Inspection on 01/03/07 for Ross Court

This inspection was carried out on 1st March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Ross Court 21/02/06

Ross Court 12/09/05

Ross Court 10/02/05

Ross Court 08/09/04

Ross Court 04/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Ross Court Overross Close Ross-on-wye Herefordshire HR9 7BQ Lead Inspector Denise Reynolds Key Unannounced Inspection 10:00 1st March 2007 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 Ross Court DS0000024732.V328119.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ross Court DS0000024732.V328119.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ross Court Address Overross Close Ross-on-wye Herefordshire HR9 7BQ 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) 01989 764349 01989 565569 rosscourt@majesticare.co.uk Ross Healthcare Limited Mrs Janet Ivery Auty Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places Ross Court DS0000024732.V328119.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Ross Court is situated at the end of a cul-de-sac in a residential area on the outskirts of the town of Ross-on-Wye. The home sits in its own grounds. It is easily accessed from the town ring road and M50 motorway. The home is registered to accommodate 42 people over 65 years of age who have needs arising from the normal ageing process at the point of admission. There is a commitment to continue providing a service for any resident who develops additional needs as long as these can be met within the Home’s resources. Ross Court DS0000024732.V328119.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection began at 10am in the morning on the first day and was resumed the following day. This was a key inspection – this is an inspection where we look at a wide range of areas covered by the National Minimum Standards. To help us plan the inspection we looked at pre inspection information requested from the Home some weeks earlier and the results of two internal audits of the service carried out by the provider organisation during 2006. We also took into account what people told us in our survey forms; we received these from residents (13), relatives (11) and health and social care professionals (4). During the two visits to the Home care records, staff records and other records and documents were inspected. There was a tour of the accommodation and interviews with five staff, including the registered manager and the deputy manager. Time was spent speaking privately with seven residents in their rooms as well as spending time out and about in the home observing what was happening. The inspector also met and spoke with the relative of one resident during the inspection. What the service does well: People living at Ross Court say that it is a lovely place to live and are happy with their choice. People are encouraged to visit before making up their minds about moving in so that they can make an informed choice. Staff arrange a wide variety of activities every day for people who want to take part. Individual activities are also arranged to help people keep up past leisure activities and contact with relatives and the local community is actively encouraged. The Home offers a choice of menu at every mealtime and serves meals in the attractive dining room or in people’s rooms if they prefer. Residents can invite guests to a weekly supper party. The accommodation is of a very high standard and is well maintained, clean and safe. People living at the Home benefit from attractive décor, good quality furnishings and lovely, well maintained gardens. The residents speak very highly of the staff and manager and said that nothing is too much trouble. These are some of the comments made – • We are always impressed and grateful to the staff at Ross Court for the care and affection shown in looking after my mother and other residents. DS0000024732.V328119.R01.S.doc Version 5.2 Page 6 Ross Court • • • • • • • • Ross Court is, quite rightly highly regarded in the area. My mother has been there for over 6 years and the care has been superb. My mother has been there for over 2 years. It is, in my and her view a model establishment. Absolutely outstanding. There is always a friendly atmosphere and all the staff are very approachable. Never had any complaints. Always beautiful flowers and superb gardens. A safe, secure and happy environment. Wonderful staff with the inspired leadership of Mrs Auty. The staff always have time to listen and discuss my opinions. The staff are all very friendly and considerate. The efforts that you make to keep your residents interested in things, the activities that you plan and provide, and the outings that you arrange are in themselves a tribute to the care that you give. What has improved since the last inspection? What they could do better: The service user guide needs to be available in alternative formats (eg large print, tape, cd, Braille) so that prospective and current residents can be given a copy in the best format for them. The service provider could also consider reviewing the statement of purpose so that more of it is in plain English. The statement of purpose also needs to be available in other formats. Some parts of the care records are not filled in as thoroughly as they need to be. This means that information about some residents’ care might not be complete; this reduces how effective they are as a tool for evaluating and monitoring care. The service provider has acknowledged that it needs need to improve the way they communicate with people who make a complaint. The service provider should provide small windows in the rooms with patio doors so service users can have natural ventilation without having to open the doors. The staff recruitment procedures need to be improved to reduce the chance of any unsuitable staff being appointed. A programme of regular maintenance of bedrails is needed. Ross Court DS0000024732.V328119.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ross Court DS0000024732.V328119.R01.S.doc Version 5.2 Page 8 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 Ross Court DS0000024732.V328119.