Inspection on 12/05/05 for Soroptimist House

This inspection was carried out on 12th May 2005.

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

Soroptimist House 15/05/06

Soroptimist House 22/06/04

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 Soroptomist House 91 Tettenhall Road Chapel Ash Wolverhampton WV3 9PG Lead Inspector Ian Harris Unannounced 12 May 2005 09:00 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 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. Soroptomist House E56 000030054 Soroptomist House V225049 UI 120505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Soroptomist House Address 91 Tettenhall Road, Chapel Ash, Wolverhampton, WV3 9PG Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01902 710581 01902 710581 Wolverhampton Soroptomist House Association Annette Massey Care Home only 30 Category(ies) of Old Age (30) registration, with number of places Soroptomist House E56 000030054 Soroptomist House V225049 UI 120505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1) Category, old age not falling within any other category including females over the age of 60 years. Date of last inspection 13/09/2004 Brief Description of the Service: The home is a modern purpose-built building situated on the main road approximately one mile from Wolverhampton city centre with convenient access to public transport and the local shops. The home accommodates 30 residents, in single bedrooms, on three floors. There is a passenger lift that serves all floors. There is also a communal dining room, which has recently been extended, comfortable lounges and a well-equipped kitchen. There are well-maintained gardens at the front and the rear of the premises. Soroptomist House E56 000030054 Soroptomist House V225049 UI 120505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 5 hours. The main purpose of the inspection was to check the progress made by the home regarding the recommendations and requirements made in the last inspection report. The fullest co-operation was given to the inspection officer by the Care Manager, staff and residents. During the inspection a tour of the premises took place and staff and care records were inspected. Also staff rotas and general records regarding the maintenance of the home were checked. 6 of the 22 staff were on duty, and 10 of the 29 residents were spoken to. On the day of inspection the atmosphere within the home was found to be warm, friendly and comfortable with contented residents. What the service does well: What has improved since the last inspection? There have been considerable improvements made to the home’s environment since the last inspection. The top floor corridors, lobby , ground floor corridors Soroptomist House E56 000030054 Soroptomist House V225049 UI 120505 Stage 4.doc Version 1.30 Page 6 and 6 residents bedrooms have all been redecorated. New light fittings have been fitted to the top floor and a old fire door on the ground floor has been replaced. A new revised Induction Programme for staff has been implemented and a Quality Assurance system is now in place. 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. Soroptomist House E56 000030054 Soroptomist House V225049 UI 120505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Soroptomist House E56 000030054 Soroptomist House V225049 UI 120505 Stage 4.doc Version 1.30 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 standard(s) 2,3, and 6 The statement of terms and conditions used by the home meet the standard All the residents who are funded by the Local Authority undergo a full multidisciplinary assessment prior to admission. The resident’s, who are self funding are assessed by the Care Manager, using the homes assessment forms. The home does not provide intermediate care EVIDENCE: The statement of terms and conditions used by the home meets the standard and there are signed copies in the resident’s files. All the residents who are funded by the Local Authority undergo a full multi-disciplinary assessment prior to admission. The residents’ who are self funding are assessed by the Care Manager, using the homes assessment forms. Copies of the assessment ,Care Plan and Reviews are on the residents’ files. The home does not provide intermediate care Soroptomist House E56 000030054 Soroptomist House V225049 UI 120505 Stage 4.doc Version 1.30 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 standard(s) 7,8, And 9 Each resident has a comprehensive individual care plan that is reviewed on a monthly basis. It was noted that the folder system being used for case files can be improved on by introducing ring binders, which have separate compartments for medical, finance, correspondence etc. The home has good contact with local G.P. s. local hospitals and paramedical services. The systems for the administration and recording of medication are good with clear and comprehensive arrangements being in place to ensure residents’ medication needs are met. EVIDENCE: The home provides a comprehensive Care Plan for each individual resident based on the initial assessment. The Care Plans are drawn up by the Care Staff in consultation with the resident and their family. There was evidence on the files to show the care Plans are being carried out and reviewed on a monthly basis. The home is well supported by