Inspection on 18/01/07 for The Cottage

This inspection was carried out on 18th January 2007.

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 13/12/05

The Cottage 12/08/05

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 Hull East Yorkshire HU139NW Lead Inspector Malcolm Stannard Unannounced Inspection 18th January 2007 11:00 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 The Cottage DS0000000841.V328025.R01.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 DS0000000841.V328025.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Cottage Address 2050-2052 Hessle Road Hessle Hull East Yorkshire HU139NW 01482 645098 01482 633395 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 Crowther Mrs Karen Serena Harrison Care Home 30 Category(ies) of Dementia (30), Old age, not falling within any registration, with number other category (30) of places The Cottage DS0000000841.V328025.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th December 2005 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 accommodation for up to 30 older people. Accommodation 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 proximity to the home, with local bus services available adjacent to the home. The Cottage DS0000000841.V328025.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit to the home was unannounced and was the first visit to the home in this inspection year. A pre inspection questionnaire, which was sent to the homes management, was not returned to the Commission for Social Care Inspection and consequently some information cannot be contained in this report. During the visit, some records were looked at, a tour of the premises was undertaken, some of the residents were spoken with, the medication system was looked at and staff were observed carrying out their duties. The assistant manager was available throughout the visit and the manager was present for some of the time. What the service does well: What has improved since the last inspection? What they could do better: The exterior of the building is beginning to look tired and all paintwork needs to be addressed. The Cottage DS0000000841.V328025.R01.S.doc Version 5.2 Page 6 Some of the carpets in the home are becoming worn and are ready for replacing. The record, which is held of when people complain about the service, needs to contain information, which shows that the person who complained is happy with the outcome. 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 summary of this inspection report can be made available in other formats on request. The Cottage DS0000000841.V328025.R01.S.doc Version 5.2 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 The Cottage DS0000000841.V328025.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 & 6. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Information is available for prospective residents and an opportunity to visit the home is available. Assessments are carried out prior to any admission. EVIDENCE: A statement of purpose and service user guide are both available for prospective residents or their advocates. These documents were also seen to be available in the hallway of the home. A copy of the terms of residence at the home was available on the residents files seen. The manager or her assistant assesses every service user prior to admission. A copy of the assessment carried out was seen on the individual residents files seen during the visit. The Cottage DS0000000841.V328025.R01.S.doc Version 5.2 Page 9 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 would always attempt to dissuade admissions, which occur on an emergency basis. The home does not provide intermediate care. The Cottage DS0000000841.V328025.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Comprehensive plans of care set out residents needs. The medication procedures protect residents. Health care needs are identified and addressed. EVIDENCE: Individual plans of care are available for each resident. These are compiled from information contained in the community care assessment and the homes own pre admission assessment. The plans contain information on the needs of the residents and what actions are required to achieve this. The plans seen on resident’s individual files included both long and short-term goals. Evidence was available of these plans being updated in September 2006 and January 2007. A monthly review sheet was available which is completed by management detailing any amendments required to the plan of care and the auditing of notes made by the key worker. The Cottage DS0000000841.V328025.R01.S.doc Version 5.2 Page 11 The plans of care also contain details of the residents health needs, including details of proactive health appointments and a record of when a visit has being made. Good practice was observed on one of the files seen whereby a resident had requested that a particular staff member accompany her on hospital visits. This had being facilitated and recorded on the health information. A referral, which had being made to a clinic, could also be cross referenced with other information held on the file. One resident stated that he was always able to access a GP when he requested an appointment. The system used in the home for the storage, administration and recording of medication was looked at. The home uses the Nomad system of medication, which provides a monitored dosage facility. Medication is supplied to the home by the pharmacy on a weekly basis. Medication is dispensed by senior members of staff only after they heave received appropriate training. Three residents medication was checked against the record sheets and found to be correct, with no gaps apparent on the record sheets and all medication being receipted in. Medication is stored in a large locked metal cabinet with any controlled medication being held in a separate locked wall cabinet in an area accessible to staff only. There is no stock medication held and all bottles of liquid medication are used for the resident for whom it was supplied only. Observation during the visit showed that residents were called by their preferred name and staff members tapped first on residents bedroom doors prior to entering. The Cottage DS0000000841.V328025.R01.