Inspection on 19/07/05 for Steeton Court

This inspection was carried out on 19th July 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

Steeton Court 08/08/07

Steeton Court 10/08/06

Steeton Court 12/01/06

Steeton Court 15/12/04

Steeton Court 10/06/04

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

CARE HOMES FOR OLDER PEOPLE Steeton Court Steeton Hall Gardens Steeton Keighley BD20 6SW Lead Inspector Mary Bentley Unannounced 19 July 2005 09:30am 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. Steeton Court v239672 j52 j03 s19890 steeton court v239672 190705 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Steeton Court Address Steeton Hall Gardens Steeton Keighley BD20 6SW 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) 01535 656124 01535 658436 Mr A Spellman Care Home with Nursing 72 Category(ies) of Old Age (72) Terminally Ill (5) Physical Disability registration, with number (5) of places Steeton Court v239672 j52 j03 s19890 steeton court v239672 190705 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: That three of the places under the category of PD are for named individuals. Date of last inspection 15/12/04 Brief Description of the Service: Steeton Court is a purpose built property located in a residential area of Steeton close to local amenities and public transport routes. The home is registered to provide care to a total of 72 people. Steeton Court is registered to provide nursing care to older people and there are also a number of places dedicated to the care of the terminally ill. The home is built on two floors with access to the first floor by means of two passenger lifts and stair lift. The new passenger lift can accommodate stretchers. Accommodation is provided in 62 single and 5 double rooms and all but one have en-suite facilities. There is ample provision of communal space and the new conservatory provides direct access to the grounds from first floor. Steeton Court has extensive well-maintained gardens that are easily accessible to wheelchair users. Car parking is provided at the front of the building. Steeton Court v239672 j52 j03 s19890 steeton court v239672 190705 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection year runs from April to March and within that time, the CSCI must do a minimum of two inspections of all care homes. This was the first inspection for this year. It was unannounced and carried out by one inspector between 9.30 am and 4.00 pm on 19 July 2005. A new manager started in the home in May 2005 and the main purpose of this visit was to meet the manager, to assess what impact the change of management was having on the delivery of care and to follow up progress on the requirements made at the last inspection, which was carried out in December 2004. The methods used in this inspection included discussions with residents’, visitors, staff and management, examination of care records, observing care staff carrying out their duties and looking at some parts of the home. Comment cards were left at the home to be given to residents and relatives. These cards provide an opportunity for people to share their views of the home with the CSCI. Comments received in this way will be shared with the provider without revealing the identity of those completing them. What the service does well: What has improved since the last inspection? Staffing levels have been increased and for the most part service users said that there were enough staff to meet their needs without waiting too long. Steeton Court v239672 j52 j03 s19890 steeton court v239672 190705 stage 4.doc Version 1.40 Page 6 Changes have been made in the kitchen, service users said that the food was good and if they did not like what was on the menu they could have something different. 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. Steeton Court v239672 j52 j03 s19890 steeton court v239672 190705 stage 4.doc Version 1.40 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 Steeton Court v239672 j52 j03 s19890 steeton court v239672 190705 stage 4.doc Version 1.40 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) 1, 3 & 5. Standard 6 does not apply to this home. People are able to make an informed decision about the home from the written information they receive and from what they see when they visit the home. EVIDENCE: The Statement of Purpose is available in the home; it is updated as things change within the home. Visitors said they had visited the home when looking for a place for their relative; they liked Steeton Court because they saw that the people living there looked content and were occupied. Another visitor said that the manager had come to visit them in their own home before their relative was admitted. Steeton Court v239672 j52 j03 s19890 steeton court v239672 190705 stage 4.doc Version 1.40 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) These standards were not inspected EVIDENCE: Steeton Court v239672 j52 j03 s19890 steeton court v239672 190705 stage 4.doc Version 1.40 Page 10 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) 12, 13, 14 & 15 People living in the home are encouraged to take part in social and leisure activities, to keep in contact with their friends and family and to exercise choice and control over their lives. EVIDENCE: The programme of activities is displayed and service users were happy with the range offered. These include bingo, quizzes, scrabble and entertainers. There are regular trips to places like the Lake District and St Anne’s and people said how much they had enjoyed a BBQ held last week. The activities organiser produces a regular newsletter; it includes information about planned events. One service user who had recently been admitted to the home said she was happier now than she had been for years. There are communal areas where service users can spend their time. Those who prefer to remain in their own rooms can do so. There are no restrictions on visiting and visits can take place in private. Some service users have their own phones and there is a phone that can be plugged into a phone point in the bedrooms so that phone calls can be made in private. Steeton Court v239672 j52 j03 s19890 steeton court v239672 190705 stage 4.doc Version 1.40 Page 11 Service users said that the food was good and that alternatives to the published menu are available on request. Steeton Court v239672 j52 j03 s19890 steeton court v239672 190705 stage 4.doc Version 1.40 Page 12 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 & 18 Residents’ are protected by the homes complaints and adult protection procedures. EVIDENCE: The complaints