Inspection on 10/08/06 for The Cottage

This inspection was carried out on 10th August 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Cottage 03/07/08

The Cottage 08/08/07

The Cottage 16/01/06

The Cottage 26/07/05

The Cottage 28/02/05

The Cottage 31/08/04

The Cottage 25/02/04

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE The Cottage 1a Church Street Rastrick Brighouse West Yorkshire HD6 3NF Lead Inspector Liz Cuddington Unannounced Inspection 11:00 10th August & 6 September 2006 th 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 The Cottage DS0000000986.V293595.R02.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. The Cottage DS0000000986.V293595.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Cottage Address 1a Church Street Rastrick Brighouse West Yorkshire HD6 3NF 01484 718808 None 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) Mr Ian Robert Moffat Mrs Jennifer Moffat Mrs Elaine Wood Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places The Cottage DS0000000986.V293595.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th January 2006 Brief Description of the Service: The Cottage is a converted property situated on the main road into Rastrick, coming from Huddersfield. Although the road can be busy during the day it is quiet at night. Once inside the home the traffic noise is minimal. The home is close to some local shops. The Cottage is a family owned home providing personal care and accommodation for nineteen men and women over the age of 65 years. The living accommodation is over two floors with a stair lift linking the ground and first floors. There is a conservatory and patio to the rear of the property. The home has a small car park and there is parking on nearby streets. The current fees are between £335.50 and £379.00 per week. The Cottage DS0000000986.V293595.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group, for example ‘Choice of Home’, and ‘Health and Personal Care’. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers these outcomes to the people who use the service. The judgement categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded in the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk Over an inspection year care homes usually have one or two inspections; these may be announced or unannounced. One inspector carried out the site visit, which lasted six hours over two days. The methods I used to gather information included conversations with residents and staff, case tracking, examining records and touring the house. I also sent out questionnaires for residents and their relatives to complete. This purpose of the inspection was to assess a selection of the National Minimum Standards for Older People. I looked at twenty-two of the thirty-eight standards. At the last inspection in January 2006 I made five requirements and three good practice recommendations. Six requirements and two good practice recommendations have been made been made following this inspection. Two of these requirements are brought forward from the January 2006 inspection report. Although there are still a number of areas for improvement the home continues to make significant improvements. The outcomes for residents in three of the seven outcome groups were judged to be “good”. The remaining four groups were judged as “adequate”. This means that the overall judgement for The Cottage is “adequate”. I would like to thank everyone who lives and works at The Cottage for their welcome and hospitality during the inspection. What the service does well: The care plans are clearly set out and show how each person’s needs are being met and regular reviews are carried out. Staff are aware of individual needs, which are respected and supported, and residents’ privacy and dignity is maintained. The Cottage DS0000000986.V293595.R02.S.doc Version 5.2 Page 6 Visitors are welcomed to the home. Residents and visitors confirmed that the care and support they receive from the staff at The Cottage is very good. They spoke highly of the caring approach of the staff and the welcoming and homely atmosphere in the home. My own observations of the interaction between residents and staff confirmed this view. The meals are good and varied and any assistance needed is offered discreetly. The dining tables are properly laid before the meals and if anyone prefers to stay in their armchair their table is also laid with a mat, cutlery, napkin and their choice of drink. Residents and relatives are aware of how to make a complaint. The home has suitable adult protection policies and procedures. The staff are well qualified, with ten of the twelve care staff having achieved a recognised care qualification. The manager is also sufficiently qualified and experienced to run the home. Enough staff are employed to meet the needs of the residents and the home. Criminal Records Bureau and Protection of Vulnerable Adults register checks have been carried out for staff. What has improved since the last inspection? What they could do better: The Statement of Purpose and Service Users’ Guide still do not include all of the required information outlined in the Care Homes Regulations 2001 and Schedule 1 of the Regulations. The home’s management have not yet developed and implemented a comprehensive quality assurance system. The method used to take medicines to residents needs to be changed to minimise any potential risks. The staff files show that in the past not everyone has provided sufficient, suitable references. This needs to be improved for newly recruited staff. All The Cottage DS0000000986.V293595.R02.S.doc Version 5.2 Page 7 care staff should have regular, individual supervision with their line manager. Detailed training records must be kept for all members of staff. To support the home’s infection control procedures there needs to be a separate wash hand basin installed in the laundry, for staff to use after handling soiled washing. All staff need to wear suitable protective clothing and wash their hands before entering the kitchen. 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 Cottage DS0000000986.V293595.R02.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 The Cottage DS0000000986.V293595.