their own belongings. Communal areas were homely in appearance and people were observed making good use of all areas of the home. Residents commented that they made good use of the garden area around the home, even during the winter. Half of the bedrooms have en suite facilities. Toilet facilities were provided through out the building, and residents have access to a range of bathing facilities, appropriate for their needs. Pool Cottage Care Home DS0000061459.V279879.R01.S.doc Version 5.1 Page 15 The separate laundry area was well organised, and equipment in good working order. Pool Cottage Care Home DS0000061459.V279879.R01.S.doc Version 5.1 Page 16 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 and 30 Staffing levels were in keeping with the needs of the people living at Pool Cottage. The staff team was not fully trained to ensure that they were competent to fulfil their roles. EVIDENCE: People living at the home benefit from a stable staff group, who were committed to improving the quality of their lives. Staff turnover was very low, which means that staff have a good knowledge of each individual persons abilities, and the areas where they need support and assistance. The home continues to provide staffing levels that were adequate to meet the needs of the resident group. Residents spoken with confirmed that in their opinion, staffing levels were sufficient to meet their needs. The manager has addressed the issue around appropriate deployment of staff, according to their skills or abilities, and duty rota clearly demonstrated which member of staff was in charge of each shift. The manager reported that she had addressed the practice of staff taking their breaks together. Staff either take separate breaks or if they do go to break together, they sit in the main lounge, where they are able to continue to observe the residents. Pool Cottage Care Home DS0000061459.V279879.R01.S.doc Version 5.1 Page 17 Although the home was working towards meeting the 50 target of care staff trained to NVQ Level 2 or equivalent, this had not been achieved. Four members of staff out of 14 have achieved this qualification and one member of staff was part way through this training. The manager was making arrangements for two more staff to start this training. Robust systems were in place for the recruitment of staff. An audit of a number of staff files supported that the required checks (references, Pova First and criminal record bureau declarations) to safe guard residents were in place. Discussion took place with the manager about full employment histories. The home has not employed any new members of staff since the last inspection. An induction and foundation programme that met the specifications was in place. The manager was due to attend a Skills for Care workshop on the induction and foundation requirements at the end of January 2006. Pool Cottage Care Home DS0000061459.V279879.R01.S.doc Version 5.1 Page 18 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, 32, 33, 35 & 38 This is a well managed home, with systems in place for consultation with residents, and evidence to support that their views were acted upon. EVIDENCE: The manager and deputy manager have achieved the Registered Manager’s Award and have started NVQ Level 4 in Care. The manager keeps herself updated by attending the same training as the staff. The manager was aware of the shortfalls in the service, and was taking action to address these through staff meetings. The registered person, Mr Kalemeera, carried out a visit under Regulation 26 on 25 November 2005, and the report was available in the home. No further visits had been carried out. Pool Cottage Care Home DS0000061459.V279879.R01.S.doc Version 5.1 Page 19 Residents’ views were regularly sought through residents meetings, and minutes of these meetings were available. Residents confirmed that they were able to raise any issues as they arose, and that the management team would listen to these and take any appropriate action. Robust systems were in place for safeguarding resident monies. The administrator manages this system, and detailed records were available on computer. A staff training matrix was in place, detailing when staff had attended mandatory training. Fire training had been arranged for March 2006. The manager reported that she was in the process of arranging any outstanding training for staff. A sample of service/maintenance records was examined (including equipment, gas and electricity services) and there was confirmation that equipment and services are properly maintained. Pool Cottage Care Home DS0000061459.V279879.R01.S.doc Version 5.1 Page 20 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 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 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 3 Pool Cottage Care Home DS0000061459.V279879.R01.S.doc Version 5.1 Page 21 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 OP9 Regulation 13(2) 23(2)(l) Requirement The dedicated medication refrigerator must be fitted with a lock (Previous timescale of 31/12/05 not met) The medication chart must be signed following the administration of medication to the resident. The medication chart must accurately reflect the medication that the resident has received. 50 of care staff must be trained to NVQ Level 2 or equivalent (Previous timescale of 31/12/05 not met) Full employment histories, including the month and year must be obtained when appointing new staff. Timescale for action 31/03/06 2 OP9 13(2) 17(1a) Sch 3 28/02/06 3 OP28 18(1)(a) (b)(c) 19 & Sch 2 30/06/06 4 OP29 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Pool Cottage Care Home DS0000061459.V279879.R01.S.doc Version 5.1 Page 22 No. 1. 2. 3. Refer to Standard OP8 OP9 OP18 Good Practice Recommendations Pressure area care and nutritional assessments should be reviewed in accordance with the local guidelines. Self administration of medication should be clearly recorded on the medication chart. An up to date copy of the local authority Protection of Vulnerable Adults procedure should be obtained. Pool Cottage Care Home DS0000061459.V279879.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Pool Cottage Care Home DS0000061459.V279879.R01.S.doc Version 5.1 Page 24 - 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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