Inspection on 26/09/05 for Pool Cottage Care Home

This inspection was carried out on 26th September 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 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 23/01/06

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 26th September 2005 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.V249861.R01.S.doc Version 5.0 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.V249861.R01.S.doc Version 5.0 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.V249861.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th March 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.V249861.R01.S.doc Version 5.0 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 6 and a half hours. Discussions were held with five residents, two relatives and with staff during the inspection. Records were examined, including care plans (as part of the case tracking process, which is used to help determine how the home meets the needs of individual service users). An assessment was made with respect to the requirements made at the last inspection of this service. What the service does well: What has improved since the last inspection? What they could do better: Staff need to ensure that they always work in a safe way, and do not put residents or themselves at risk by using poor practice. The practice of sharing medication needs to stop. The registered provider, Mr Kalemeera needs to carry out monthly unannounced visits to the home, in order to monitor the quality of the care and services provided. Pool Cottage Care Home DS0000061459.V249861.R01.S.doc Version 5.0 Page 6 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.V249861.R01.S.doc Version 5.0 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.V249861.R01.S.doc Version 5.0 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 Pre-admission procedures were in place to ensure that residents were admitted on the basis of a comprehensive assessment of their needs. EVIDENCE: The care plans of two residents were examined in detail as part of the case tracking process, which is used to help determine how the home meets the needs of individuals. There was evidence within care plans that assessments had been undertaken prior to the admission of residents, which gives confidence that the staff are making judgements about the suitability of this care home to meet the needs of residents. The admission process ensured that the needs of residents were fully assessed and detailed information recorded. Details of the individuals’ preferred 24 hour routine was available. The file supported that residents and families had been involved in the assessment and care planning process. Care plans had been developed from the assessment of needs. Pool Cottage Care Home DS0000061459.V249861.R01.S.doc Version 5.0 Page 9 Those residents spoken with commented that they felt well cared for and that that staff at the home were very good. Several residents and staff expressed concern about the deterioration in condition of one particular resident. The manager was aware of this and was taking appropriate action. Relatives spoken with commented that they were satisfied with the care provided at the home. Pool Cottage Care Home DS0000061459.V249861.R01.S.doc Version 5.0 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 and 10 The care plans provided detailed records about residents, and contain appropriate information to guide staff in caring for individuals. Residents reported staff to be respectful of their privacy and dignity. The sharing of medication potentially places residents at risk. EVIDENCE: People spoken with talked highly about the staff team, and said that ‘they felt well cared for’ and ‘happy living at the home’. People spoken with reported that staff were attentive to their needs. Residents were clearly treated as individuals by staff, and was reflected in how residents organised their day, and in their appearance. Resident files were well organised. Residents and families had been involved in planning the care. On the whole, care plans for these residents were detailed and provided sufficient information for staff to deliver appropriate care. Not all appropriate risk assessments had been completed, reviewed and updated as required. The files did not support that all care plans were reviewed every month. Information recorded on the log sheets provided details of the residents’ day to day lives. Pool Cottage Care Home DS0000061459.V249861.R01.S.doc Version 5.0 Page 11 The files supported that residents had access to health care professionals as required. Although staff clearly recorded any deterioration in residents needs, they did not always recognise the need to seek specialist advice, ie referral for physiotherapist assessment, or update the risk assessment to reflect the changes. However, staff did recognise when the home was unable to continue to meet the needs of individual residents and took appropriate action. A review of medication practice was undertaken. Full administration instructions were not always recorded on the medication charts, and only stated ‘as directed’. The actual amount of medication given for variable doses was not being recorded. It was noted that prescribed medication was being shared. This practice is not acceptable and must stop. The medication refrigerator has still not been fitted with a lock. The manager reported that this issue was being addressed. Pool Cottage Care Home DS0000061459.V249861.R01.S.doc Version 5.0 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 and 15 A social and leisure programme was organised, providing opportunities for activities for residents. Residents were encouraged to maintain links with the community. Residents were encouraged to exercise choice over their lives as far as possible, and the routines at the home reflected this. EVIDENCE: Residents commented highly about the activities organised on their behalf. A visit to Calke Abbey had been arranged for the morning of the inspection, and residents commented how much they had enjoyed this. Residents spoke about a recent trip to Trentham Gardens, and photographs from this trip were on display. A number of residents continue to attend regular social clubs in the village. Several volunteers organise coffee and cake afternoons each week, which has raised money for the amenities fund. Several residents assist the volunteers with these activities. Residents were actively involved in deciding on activities and trips, through the residents meetings. Regular church services were held in the home. Residents had access to hairdressing services each week, or continued to use their own hairdresser. Routines at the home were kept to a minimum, and residents made good use of all areas of the home. Residents confirmed that they were able to use their rooms as they wished. Pool Cottage Care Home DS0000061459.V249861.R01.S.doc Version 5.0 Page 13 Residents and staff spoke about the home’s