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 Standard 6 does not apply Quality in this outcome area is adequate. This judgement has been made using the available evidence, including a visit to the service. The Statement of Purpose and Service Users’ Guide do not contain all the necessary information. The pre-admission assessments are kept in the old resident files. Relevant assessments need to be kept with the working care plan file. EVIDENCE: The Statement of Purpose and Residents Guide were examined and still do not contain all the information outlined in the Care Homes Regulations 2001 and Schedule 1 of the Regulations. It has been a statutory requirement since the 1st April 2002 that all registered care homes produce these documents and that they must include all of the information specified in the Regulations. Pre-admission assessments, carried out by the home and Social Services, must be kept in the resident’s care plan as they are used as the basis for the plan. The Cottage DS0000000986.V293595.R02.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using the available evidence, including a visit to the service. The new care plan format has now been implemented. The plans are clearly set out and show how each person’s needs are being met. Regular reviews are carried out. Medications are securely stored. There were some minor administrative errors and a better system for administering medicines needs to be implemented. Staff are aware of individual needs and residents’ privacy and dignity is maintained. EVIDENCE: The care plans I examined showed in detail how each person’s care is to be provided. Staff regularly review the care plans, along with the resident or their relatives. The signatures on the plans confirm this. The Cottage DS0000000986.V293595.R02.S.doc Version 5.2 Page 11 The care plans detail how each individual’s health is to be promoted. Advice from healthcare professionals is sought when needed and the actions taken are clearly documented. Each person has a weight chart and any special skin care needs are noted. The medications are securely stored and when a member of staff administers medicines the record charts are signed at the same time. The record charts show when someone has not taken a dose of their medicine, and the reason. When I checked the amounts of medicines in stock against the amounts received and administered, I found errors on two occasions. Otherwise the records were accurate. The home plans to make a new, more convenient area for storing medicines. At present the staff put each resident’s medicines into a pot and carry it to them. Although only one person’s medicines are administered at a time, and the staff are very careful, there is still a potential margin for error. Creation of the new storage room would be helpful. Meanwhile, the home needs to implement a safer system, such as bringing the medicines to the residents and administering them directly from the pharmacist’s packaging. My own observations confirmed that staff are very aware of each person’s needs and support was offered in a considerate way, maintaining the individual’s dignity and privacy. The Cottage DS0000000986.V293595.R02.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using the available evidence, including a visit to the service. Individual needs and preferences are respected and supported. Visitors are welcomed to the home. The meals are good and varied and any assistance needed is offered discreetly. Privacy and dignity is respected. EVIDENCE: Residents’ interests are recorded in their care plans. Staff know people’s preferences and offer any support needed to make sure that chosen interests and lifestyles can be followed. One resident told me that the staff would always help her if she asked. I saw another resident enjoying being given a manicure by a member of staff. I read information in some care plans that detailed the person’s cognitive or sensory impairments. Any actions, which need to be taken, had been noted. During this and previous inspections I saw that visitors are always welcomed. One visitor who spoke to me confirmed this and said that he was offered lunch, if he was there at lunchtime. Residents and visitors confirmed that the care and support they receive from the staff at The Cottage is very good. They spoke highly of the caring approach The Cottage DS0000000986.V293595.R02.S.doc Version 5.2 Page 13 of the staff and the welcoming and homely atmosphere in the home. My own observations of the interaction between residents and staff confirmed this view. Where residents manage their own finances this was clearly documented in the care plans. Everyone who commented said they liked the meals. The chef adapts the menus to suit the residents’ requirements and preferences. At lunchtime there is a choice of two main courses. On the first day of the inspection the choice was either pork chops or minced beef pie with a selection of vegetables. The chef is aware of individual likes and dislikes and can meet any special dietary needs. One resident sets the dining tables before the meals and if anyone prefers to stay in their armchair their table is also properly laid with a mat, cutlery, napkin, and their choice of drink. The Cottage DS0000000986.V293595.R02.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using the available evidence, including a visit to the service. Residents and relatives are aware of how to make a complaint. The home has suitable adult protection policies and procedures. EVIDENCE: The surveys completed by people who live at The Cottage, as well as comments made by the relative of one resident, confirmed that people generally know how to make a complaint if they need to. One relative I spoke to said that when he has had any concerns he has spoken to the home’s management and they have resolved the concern satisfactorily. The home has adult protection and ‘whistle-blowing’ policies and procedures in place that cover the way any concerns or allegations of abuse or poor practice would be handled. The Cottage DS0000000986.V293595.R02.