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People considering Ross Court as their home are given written information about the service and opportunities to spend time at the Home before they move in; this helps them decide if it is the right place for them. People have their care needs assessed to make sure the Home is able to provide the type and level of care they need. EVIDENCE: People thinking about moving to Ross Court are provided with an easy to read service user guide to give them information about the service. The service user guide is provided in large print on request, it is not yet available in other formats such as tape or video. A number of people living in the Home have limited vision and one of these had an ordinary version of the service user guide in her room. The service user guide contains out of date information about the senior staff team and needs to be brought up to date. Ross Court DS0000024732.V328119.R01.S.doc Version 5.2 Page 10 The organisation’s internal quality audit report dated September 2006 identified that service users moving to Ross Court were not being given copies of the Office of Fair Trading guidance on care home terms and conditions. The same report also identified that copies of contracts were not always provided to people before they move in. Evidence of this was found during the inspection when a service user said that she had signed a contract recently – after she had been at the Home for some time. However, all the people who sent a survey form to us said that they have received a contract. The care records looked at showed that the Home had assessed peoples’ needs before a decision was made for them to move in. Service users spoken to said they and their families had been asked about the care they needed. Two recently arrived service users spoke of having ample opportunities to visit or to stay at the Home before they made up their mind about moving in. The assessments showed that relevant aspects of care are taken into account and that people are viewed as individuals with varying needs and different preferences. The information gathered in the assessment is used to form the foundation of the ongoing care plan. All the service users spoken to said they have been very happy with their choice of Ross Court. Ross Court DS0000024732.V328119.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home works closely with service users’ GPs and with community nurses to make sure that people have their healthcare needs attended to. The care plans are well organised and provide good information for staff to follow about the care each person needs. Some aspects of the recording need to be more reliable; this will provide better evidence of the care given. EVIDENCE: People living at Ross Court have an individual care plan. The format of these is well constructed and covers all the expected areas of care whilst allowing scope for flexibility according to differing levels of need in specific areas. The care plans seen dealt with the issues relevant to the individual residents and provided evidence that health issues had been noted, reported and followed up. Information was seen in the records that relatives are very happy with the care – Ross Court DS0000024732.V328119.R01.S.doc Version 5.2 Page 12 • Mum has blossomed in the short time she has been here. She is well cared for in every way. Thank you. Survey forms sent back to us by residents and relatives showed that people feel they receive the care they need and contained positive comments, for example – • • • Ross Court is, quite rightly highly regarded in the area. My mother has been there for over 6 years and the care has been superb. We are well looked after. I get everything I need; whatever I ask for they see to it. In two examples looked at the records of care did not provide adequate evidence about the care being given. In one case this related to a lack of information about the person losing weight some months previously. This had been noted and followed up during an internal audit of care plans. The other example was current and related to staff on some shifts not filling in the fluid monitoring chart for a person being cared for in bed. Poor recording can result in oversights in the care of the people concerned, and the organisation is further developing the standard of recording in response to similar shortfalls identified during the investigation of the complaint referred to in the Complaints and Protection section of the report. It was established from discussion with the manager and staff, observation and other information in the records that although the records were incomplete, both people had received the care they need. One of the residents concerned had a long conversation with the inspector and spoke about being well looked after. Comments written in the care plan by relatives during a recent review supported this – • We would like to add to the above that the care afforded to … is excellent and we are most happy with the efforts of everyone at Ross Court. Medication is safely managed in accordance with the organisation’s written medication policy. This was drawn up with reference to the guidelines from the Royal Pharmaceutical Society of Great Britain and CSCI’s clinical triggers for medication. Requirements and recommendations about medication had been met. Residents spoken to said they feel well looked after and confirmed that staff respect their privacy. Staff at all levels are receiving refresher training about privacy and dignity. The service provider arranged this in response to a complaint by a family that both the privacy and dignity of their relative had been breached. Ross Court DS0000024732.V328119.R01.S.doc Version 5.2 Page 13 Ross Court DS0000024732.V328119.