local G. P. s. and all of the paramedical services. Wherever possible, the residents are encouraged to retain their own G. P s, Opticians, and Dentists. It was noted that if the resident has moved out Soroptomist House E56 000030054 Soroptomist House V225049 UI 120505 Stage 4.doc Version 1.30 Page 10 of their area the Care Manager ensures that, these services are provided by local practitioners. The records indicate that residents’ medical needs are being met. Medication is administered by means of a Boot’s monitored dosage system. The system appears to be working very well. The home receives good support from the Boot’s pharmacist who does a three monthly audit of the houses medication. All care Senior Staff have been trained to use the system before they are allowed to administer medication. The home has very good policies and procedures, which are used as an integral part of the staff induction programme. Soroptomist House E56 000030054 Soroptomist House V225049 UI 120505 Stage 4.doc Version 1.30 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 standard(s) !2 and 15 The home provides a good programme of social activities within and outside of the home, which are designed to meet the resident’s capabilities, which the staff encourage the residents to pursue. The Care Manager and staff encourage family and friends to maintain good contact with their relatives at the home. The meals in the home are good offering both choice and variety and also catering for special dietary needs. EVIDENCE: The Care Manager stated that the residents are consulted regarding the dayto-day running of the home through residents meetings and by feedback from their key-workers. The key-workers also identify interests that the residents wish to pursue. A regular programme of musical evenings, board- games, sing-a-longs, quizzes and church services is organised within the home. Also the care manager has organised trips to the theatre, garden centres and Pub lunches, which are very popular. Most resident have good contact with their relatives and a good number of residents go out with their family on a regular basis. Family and friends are welcomed at the home and are invited to attend parties and other celebrations. Soroptomist House E56 000030054 Soroptomist House V225049 UI 120505 Stage 4.doc Version 1.30 Page 12 The observations made and the comments received from the residents and their relatives confirmed that particular attention is given to the resident’s individual preferences. It was noted that breakfast is served in resident’s bedrooms on individual trays. In regards to food all the comments made by residents regarding the quality, quantity and variety of food provided were highly complimentary. Soroptomist House E56 000030054 Soroptomist House V225049 UI 120505 Stage 4.doc Version 1.30 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 standard(s) 16 and 18 The home has a satisfactory complaints system and the residents feel their views are listened to and acted upon. The home has good policies and procedures regarding protection from abuse, which includes a whistle blowing policy. EVIDENCE: The home has a very good complaints procedures and all complaints are recorded in a complaints book. Residents and their families are given a copy of the complaints procedure at admission and there are copies readily available in the reception area. From the records it was noted that no formal complaint has been made since the last inspection. The home has good policies and procedures regarding Restraint, dealing with Aggressive Behaviour and Prevention of Abuse, which includes a WhistleBlowing policy. These issues are also covered in the N.V.Q. training, which the Staff have or are undertaking. Soroptomist House E56 000030054 Soroptomist House V225049 UI 120505 Stage 4.doc Version 1.30 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 standard(s) 19 and 26 The residents live in a well maintained comfortable environment which could be further improved. EVIDENCE: There is a good programme of refurbishment and redecoration in the home. The home is maintained to a high standard. However it was noted that the Carpets in the corridors still have not been replaced and are spoiling the appearance of the home. There is a double glazed window in the lounge that has steamed up and needs replacing. It was also noted that the home needs more parking spaces and the car park need repairing. The home was found to be clean and tidy and free from odour. The home has good policies and procedures regarding infection control and all the staff have received training in food hygiene All staff appeared to be conscious of the dangers of cross infection. Soroptomist House E56 000030054 Soroptomist House V225049 UI 120505 Stage 4.doc Version 1.30 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 30 The home is well staffed with adequate numbers and skill mix of staff. The staff have a very good understanding of the residents support needs. This is evident from the positive relationships which have been formed between staff and residents. The home has good policies and procedures regarding the recruitment of staff which include all the appropriate staff checks and references. There is a good training programme in place that ensures that the staff are competent to do their job. EVIDENCE: The inspection of staff rotas and discussions with staff indicated that the home is well staffed. There is a good balance within the staff group, which includes experience, mature and younger staff who are embarking on a new career The Care Manager and staff are committed to developing their knowledge and skill through training. The home has a good induction programme and training programme, which meets the T.O.P.S.S standards. In addition to the N.V.Q training programme staff have attended training courses on the following subjects. Manual handling and lifting, Fire prevention, First Aid and Basic Food Hygiene, infection control and Safe Handling of Medication. Soroptomist House E56 000030054 Soroptomist House V225049 UI 120505 Stage 4.doc Version 1.30 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,36,37, and 38 The manager has very good leadership skill and has a clear development plan and vision for the home, which she has effectively communicated to the resident’s staff and relatives. The manager is well supported by the proprietor and demonstrates an awareness of her roles and responsibilities. All the records that were inspected, were found to be well maintained. However it was note, that the folder system being used for case files can be improved on by introducing ring binders, which have separate compartments for medical, finance, correspondence etc. The staff are not being supported by regular formal staff supervision meetings The commission is not receiving copies of the report of the monthly regulation 26 visits to the home. The home has good policies and procedures regarding Health and safety. It was noted, that the safety of the home is being compromised by the digital lock that has been fitted to the front door. EVIDENCE: Soroptomist House E56 000030054 Soroptomist House V225049 UI 120505 Stage 4.doc Version 1.30 Page 17 The Care Manager has considerable experience in managing homes for older people and has been in post for some years. There are clear lines of accountability within the Home. The Care Manager has regular supervision meetings with the proprietors representative. From observations made and discussions with residents and staff indicated that the Care Manager is very approachable and operates an open door policy. The staff and residents stated that they are happy to approach the Care Manager with any problems they might have. All the records and administrative procedures within the home that were inspected were found to be well maintained. However, it was noted that the folder system being used for case files can be improved on by introducing ring binders, which have separate compartments for medical, finance, correspondence etc. The home has a good heath and safety policy and all staff are aware of their responsibilities regarding these issues and a number of staff have received training. Fire fighting equipment is well maintained and the systems are regularly checked. However it was noted that the safety of the home is being, compromised by the digital lock that has been fitted to the front door. This must be removed immediately or wired up to the fire alarm in order for the lock to be released in the event of the fire alarm sounding. In regards to any accidents, they are all recorded in an appropriate record book. Soroptomist House E56 000030054 Soroptomist House V225049 UI 120505 Stage 4.doc Version 1.30 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 x x x 2 3 2 Soroptomist House E56 000030054 Soroptomist House V225049 UI 120505 Stage 4.doc Version 1.30 Page 19 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 19 Regulation 23 (2) (b) Requirement The registered person must replace ALL carpets in corridors, which are showing signs of wear and tear. (Timescale 0f 01/10/04 not met). The registered person must replace the steamed up window in the lounge on the ground floor(Timescale of 01/10/04 not met) The registered person must ensure that all staff members receive formal supervision meetings at least 6 times a year. The registered person must ensure that a copy of the report of the monthly regulation 26 visist the the home is sent to the commission. The registered person must ensure that the digital lock is removed from the front door our wired up to the fire alarm. Timescale for action 01/07/05 2. 19 23 (2) (b) 01/07/05 3. 36 18 ( C ) (i) 26 01/07/05 4. 36 01/06/05 5. 38 23 (4) (b) 12/05/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Soroptomist House E56 000030054 Soroptomist House V225049 UI 120505 Stage 4.doc Version 1.30 Page 20 No. 1. 2. Refer to Standard 19 38 Good Practice Recommendations That the registered person provides more parking spaces and repairs the car park. That the folder system being used for case files can be improved on by introducing ring binders, which has separate compartments for medical, finance, correspondence etc. Soroptomist House E56 000030054 Soroptomist House V225049 UI 120505 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection 2nd Floor St Davids Court Union Street Wolverhampton WV1 3JE 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 Soroptomist House E56 000030054 Soroptomist House V225049 UI 120505 Stage 4.doc Version 1.30 Page 22 - 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. 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