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using the available evidence, including a visit to the service. The home is generally well maintained. Improvements to the décor and furnishings have been started, since the last inspection. The laundry needs improvement to bring it up to present day standards. EVIDENCE: Since the last inspection the upstairs, smokers’ conservatory lounge has been re-decorated and refurbished and is now a much pleasanter place to sit. Some bedrooms and the upstairs corridors have been re-decorated since the last inspection. Some new carpets have also been fitted. The kitchen has been re-fitted and the chef said it is a great improvement and much better to work in. New kitchen flooring is to be laid soon. There are plans to refurbish the ground floor bathroom. The Cottage DS0000000986.V293595.R02.S.doc Version 5.2 Page 16 The rest of the house is well looked after, with a comfortable lounge, a conservatory and an outside patio with tables and chairs. There have not been any changes to the laundry since the last inspection, although I was told there are plans to refurbish the laundry in the next phase of improvements. This needs to be done with minimal delay as a safe, hygienic laundry supports the infection control measures within the home. The Cottage DS0000000986.V293595.R02.S.doc Version 5.2 Page 17 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 & 30 Quality in this outcome area is adequate. This judgement has been made using the available evidence, including a visit to the service. The staff are well qualified and are employed in sufficient numbers to meet the needs of the residents. Mandatory CRB and POVA checks have been carried out, but not all staff files show that other safe recruitment procedures have been completed. There were no staff training records available. Induction and foundation training packages for new staff are suitable. EVIDENCE: The staff rotas show that there are sufficient staff on duty at all times of the day and night to meet the needs of the residents and the home. Ten of the twelve care staff have completed a National Vocational Qualification (NVQ) in care. This is an excellent achievement. I examined six staff files. All showed that an up to date Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) check has been carried out. Most of the staff have been employed at The Cottage for a long time. Many do not have sufficient, suitable references. I was assured that any new recruits would provide two references, as well as all the other preemployment checks. The files I looked at contained completed appraisal forms and employment contracts. The Cottage DS0000000986.V293595.R02.S.doc Version 5.2 Page 18 There were no staff training records available although there was some evidence that staff have completed training courses. All the staff were booked to attend a basic emergency aid course soon after the site visit. The home has recognised induction and foundation training packages for new care staff. The Cottage DS0000000986.V293595.R02.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using the available evidence, including a visit to the service. The manager is sufficiently qualified and experienced to run the home. Staff are not currently having individual, recorded supervision sessions with their line manager. The home’s quality assurance systems need developing to make them effective. Opened food packages in the refrigerators and deep freezers are not being resealed and date labelled. Refrigerator and deep freezer temperatures are being recorded daily. The kitchen is clean and hygienically maintained. Staff continue to use the kitchen as a thoroughfare, and do not always wash their hands or wear protective clothing when entering the kitchen. Fire safety drills and lectures are either planned or have already been carried out. The Cottage DS0000000986.V293595.R02.S.doc Version 5.2 Page 20 EVIDENCE: The home’s manager has achieved the NVQ level 4 Registered Managers’ Award and is an NVQ assessor. The manager also has sufficient experience to manage the home. The quality assurance system is an area that the home’s owner, Mrs Moffat, has started working on. More informal methods of quality assurance, such as talking to residents and relatives to gain their views, already take place. One to one supervision sessions between staff and the manager do not appear to be taking place. Supervision needs to happen every two months, and a record of the discussion and outcomes kept. I looked at the refrigerators and deep freezers. Any opened packages need to be sealed and labelled with the date they were opened, to ensure good stock rotation. The refrigerator and deep freezer temperatures are being recorded daily. It would be helpful if there were a thermometer in each appliance to make checking quicker and ensure accuracy. The kitchen is clean and hygienically kept. However it is still being used as a thoroughfare by staff that, I noticed, do not always wash their hands or wear protective clothing when entering the kitchen. There is a wash hand basin in the kitchen and all staff should use it. Clean kitchen overalls or disposable plastic aprons, should be worn by staff when they enter the kitchen. The records showed that a fire drill had taken place in June 2006 and another is planned to take place before the end of the year. A fire safety trainer is to be employed to carry out additional staff training. The Cottage DS0000000986.V293595.R02.S.doc Version 5.2 Page 21 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 1 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 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 2 X X 2 X 2 The Cottage DS0000000986.V293595.R02.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? YES 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 OP1 Regulation 4&5& Schedule 1 Requirement The Statement of Purpose and Residents Guide must contain all the information required by the Care Home Regulations 2001. This is brought forward from the last inspection. Original timescale: 31/10/05 The method of administering medicines to residents must be revised to ensure it is completely safe. Staff hand washing facilities, separate to the sluice sink, must be fitted in the laundry. This is brought forward from the last inspection. Original timescale: 30/06/06 The staff files must show that all pre-employment checks have been carried out for all newly recruited staff. Records of all staff training must be kept. All care staff must have regular, individual supervision sessions with their line manager. Timescale for action 31/12/06 2. OP9 13(2) 31/10/06 3. OP26 13(3) 31/03/07 4. OP29 19 & Schedule 2 18 18(2) 31/12/06 5. 6. OP30 OP36 31/12/06 31/01/07 The Cottage DS0000000986.V293595.R02.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP33 OP38 Good Practice Recommendations The quality assurance systems need further development in order to obtain useful information. When entering the kitchen all staff should wear suitable protective clothing and wash their hands. The Cottage DS0000000986.V293595.R02.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 The Cottage DS0000000986.V293595.R02.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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