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Ross Court provides a varied and interesting range of group activities for those who wish to take part and are able to; this gives people opportunities to meet each other and enjoyable ways to pass the time. Individual activities are also arranged to help people keep up leisure activities they enjoy. Contact with relatives is actively encouraged. The Home offers a choice of menu at every mealtime and serves meals in the attractive dining room or in people’s rooms if they prefer. EVIDENCE: The Home provides a wide range of group activities and employs two staff to take specific responsibity for this. Group activities include crafts, games, crosswords, quizzes and music and take place every day. They are held in different parts of the building to encourage people to move about and get a change of scenery. On the first day of the inspection two young musicians came to play musical instruments; during their recital there was a lot of enthusiastic applause and afterwards the residents said they had really enjoyed it. A staff member wrote in one person’s care records ‘she said she was transported back to being 18 and her first ball gown’. People are told Ross Court DS0000024732.V328119.R01.S.doc Version 5.2 Page 15 about forthcoming activities in a regular newsletter. Notices are placed on the dining tables each morning to remind people of the day’s activity and where it is being held. One person said – ‘There is always lots to do.’ Someone else confirmed that there are lots of things arranged but she prefers not to take part because she prefers own company. One resident and her son said there are lots of activities and that staff are ‘imaginative and take lots of trouble’. Individual activities are also encouraged so that people can continue to do the things they enjoy, for example one person looks after his display of house plants in an alcove in the corridor outside his room; staff have arranged the furniture to make access easier for him. During the inspection staff took two residents to the garden centre to start planning for growing tomatoes this coming summer. Staff also use activity to help resident keep in touch with the outside world, so, for example seasonal events are arranged to reflect the time of year (eg pancake party, midsummer tea party, autumn coffee morning) or introduce a different cultural perspective (eg Scottish evening, Last Night of the Proms evening, Jamaican themed supper, Italian pizza evening, harvest supper). Residents are also able to invite guests to weekly supper parties where they are served a three course meal with wine. Residents meetings are held four times a year to give people the opportunity to give their views about how the Home is run. Differing views were put forward about the quality of food. Just under 50 of the 11 residents who filled in survey forms said they always liked the food, the rest said they usually liked the food. This variation was reflected in conversation with residents. Some said the food is very good, others said it varies. Most were not specific about what it is they don’t like - some said they feel some people are too fussy while others said they think people are too easily pleased! A comment was made that not enough green vegetables are served and one person thought the staff clear the table too quickly. All of the residents spoken to knew that there is such a thing as ‘an inspector’ and were interested in the inspection. The residents and relative spoken to were unanimous in saying that it is a good Home. Ross Court DS0000024732.V328119.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Most staff at Ross Court have been trained in the correct adult protection procedures; training for the remaining staff is booked so that the whole staff group will know the right steps to take if they are concerned about the welfare or safety of someone living at the Home. The Home rarely receives complaints and acknowledges that it needs to develop its practice in this area so that staff are confident to deal with these situations when they occur. EVIDENCE: Ross Court has a written complaints procedure which is prominently displayed in the entrance to the Home. Ten of the eleven relatives who returned comment cards were aware of this procedure and all thirteen forms from residents confirmed that they know who to speak to if they are not happy. The records of compliments and complaints were looked at. The Home receives regular cards and letters from relatives thanking staff for the care given to residents, examples seen included the comments – • • genuine relaxed and contented ….due to the care and real affection shown ….could not have wished for a better Home. Last few months spent in the comfort of your tender care … greatly appreciated all you have done and the considerate understanding shown at all time. Ross Court DS0000024732.V328119.R01.S.doc Version 5.2 Page 17 • ..thank you and all your excellent staff for all the kindness and attention given to … over the last 7 years. Similarly, comments in the survey forms also showed a high level of satisfaction with the service, for example – • • We are always impressed and grateful to the staff at Ross Court for the care and affection shown in looking after my mother and other residents My mother has been there for over 2 years. It is, in my and her view a model establishment. Absolutely outstanding. None of the relatives or professionals who retuned survey forms to us had ever needed to make a complaint. The record of complaints showed that there has been only one significant complaint received. This related to concerns from a family; primarily about specific care issues, privacy and dignity. They were also dissatisfied with the way the organisation dealt with the complaint. The matter was referred for consideration under the Herefordshire multi agency adult protection arrangements and Majesticare undertook a detailed review of the service. As a result of this review they have initiated a range of improvements such as an overhaul of the care planning process, refresher training for all staff about privacy and dignity and the creation of two new senior posts. Majesticare has also acknowledged that they need to improve the way they communicate with people who make a complaint. Most, but not all staff have done training about how the multi agency adult protection procedures work in practice; arrangements are in hand for the rest of the staff to do this. All the staff spoken to said they would report any suspicion of abuse or neglect to the manager and would take it further if they didn’t think it was being dealt with. The manager had referred a financial concern drawn to her attention by relatives for investigation under the Herefordshire multi agency adult protection arrangements. Residents spoken to were very positive about living at Ross Court and said they feel safe there. Ross Court DS0000024732.V328119.