involvement in a recent Art and Craft show organised in the village. Residents who choose to participate provided the organisers with photographs, which were then enlarged and displayed in the quiet lounge. The home was part of the trial, and visitors entered through the front door, so as not to disturb the residents. Visitors were welcome in the home at any time, and those spoken with stated that they were always made welcome. Relatives commented they received a monthly newsletter, which informed them about forthcoming events. An audit of the kitchen was not undertaken as part of this inspection. However, residents commented that the meals provided at the home were very good, choices were provided and that they enjoyed them. Pool Cottage Care Home DS0000061459.V249861.R01.S.doc Version 5.0 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 Residents were confident that their concerns were listened to, taken seriously and acted upon. EVIDENCE: The complaints procedure was on display. Residents spoken with were aware of how to raise any concerns and knew to speak with the manager. Residents were confident that their concerns would be listened to and acted upon appropriately. Complaint records will be examined at the time of the next inspection. The Commission has not received any complaints relating to Pool Cottage since the last inspection. Pool Cottage Care Home DS0000061459.V249861.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed during this inspection. EVIDENCE: Pool Cottage Care Home DS0000061459.V249861.R01.S.doc Version 5.0 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 and 28 Staffing levels were in keeping with the needs of the residents living at the home. However, deployment of staff did not always provide a balanced skill mix on all shifts. EVIDENCE: Discussion with residents and staff supported that staffing hours were sufficient to meet the needs of the current resident group. However, the rotas demonstrated that staff were not always deployed according to their skills or abilities. It was noted that on occasions the two senior care assistants worked on the same shift, leaving less experienced staff in charge of other shifts. It was also noted that the manager and the deputy often work the same shifts, sometimes both carrying out office duties. It was not clear from the duty rotas which member of staff was in charge of each shift. These issues were discussed with the manager at the time of the inspection. It was also observed during the inspection that all staff sat down together to have a break in the conservatory. During this period of time, the majority of residents were unsupervised. Progress was being made towards meeting the 50 target of care staff trained to NVQ Level 2 or equivalent. Six members of staff have achieved this qualification and two more staff had commenced this training. Pool Cottage Care Home DS0000061459.V249861.R01.S.doc Version 5.0 Page 17 Staff files were not checked during this inspection. Discussion with the manager and administrator indicated that they were aware of the requirements around recruitment and selection of staff and that the required information was on file. Pool Cottage Care Home DS0000061459.V249861.R01.S.doc Version 5.0 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, 33 and 38 Poor staff practice did not promote the health and safety of all residents. EVIDENCE: The manager and deputy manager had completed the Registered Manager’s Award and were awaiting confirmation and certification, and still had to completed NVQ Level 4 in Care. The registered person, Mr Kalemeera, was not carrying out his responsibilities under Regulation 26 and visiting the home, unannounced once a month and providing a written report of his findings. Several residents also commented that they had not seen the owner since he introduced himself as the new owner earlier this year. Pool Cottage Care Home DS0000061459.V249861.R01.S.doc Version 5.0 Page 19 One member of staff was observed using extremely poor and inappropriate practice to transfer a resident from wheelchair to chair. This member of staff was trying to carry out a transfer on their own, did not allow the resident sufficient time to transfer herself, or make the environment safe. This member of staff also transferred the resident in a wheelchair without footplates on. The manager also observed this incident. Pool Cottage Care Home DS0000061459.V249861.R01.S.doc Version 5.0 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X X X X X STAFFING Standard No Score 27 2 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X X 2 Pool Cottage Care Home DS0000061459.V249861.R01.S.doc Version 5.0 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 OP8 Regulation 12(1)(a) Requirement Pressure area care assessment and nutritional screening must be undertaken for all residents on admission, and these assessments must be reviewed regularly (Previous timescale of 30 June 2005 not met) Where a variable dose is prescribed the actual dose administered must be recorded (Previous timescale of 31 May 2005 not met) Prescribed medication must not be used for anyone other than the person for whom it is prescribed. The dedicated medication refrigerator must be fitted with a lock. Deployment of staff must be reviewed to ensure that at all times suitably qualified, competent and experienced persons are working in such numbers as are appropriate for the health and welfare of residents. 50 of care staff must be trained to NVQ Level 2 or DS0000061459.V249861.R01.S.doc Timescale for action 31/12/05 2 OP9 13(2) 17(1)(a) Sch 3 13(2) 30/11/05 3 OP9 30/11/05 4 5 OP9 OP27 13(2) 23(2)(l) 18(1)(a) 31/12/05 31/12/05 6 OP28 18(1)(a) (b)(c) 31/12/05 Pool Cottage Care Home Version 5.0 Page 22 7 OP33 26 8 OP38 12(1)(a) (b) 13(4)(c) equivalent. The registered provider must visit the home unannounced once a month, and interview with their consent and in private, residents and representatives and staff, inspect the premise, its record of events and records of any complaints and prepare a written report on the conduct of the home. This report must be made available to the Commission and manager. Staff must use demonstrate safe and appropriate moving and handling practice at all times. 30/11/05 30/11/05 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 2 3 4 Refer to Standard OP7 OP9 OP27 OP27 Good Practice Recommendations Care plans should be reviewed every month. The GP should be asked to provide full administration instructions on the prescriptions, rather than ‘take as directed’. The duty rota should clearly show which member of staff is in charge of the shift. The manager should review the practice of all staff taking break at the same time. Pool Cottage Care Home DS0000061459.V249861.R01.S.doc Version 5.0 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.V249861.R01.S.doc Version 5.0 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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