Inspection on 12/08/05 for The Cottage

This inspection was carried out on 12th August 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

The Cottage 22/01/08

The Cottage 18/01/07

The Cottage 13/12/05

The Cottage 09/11/04

The Cottage 15/07/04

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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 The Cottage 2050-2052 Hessle Road Hessle East Yorkshire HU13 9NW Lead Inspector Malcolm Stannard Unannounced 12 August 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. The Cottage J54_s841_The Cottage_v232823_120805_stage 2.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Cottage Address 2050-2052 Hessle Road Hessle East Yorkshire HU13 9NW 01482 645098 01482 633395 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) Mr Ian Crowther Mrs Karen Serena Harrison Care Home 30 Category(ies) of OP Old age 30 registration, with number DE Dementia 30 of places The Cottage J54_s841_The Cottage_v232823_120805_stage 2.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 09/11/2004 Brief Description of the Service: The Cottage is situated on the outskirts of Hull, adjacent to the town of Hessle. The home is registered to provide care and accomadation for up to 30 older people. Accomadation is provided on two floors, with a passenger lift allowing access to the first floor. Access to two rooms on the first floor still requires the negotiation of a short flight of stairs. Local shops, health services and large retail shops are within close proximety to the home, with local bus services available adjacent to the home. The Cottage J54_s841_The Cottage_v232823_120805_stage 2.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over 5 hours. Some parts of the building were looked around and a few of the records were inspected. Time was spent chatting with residents, although visitors were few during the visit. The assistant manager was available throughout the visit. What the service does well: What has improved since the last inspection? What they could do better: Some work is required to be carried out to the premises, namely exterior paintwork and the protection of radiator surfaces inside the home. The requirement to provide temperature protection for radiators has been outstanding for some time now and must be addressed without delay. Only a quarter of the homes care staff are qualified to a level equivalent to NVQ 2, the requirement is for at least 50 of staff to be qualified. The homes management are promoting the availability of training with staff and it is important that this motivation continues. The Cottage J54_s841_The Cottage_v232823_120805_stage 2.doc Version 1.40 Page 6 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 J54_s841_The Cottage_v232823_120805_stage 2.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 The Cottage J54_s841_The Cottage_v232823_120805_stage 2.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, 2, 3, 4, 5 & 6. The admission procedure ensures that a proper assessment is carried out prior to people moving into the service. This process means that a resident and their representatives can be sure the home will meet their needs. EVIDENCE: A statement of purpose and service user guide are both available for prospective residents or their advocates. Every service user is assessed prior to admission by the manager or her assistant. A visit is carried out either at the residents home or in hospital. Following the assessment, if the home feels they can meet the needs presented, an offer of care is made either verbally or in writing. An opportunity to look around the home and stay for a meal is offered prior to any admission taking place. The deputy manager stated that the home do not accept admissions on an emergency basis. The home does not provide intermediate care. The Cottage J54_s841_The Cottage_v232823_120805_stage 2.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) 7, 8, 9, & 10. Health care needs of residents are identified and met. Residents are able to live in the home experiencing respect and privacy. EVIDENCE: Each resident has a individual plan of care generated from the care management and homes own assessment. The plans detail the needs of each resident and the actions required by the home. Each plan of care is reviewed on a monthly basis. Staff were observed to address residents with dignity and knock on doors prior to entering any room. The home uses the Nomad system for medication storage and administration and regular reports from the pharmacist are available. Five senior staff, the manager and assistant manager are responsible for administrating medication. Some training is carried out by a local chemist. Residents said that they were able to see a doctor when they asked. The Cottage J54_s841_The Cottage_v232823_120805_stage 2.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. Daily choice for residents is enabled and contact with friends, family and within the local community is encouraged. Residents have choice, diversity and experience good quality in the meals provided. EVIDENCE: Residents spoken with stated that they are able to choose what they do during the day, one gentleman said he liked to watch the cricket however the availability of teletext would help him with this. This was conveyed to the assistant manager who said she would deal with this immediately. Visitors are able to call and see residents at any appropriate time during the day. The assistant manager explained that two residents were having forthcoming birthdays and that themed parties had been planned, the first is planned to have an Egyptian theme. There is a display of weekly activities available including clothes parties and visiting artists etc. Residents spoken with expressed satisfaction with the food provided, stating, “The food is excellent” and “ You can usually ask for what you want”. Food provision seen during the visit was of a high standard. The Cottage J54_s841_The Cottage_v232823_120805_stage 2.doc Version 1.40 Page 11 The home caters for a variety of diets and information on these and any likes and dislikes is recorded during the pre admission process. The Cottage J54_s841_The Cottage_v232823_120805_stage 2.