Inspection on 15/05/06 for Soroptimist House

This inspection was carried out on 15th May 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 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

Soroptimist House 12/05/05

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 Soroptimist House 91 Tettenhall Road Chapel Ash Wolverhampton West Midlands WV3 9PG Lead Inspector Mr Ian Harris Unannounced Inspection 15th May 2006 08:00 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 Soroptimist House DS0000030054.V294639.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. Soroptimist House DS0000030054.V294639.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Soroptimist House Address 91 Tettenhall Road Chapel Ash Wolverhampton West Midlands WV3 9PG 01902 710581 01902 710581 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) Wolverhampton Soroptimist Housing Association Miss Annette Massey Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Soroptimist House DS0000030054.V294639.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Old age,not falling within any other category including females over 60 years of age. 17th August 2005 Date of last inspection 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. Soroptimist House DS0000030054.V294639.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a Key unannounced inspection and took place over 5 hours. The fullest co-operation was given to the inspection officer by the Care Assistant 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 23 staff were on duty, and 8 of the 28 residents were spoken to. On the day of inspection the atmosphere within the home was found to be warm, friendly, comfortable and safe with contented residents. This was confirmed by the comments made by the residents spoken to that they were well looked after happy and content. 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 first floor corridors and stairs down to the Soroptimist House DS0000030054.V294639.R01.S.doc Version 5.1 Page 6 ground floor have been re-carpeted and six bedrooms have been redecorated. The double glazed windows that had steamed up have been replaced. 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. Soroptimist House DS0000030054.V294639.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 Soroptimist House DS0000030054.V294639.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Appropriate assessments of need are in place and are carried out. The home does not provide intermediate care they only provide short stay and introductory stays when the home has a vacancy. The home has good policies and procedures regarding assessment and admission. EVIDENCE: There is evidence on the residents files that 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. All the residents are permanent. The home does not provide intermediate care. Soroptimist House DS0000030054.V294639.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): 7, 8, 9, and 10 Each resident has a comprehensive, individual care plan that is reviewed on a monthly basis. The home has good contact with local G.P. s. local hospitals and paramedical services, which ensures that resident’s health needs are met. The systems for the administration of medication are good with clear and comprehensive recording arrangements being in place to ensure resident’s 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 Soroptimist House DS0000030054.V294639.R01.S.doc Version 5.1 Page 10 G. P s, Opticians, and Dentists. It was noted that if the resident has moved out of their area the Care Manager ensures that, these services are provided by local practitioners. The records indicate that resident’s medical needs are being met this was confirmed by a number of residents and through observation on the day of inspection. Medication is administered by means of a Boots monitored dosage system. The system appears to be working very well. The home receives good support from a Boots pharmacist who does a three monthly audit of the homes medication. All Senior Staff have been trained to use the system before they are allowed to administer medication and are currently under going a Safe Handling of Medication training course. The home has very good policies and procedures, regarding the administration, storage and recording of medication. Soroptimist House DS0000030054.V294639.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, and 15 The Staff work in close liaison with residents and their relatives to understand their individual lifestyles and preferences in order that these can be continued when they move into the home. Individuals are enabled to exercise choice and control over their lives wherever possible balancing the rights and risks with each individual The meals in the home are good homely type offering both choice and variety and also catering for special dietary needs. EVIDENCE: Residents and staff confirmed that the residents are consulted regarding the day-to-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, boardgames, Keep Fit, Bingo, and church services, are organised within the home. The staff at the home encourages regular contact between residents and their relatives by inviting them to coffee mornings, parties, fetes and celebrations. It was noted that approximately 6 resident’s are regularly taken out by their relatives. The observations made, examination of menus and the comments received from the residents and their relatives confirmed that particular attention is Soroptimist House DS0000030054.V294639.R01.S.doc Version 5.1 Page 12 given to the residents’ individual preferences. Most of the comments made by residents regarding the quality, quantity and variety of food that is provided was complimentary. Soroptimist House DS0000030054.V294639.