procedure is displayed in the home and service users said they knew how to raise concerns. The home keeps a record of all complaints. During the inspection one relative made a complaint, which the manager is investigating. The manager is aware of the local authority Adult Protection procedures and all staff are due to have training on issues relating to abuse and adult protection in August. Steeton Court v239672 j52 j03 s19890 steeton court v239672 190705 stage 4.doc Version 1.40 Page 13 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 & 26 Service users live in a comfortable, clean and safe environment. The system used to identify service users personal clothing creates the opportunity for clothing to be given to the wrong people. EVIDENCE: All parts of the home that were seen were clean, free of odours and well maintained. An Environmental Health Officer inspected the kitchen on 19 July 2005 and no action was needed. The home had an inspection by an officer from the Health and Safety Executive and as a result of this visit a programme of moving and handling training for staff has been put in place. One service user said some of her clothing had been mislaid in the laundry but most of it had now been returned to her. The home helps service users to Steeton Court v239672 j52 j03 s19890 steeton court v239672 190705 stage 4.doc Version 1.40 Page 14 make sure their clothes are properly marked by ordering name tapes if requested, however some items of clothing in the laundry were still marked with initials in pen. Marking clothes in this way is not recommended as it is likely to cause problems when there are a number of service users with the same initials and because the ink tends to fade with washing. Steeton Court v239672 j52 j03 s19890 steeton court v239672 190705 stage 4.doc Version 1.40 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 The numbers of staff working in the home are sufficient to meet the needs of service users. EVIDENCE: Staffing levels have been increased and for the most part service users were satisfied that there were enough staff to meet their needs. Staff felt that they now had more time to attend to service users needs. The home uses agency staff where necessary to cover for vacancies or absence. One visitor said that the staff at weekends did not seem to be as experienced as those working during the week. They were concerned that their relative was not getting the help needed, with their permission the manager was told about these concerns and a meeting was arranged to discuss them. The manager is working with staff to develop the role of senior care assistants within the home. Steeton Court v239672 j52 j03 s19890 steeton court v239672 190705 stage 4.doc Version 1.40 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 & 33 The home is well managed and the views of service users and their representatives are taken into account. EVIDENCE: The manager is a nurse with several years experience in the care of older people. The law requires that all care home managers be registered with the CSCI, the manager has sent in her application and this is being dealt with. The manager sent out questionnaires to all relatives when she started, the responses highlighted a number of areas where people felt the service could be improved, these included staffing levels, laundry services, involvement of relatives in care planning and the decoration in the dining room. The manager has done an action plan to address these issues. A residents/relatives meeting is planned for July 26th 2005 and the manager said she would be sending a questionnaire to residents after this meeting. Steeton Court v239672 j52 j03 s19890 steeton court v239672 190705 stage 4.doc Version 1.40 Page 17 A questionnaire was given to staff and meetings have been held with staff from all departments in the home. Plans to improve the service have been discussed at these meetings. Staff said the manager is fair and approachable. The owner visits the home regularly and reports of these visits are sent to the CSCI. Steeton Court v239672 j52 j03 s19890 steeton court v239672 190705 stage 4.doc Version 1.40 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 3 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 2 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 3 3 x x x x x Steeton Court v239672 j52 j03 s19890 steeton court v239672 190705 stage 4.doc Version 1.40 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 7 Regulation 15 Requirement Service users plans must set out in detail how all the needs identifed by the assessment process will be addressed. The plans must provide evidence of involvement by service users and/or their representatives. All the records relating to individual service users must be clearly named. Carried forward from the last inspection. When service users are identified as being at risk of developing pressure sores a care plan must be put in place to address the risk. Care plans relating to wound care must be maintained up to date. Weights must be recorded in accordance with the instructions in the care plans. Carried forward from the last inspection. Steeton Court v239672 j52 j03 s19890 steeton court v239672 190705 stage 4.doc Version 1.40 Page 20 Timescale for action 31 October 2005 2. 8 17 Sch 3.3(m) & (j) 31 October 2005 3. 26 16(2) (e) 4. 28 18 The provision of laundry services must be reviewed to ensure that service users personal clothing is clearly identified. A minimum of 50 of care staff must achieve NVQ level 2 or equivalent within the target timescale Carried forward from the last inspection. All staff must be provided with a programme of training that meets the workforce training targets of content and timescales. 30 September 2005 31 December 2005 5. 30 18 31 October 2005 6. 38 13(4)(a) Carried forward from the last inspection. The pantries where the hot water 30 boilers are located must be kept September locked when not in use. 2005 Carried forward from the last inspection. 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 7 Good Practice Recommendations It is recommended that the use of pre-printed care plans be reviewed. It is recommended that the pre-admission assessment be reviewed and updated following admission so that staff are better able to make an assessment of the service users needs within the home environment. Carried forward from the previous inspection. Steeton Court v239672 j52 j03 s19890 steeton court v239672 190705 stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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. 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