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The accommodation is of a very high standard and is well maintained, clean and safe. People living at the Home benefit from attractive décor, good quality furnishings and lovely, well maintained gardens. EVIDENCE: The Home is very well maintained and has been extended and upgraded to a high standard. The building is clean, light and spacious with good sized bedrooms, most with ensuite facilities. People moving to the Home are encouraged to bring furniture and belongings with them (provided they will fit in their room). Some of the new ground floor rooms have patio doors and their own outside space. A problem has been identified with a small number of these rooms because the door sets did not have a small window to open. This has not yet been resolved. Ross Court DS0000024732.V328119.R01.S.doc Version 5.2 Page 19 Fridges are provided in all rooms and, following a risk assessment, kettles are also provided for those people able to manage and who want to be able to make themselves a drink. The communal rooms are spacious and comfortable and each is furnished differently to prevent an institutional feel. Corridors, toilets and bathrooms in the new extension have been designed to provide as much space as needed for people with walking aids or wheelchairs, and for the safe movement of hoists. The majority of bedroom doors are fitted with automatic closers which operate when the fire alarm sounds but do not put heavy pressure on the doors at other times; this makes them easier for residents to manage and means they can have their doors positioned as they prefer. One of the communal rooms is fitted with an induction loop to assist residents with hearing aids. Outside there are large lawned grounds, flower beds and mature trees. Several residents said they get a lot of pleasure from the gardens – ‘Always beautiful flowers and superb gardens’. The service areas such as the kitchen and laundry are well equipped and clean. Protective clothing such as disposable aprons and gloves is provided and there are paper towels and liquid soap in all bathrooms and toilets. The pre inspection documents received confirmed that all regular maintenance tests and checks have been carried out as required and that the requirements of other regulatory authorities have been complied with. The ongoing maintenance book showed that the handyman corrects all the faults reported by staff promptly. An internal audit by the organisation had found that some radiators had not yet had covers fitted; the remaining covers were delivered during the inspection and the manager said they would be painted and fitted ‘very soon’. Ross Court DS0000024732.V328119.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents say the staff are very good and look after them well but a small minority think staff are sometimes too busy. Staff receive a range of relevant training to develop their knowledge and skills and enable them to provide safe, competent care. The recruitment procedures operating at the Home are not robust this increases the risk of unsuitable staff being employed. EVIDENCE: The rotas show staffing levels at the Home are good. The majority of responses to our survey gave a positive view of staffing arrangements. Eleven of the thirteen residents said they always get the care they need and the other two said they usually do. Some added comments such as – • • There is always a friendly atmosphere and all the staff are very approachable. The staff always have time to listen and discuss my opinions. The staff are all very friendly and considerate. All eleven relatives who replied said there are always enough staff on duty. Most people spoken to on the day agreed but one said staff are sometimes too busy – especially if someone is off sick or on holiday. Another person commented that there are a lot of staff making it hard to remember who they Ross Court DS0000024732.V328119.R01.S.doc Version 5.2 Page 21 all are. A comment was made that staff are not always well organised leading to inconsistency about things like the time people are first given help in the mornings or the time the meal trolley arrives. Staff receive training in a range of mandatory health and safety and care related subjects. Staff spoken to confirmed they attend courses and the manager keeps copies of their certificates in a file. A structured training matrix or spreadsheet would facilitate planning staff training and identifying when updates area due. The manager said plans for this are in hand. Staff induction training is provided at the start of their employment but the records of this do not give much information. Examples were seen of induction courses being signed off as completed with only the month and year (eg January 2007) against the whole course i.e. there was no specific date against individual topics and it was not clear who the trainer was. There did not appear to be supporting evidence of the course content kept with this record although the manager explained that it is based on the Skills for Care standards. The internal audit report by Majesticare dated September 2006 identified that staff recruitment procedures needed to be improved. Staff recruitment files for six staff were examined during this inspection and the same shortfalls were identified. The files contained no evidence that gaps in employment history were explored during interviews. In one example a person had been appointed to work at the Home although they had given no information on their application form of their employment history before 2006. There was no evidence that references are routinely authenticated. There were no interview records and the manager said that she does not use the forms provided by the organisation for this purpose. The files did not all contain a photograph of the staff or documentary proof of identity as required. Ross Court DS0000024732.V328119.