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. The home has a complaints procedure, which meets the needs of residents, and relatives who feel their views are listened to. A vulnerable adults procedure and policy is available and staff are formally supervised in order to protect residents from abuse. EVIDENCE: The manager and assistant managers have all undertaken vulnerable adults training and this is cascaded down to staff on an individual basis. A copy of the multi agency, prevention of abuse to vulnerable adults guidance is available along with relevant policies and procedures. All staff receive supervision and are checked via the criminal records bureau, including a POVA 1st check. A complaints procedure is available, which had been made simple and clear to understand. Information is given to residents on admission and also displayed on the noticeboard. There were no recently recorded complaints to view. Two of the residents spoken with said that they would know how to make a complaint should this be necessary. The Cottage J54_s841_The Cottage_v232823_120805_stage 2.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, 20, 23, 25, & 26. The home provides a comfortable and clean environment for residents. Some areas of maintenance require to be addressed. Individual rooms meet resident’s needs. EVIDENCE: The home is generally well presented and was found to be hygienic and clean. Resident’s rooms seen during the visit were suitable for individual needs. There is a routine ongoing maintenance programme in place to address the internal decorations. Some corridors are presently been addressed following which it is intended to move onto the bedrooms. A small lounge is been decorated presently and the larger lounge will be dealt with when this has been completed. The exterior window frames and other exterior paintwork require attention, due to some of it showing severe signs of aging and effects of the weather. The Cottage J54_s841_The Cottage_v232823_120805_stage 2.doc Version 1.40 Page 14 Not all of the radiators have guards or are provided with a guaranteed low surface temperature. The Assistant manager stated that this was been addressed. The requirement for radiators to be protected has been made at the last three CSCI inspections and this area must be dealt with promptly. There are ample communal areas for residents and facilities to enjoy the outdoors during warmer weather. The Cottage J54_s841_The Cottage_v232823_120805_stage 2.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) 28, 29, & 30. Procedures for the recruitment of staff are satisfactory and offer protection for the residents in the home. Staff training and checking of their competence enables good quality care to be offered. Formal staff qualifications do not meet the required standard. EVIDENCE: Members of care staff who are qualified to NVQ level 2 or equivalent is at a low level, only 21.5 of staff been qualified whilst the requirement is for at least 50 to hold this qualification. Four members of care staff are undertaking NVQ training and the assistant manager is undertaking an NVQ 3. The home has three staff members who are NVQ qualified assessors. All new members of staff undertake an induction programme within their first two days of starting employment. All staff including domestics are talking part in health and safety training via a local college and vulnerable adults procedures are discussed individually in supervision with each staff member. Staff members receive six weekly supervision along with an annual review. The Cottage J54_s841_The Cottage_v232823_120805_stage 2.doc Version 1.40 Page 16 Two staff member’s files were looked at, these contained the required information, including evidence of a CRB check having been carried out, written references sought and copies of relevant qualifications. During the visit staff members were observed to have time to talk with residents. All staff wear identification badges whilst in the home. The Cottage J54_s841_The Cottage_v232823_120805_stage 2.doc Version 1.40 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 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, 36, & 38. Health and safety provision within the home is addressed positively. The experience of the management team and availability of guidance ensures residents receive a quality of care, which is consistent. EVIDENCE: The manager of the home is registered with the Commission for Social Care inspection and has recently completed the registered managers award. She is experienced in the care of older people. Residents are enabled to be part of the decision making process in the home by the holding of regular residents meetings, and staff were observed to be open to any suggestions made on a day to day basis. The Cottage J54_s841_The Cottage_v232823_120805_stage 2.doc Version 1.40 Page 18 The home holds a local authority quality development award and questionnaires are issued to residents, staff and relatives as part of the quality system. The management of the home encourage residents to deal with their own financial arrangements where able, families and solicitors would be used where needed. The small amount of money, which the home does hold for residents, is recorded and held securely. Servicing of electrical equipment is carried out via contracts, and fire drills are held monthly with a record been held. Checks of fire prevention and detection equipment are carried out weekly. Any accidents or illness are recorded and appropriate persons informed. The Cottage J54_s841_The Cottage_v232823_120805_stage 2.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 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 3 15 3 COMPLAINTS AND PROTECTION 1 3 x x 3 x 1 3 STAFFING Standard No Score 27 x 28 2 29 3 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 3 x x 3 x 3 The Cottage J54_s841_The Cottage_v232823_120805_stage 2.doc Version 1.40 Page 20 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 OP25 Regulation 16,23 Requirement The registered person must ensure that radiators are guarded or have guaranteed low surface temperatures. The exterior paintwork, namely window frames must be maintained to an acceptable standard Timescale for action December 2005 December 2005 2. OP19 17,23 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. Refer to Standard OP28 Good Practice Recommendations The registered provider should have at least 50 of the care staff trained to NVQ level 2 or equivilent. The Cottage J54_s841_The Cottage_v232823_120805_stage 2.doc Version 1.40 Page 21 Commission for Social Care Inspection Unit 3 First Floor Hesslewood Country Office Park Ferriby Road Hessle East Yorkshire HU13 0QF 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 J54_s841_The Cottage_v232823_120805_stage 2.doc Version 1.40 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. 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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