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 and 18 The home has a satisfactory complaints system and there is evidence that residents’ and their families feel that 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 comprehensive complaints procedure. The residents and relatives are made aware of the procedure through the statement of their terms and conditions of residence the service users guide, copies of which are placed in all residents’ bedrooms and copies are also placed on the notice board in the hall. The home has a complaints file in which all complaints are recorded. It was noted that the home has received no formal complains’ since the last inspection this and all minor complaints are dealt with appropriately and quickly. 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 all care Staff has undergone. Soroptimist House DS0000030054.V294639.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 and 26 The standard of the environment is good providing service users with a safe well-maintained environment to live in. The standard of cleanliness reflects the on-going cleaning schedule, which maintains this standard throughout the home. EVIDENCE: There is a good programme of refurbishment and redecoration within the home. The home is maintained to a high standard. It was noted that the programme of replacing the carpets in the corridors and stairs has started with the top floor down to the second floor completed. Also the lounge and dining room have been re-carpeted. Six residents bedrooms have been redecorated and the number of double glazed window in the resident’s bedrooms that has steamed up have been replaced. It was also noted that the carpets in the ground floor corridors and hall need replacing and the taps in the first floor bathroom are leaking badly. The staff stated that this bathroom is hardly used. It is recommended that this bathroom is converted into a walk in/ wheelchair shower room Soroptimist House DS0000030054.V294639.R01.S.doc Version 5.1 Page 15 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. Soroptimist House DS0000030054.V294639.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 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. The home has good policies and procedures regarding the recruitment of staff, which includes all the appropriate staff checks and references. 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 home operates an efficient recruitment procedure and has registered with the West Midlands Homes Association in order to complete the appropriate checks on staff. There was evidence within the home that all the checks are being carried out. On inspection of the staff files it was noted that there was no record of staff induction or formal supervision taking place. Soroptimist House DS0000030054.V294639.R01.S.doc Version 5.1 Page 17 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 and 38 The home is a well managed, where service users interests and welfare is well promoted. The systems for resident consultation are good with evidence suggesting that their views are sought and acted upon EVIDENCE: The Care Manager has been in post for a good number of years and is qualified in both practice and management and has considerable experience in caring for older people, in a residential home setting. There are clear lines of accountability within the home and the manager is well supported by the management committee. Observations made and discussions with residents and staff indcated that the Care Manager is very approachable and operates an open door policy and is proactive in meeting all the residents on a daily basis. The staff and residents who could express themselves stated that they are happy to approach the Care Manager with any problems they might have and are confident that they will Soroptimist House DS0000030054.V294639.R01.S.doc Version 5.1 Page 18 be resolved. The routines and activities within the home are flexible and built around the needs of the residents. There was also evidence to show that staff consult with the residents regarding the choice of meals and activities within the home. There are regular resident meetings where residents are consulted about menus and entertainment etc. Also the Key-Worker system in operation is designed to ensure residents’ wishes are responded to. All the records and administrative procedures within the home that were, inspected were found to be well ordered and maintained. 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 on these issues. All safety equipment is checked and well maintained. Soroptimist House DS0000030054.V294639.R01.S.doc Version 5.1 Page 19 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 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X 2 X 3 Soroptimist House DS0000030054.V294639.R01.S.doc Version 5.1 Page 20 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 OP19 Regulation 23 (2) (b) Requirement The registered person must ensure the carpets in the Hall and corridors on the ground floors are replaced. The registered person must ensure that all new staff receive formal induction training. The registered person must ensure that all staff receive formal supervision at least six times a year. Timescale for action 01/08/06 2. 3. OP 30 OP 36 18 18 01/08/06 01/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP19 Good Practice Recommendations That the first floor bathroom be converted into a walk in / wheelchair shower room. Soroptimist House DS0000030054.V294639.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Wolverhampton Area Office 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 Soroptimist House DS0000030054.V294639.R01.S.doc Version 5.1 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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