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Many elements of the management of Ross Court are sound and support a safe, stimulating environment where people enjoy living. The service provider audits and reviews the service to identify areas that need to be improved. The findings of these reviews need to be followed through promptly to ensure that action has been taken. EVIDENCE: The manager of the Home is experienced and appropriately qualified. Many positive comments were made in survey forms and in conversations with residents about her contribution to the life of the Home, for example – • A safe, secure and happy environment. Wonderful staff with the inspired leadership of Mrs Auty. DS0000024732.V328119.R01.S.doc Version 5.2 Page 23 Ross Court • Ross Court is a first class residential Home with an excellent manager who lives on the premises. The organisation has internal quality assurance processes and during 2006/07 produced two reports following internal audits of the service. The first of these reports was in response to a complaint from a family about their relative’s care; the second was a routine quality assurance review of the service. The routine quality report took into account the views of people living at the Home and the results indicated high levels of satisfaction with the overall service. Both reports identified areas in need of development and improvement and the service provider put action plans in place to address these. This inspection identified that some of these issues (particularly those relating to staff recruitment) have not been addressed indicating that the action plan has not yet been fully implemented. The manager has a very hands-on approach to care in the Home; this has the benefits seen in her close relationship with residents but has an impact on the strategic aspects of her role. The service provider is planning to recruit a care co-ordinator; part of this person’s role will be to strengthen the monitoring of care on each shift. A guest services manager was recently appointed to line manage the housekeeper and the catering manager. These initiatives should free some of the registered manager’s time so that outstanding matters are put right quickly. The Home has minimal involvement in the management of residents’ personal finances; either residents attend to this themselves, thus maintaining their independence, or relatives are asked to assist them. There is a framework for individual and group supervision, including a calendar for scheduling supervision sessions during the year. There is a formal written agreement with staff about the content and format of supervision and written notes of meetings are kept. Health and safety is generally well managed with maintenance procedures that ensure faults are put right promptly, either by the in house handyman or by external contractors. It was however found that the Home does not have nay records of the maintenance of bedrails; this is essential to minimise any risk to residents from faulty rails going unnoticed. A notice about fire safety contained ambiguous information about how staff should respond when they suspect there may be a fire. This was pointed out to the manager who agreed to seek clarification from an external fire safety consultant. The staff training programme covers mandatory safety related topics and staff spoken to confirmed they take part in this. Infection control is well managed with necessary equipment available and relevant training provided. Stocks of gloves and aprons in two bathrooms were low on the first day of the Ross Court DS0000024732.V328119.R01.S.doc Version 5.2 Page 24 inspection; the manager arranged for these to be replenished as soon as it was drawn to her attention. Ross Court DS0000024732.V328119.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 4 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 Ross Court DS0000024732.V328119.R01.S.doc Version 5.2 Page 26 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 OP29 Regulation 19, Schedule 2 Requirement The staff recruitment procedures must be improved to minimise the risk of any unsuitable staff being appointed. This must include taking reasonable steps to authenticate references, exploring gaps in employment history and ensuring that staff photographs and documentary proof of identity are held on staff files. A programme of regular maintenance of bedrails must be established to ensure that they are kept in good working order. This is essential to reduce the risk of accidents involving the use of bedrails. Timescale for action 30/04/07 2 OP38 13(4), 23(2)(c) 30/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ross Court DS0000024732.V328119.R01.S.doc Version 5.2 Page 27 1 OP1 2 3 OP1 OP7 4 5 6 7 OP25 OP29 OP30 OP33 Work on producing the service user guide in alternative formats needs to be completed so that prospective and current service users can be offered the information in the format most suited to them. The service provider should consider reviewing the wording of the statement of purpose in line with plain English principles. Staff need to be more diligent about always recording information about the care given so that the Home has robust information to evaluate and monitor the care provided. The service provider should provide small windows in all the rooms with patio doors so service users can have natural ventilation without having to open the doors. The service provider is strongly advised to implement the use of written interview records. Induction training sessions need to be individually dated and signed by the staff member and the person training them The service provider needs to monitor the action taken to put things right following internal quality assurance audits and other reviews. Ross Court DS0000024732.V328119.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Ross Court DS0000024732.V328119.R01.S.doc Version 5.2 Page 29 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!