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. 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 available evidence including a visit to this service. Leisure interests are supported by the staff. Contact with families and friends is encouraged. Appropriate diets are provided. EVIDENCE: A range of activities are undertaken in the home, with many themed evenings held. Staff said that a valentines evening with music and a sing along was planned. A record is held of events undertaken. One resident said that he liked watching the sport on the television and he is free to do this whenever he wishes. DVD and CD recordings are also available for residents entertainment. Any religious requirements are recorded on an individual residents file and arrangements made to cater for these where necessary. Individual residents files also held a record of any activities or interests they had taken part in. The home caters for a variety of diets and information on these and any likes and dislikes is recorded during the pre admission process. Fresh ingredients are used wherever practical in the preparation of food and a delivery of fresh fish was observed during the visit. Residents who commented on food said “The meals are lovely” and “You can ask for something else if you don’t like what is cooked”. The Cottage DS0000000841.V328025.R01.S.doc Version 5.2 Page 13 Residents are able to choose when to get up, go to bed or if they wish to spend time in their own room away from the communal areas. Visitors to the home are encouraged and are able to visit at any reasonable time, they can be received in private should this be required. The Cottage DS0000000841.V328025.R01.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. 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 available evidence including a visit to this service. A complaint procedure is available and staff and management are aware of vulnerable adults issues. EVIDENCE: A complaints procedure is available, which is written in such a manner as to enable easy understanding of the process. Information is given to residents on admission and also displayed on the notice board. Whilst the deputy manager explained that they had very few formal complaints and preferred to sort out any issues at an early stage, a record is available of any complaints made. Practice in this area must be enhanced by the record containing information in relation to the final outcome of the complaint holding evidence that the complainant was happy with the outcome. One of the residents spoken with said that they would know how to make a complaint should this be necessary. The manager and her deputy have both attended training provided by the local safeguarding adults board. The Manager has also recently updated her knowledge by attending the vulnerable adults managers update training. Staff members are also made aware of the procedures to follow by undertaking either a cascaded form of training or by attending the formal training courses. It was noted that any need for a staff member to receive this training was noted on their individual training plan. The Cottage DS0000000841.V328025.R01.S.doc Version 5.2 Page 15 The home has the availability of appropriate policies and procedures and a copy of the multi agency guidance. All staff members receive formal supervision and undergo a CRB check including a Pova 1st clarification where necessary as part of their recruitment process. The Cottage DS0000000841.V328025.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 24, 25 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some areas of building maintenance are required to be carried out. Redecoration of some areas of the home has being carried out. EVIDENCE: Maintenance in the home is carried out on a regular basis and an employee who is responsible for the premises is available. Since the last visit by the Commission for Social Care Inspection the redecoration of the larger lounge has being completed and some of the residents bedrooms have being redecorated. On the day of visit a large area of the car park was underwater following recent inclement weather. The deputy manager explained that this was an occurrence, which had happened before, a problem with local drains being to blame. The Cottage DS0000000841.V328025.R01.S.doc Version 5.2 Page 17 Whilst a few of the window frames have being replaced with new style provision, due to the failure of the sash style windows, many of the original window frames still require work to be carried out. The exterior paintwork to the windows and other wood fascias etc is flaking to a large extent. This area has being outstanding for some time now and requires addressing as soon as possible. Many of the carpets in the communal areas are now at the stage where they require to be replaced. Carpets in the corridors, lounges and on the stairs require auditing for safety and presentation and to be replaced where necessary. Recorded evidence was available that a relative had requested the flooring in her family members room be replaced, the assistant manager explained that this was being dealt with and that a carpet provider had been asked to attend to measure the room. Radiator covers have being fitted to all radiators in areas where residents have access. The only radiators not covered are those in the staff room, office and the corridor outside these rooms. The assistant manager said that whilst residents do not access these areas, it was intended to provide covers for these radiators as well. Resident’s bedrooms were generally well presented, clean and tidy. Residents are able to have their own processions, including pictures, photographs and ornaments on display. One resident who was tracked had a key to her room, which had being provided following a suitable risk assessment. There are ample communal areas for the residents to use including external areas where they can sit during the warmer weather. The assistant manager said that an amount of bulbs and planters etc had just being purchased for these outdoor areas. The Cottage DS0000000841.V328025.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The practice of staff recruitment protects residents. Formal qualifications and training undertaken by staff is addressed as an important area of development. EVIDENCE: Recruitment polices and procedures are in place to facilitate the safe employment of staff members. Two staff member’s files were looked at during the visit. Available on the files were an application form, two references, proof of a CRB check, a copy of birth certificate and proof of identity such as copies of passports and medical cards etc. A photograph of each of the workers was also held on the files. Induction records and training plans were also available, the training records showed that training in the areas of medication, moving and handling, food hygiene, first aid, POVA awareness and values and attitudes had either being accessed or was planned to be completed. Rotas seen showed that four care staff are available during the morning and evening shifts with two staff working during the night. These staffing numbers are supplemented by domestic and kitchen staff. The manager and deputy are additional to the rota. The staff group comprise of a mix of experienced workers and those who are new to care. There are both male and female carers available. Staff members receive formal supervision and staff meetings are held where issues can be discussed. The Cottage DS0000000841.V328025.R01.S.doc Version 5.2 Page 19 Managers and staff at the home have made a large effort in terms of achieving formal NVQ qualifications and this is to be commended. From a position where just over 20 of staff held an NVQ level 2 qualification or equivalent a year ago, fourteen staff members now hold a level 2 qualification, three hold a level 3 and one a level 4. The percentage of staff who hold a qualification therefore stands presently at 82 . The four staff members who do not yet hold a qualification are either in the process of undertaking or are due to start shortly a level 2 course. There are 3 NVQ assessors available in the home, two of which have also undertaken the A1 upgrade. Staff members seen during the visit were observed to speak with residents with dignity and use their preferred name. One resident said he got on “very well” with one particular staff member. The Cottage DS0000000841.V328025.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management and supervision of staff is of a good standard. Policies and procedures are available to offer protection for residents. EVIDENCE: The manager of the home is registered with the Commission for Social Care Inspection and is experienced in the care of older people. She has recently updated her knowledge in areas such as adult protection and she holds the registered managers award. An assistant manager supports the manager in the running of the home. Staff members files seen contained details of formal supervision sessions. A new member of staff was seen to have undergone supervision during her first month of employment. Another staff members file seen showed that supervision had being held on a frequent basis every two to three months. The Cottage DS0000000841.V328025.R01.S.doc Version 5.2 Page 21 The assistant manager said that the aim was to hold formal supervision for staff members approximately every six weeks. The home holds a local authority quality development award and the views of residents; staff and relatives are sought as part of the quality system. Residents are enabled to be part of the decision making process in the home by the holding of residents meetings, one resident spoken with said that he is able to speak to staff on a daily basis and request any assistance he feels necessary. Monthly visits and reports are compiled in line with the requirements of Regulation 26. Appropriate records and policies and procedures are available in the home. 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. The manager sated that she does not hold any appointeeships. 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. A record of any accidents occurring in the home is held and appropriate notifications are made to the required authorities. The Cottage DS0000000841.V328025.R01.S.doc Version 5.2 Page 22 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 3 3 3 3 3 N/A 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 Standard No Score 16 2 17 X 18 3 2 3 X X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 3 The Cottage DS0000000841.V328025.R01.S.doc Version 5.2 Page 23 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 OP19 Regulation 17,23 Requirement The exterior paintwork, namely window frames and other fascias, must be maintained to an acceptable standard TIMESCALE OF 28/02/06 NOT MET. Carpets in communal areas, lounges and stairways must be audited to ensure they are safe and presentable, being replaced where necessary. The registered person must ensure that the complaints record holds evidence that complainants are satisfied with the outcome. Timescale for action 30/04/07 2. OP19 17 31/03/07 3. OP16 22 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Cottage DS0000000841.V328025.R01.S.doc Version 5.2 Page 24 The Cottage DS0000000841.V328025.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000000841.V328025.R01.S.doc Version 5.2 Page 26 - 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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