Inspection on 26/07/05 for The Cottage

This inspection was carried out on 26th July 2005.

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 10/08/06

The Cottage 16/01/06

The Cottage 28/02/05

The Cottage 31/08/04

The Cottage 25/02/04

Similar services:

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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 HD6 3NF Lead Inspector Liz Cuddington Announced 26 July 2005 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 J52J01_s986_The Cottage_v229547_260705.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Cottage Address 1a Church Street Rastrick Brighouse HD6 3NF 01484 718808 None 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 Moffat and Mrs Jennifer Moffat Mrs Elaine Wood Care Home - personal care only 19 Category(ies) of 19 x Old age (over 65 years) registration, with number of places The Cottage J52J01_s986_The Cottage_v229547_260705.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Conditions of this registration are listed on the registration certificate displayed at the service. Date of last inspection 28 February 2005 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 provides personal care only to men and women over the age of 65 years. The accommodation is over two floors with a stair lift linking the ground and first floor areas. There is a large garden to the rear of the property with a conservatory and a patio area. The home has a small car park. The Cottage J52J01_s986_The Cottage_v229547_260705.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a mixed inspection resulting in six statutory requirements and four good practice recommendations. A number of these are brought forward from the last inspection in February 2005. Although the care and support offered to service users was seen to be of a good standard this was not reflected in the individual plans of care which do not show clearly how each person’s current needs are to be met. The ladies and gentlemen who commented all said that they were content with the care and support they receive at The Cottage. During the day nine service users as well as a visitor and some of the staff spent time talking with the inspector. Thanks are due to the service users, the staff and the management for the warm welcome and hospitality during the inspection. What the service does well: What has improved since the last inspection? What they could do better: The home’s Statement of Purpose and Service Users Guide both still need to be amended to include all the necessary information. The individual plans of care all need a complete review and re-write because at present they do not include sufficient up to date information to show how each The Cottage J52J01_s986_The Cottage_v229547_260705.doc Version 1.30 Page 6 person’s assessed health and social care needs are to be met. Any changes in someone’s needs or state of health must always be reflected in their plan. The service user or their representative must be consulted and agree the final plan or any amendments. Medication storage must be more secure and suitable facilities for storage and recording of any controlled drugs needs to be provided. Maintenance records and Legionella testing are still outstanding matters from the last report, as is the need for all staff to receive two fire safety training sessions each year. The quality assurance system also needs further development. The way the kitchen is used by staff, other than those directly involved in the preparation and serving of meals, needs to be changed as its current usage constitutes a health, hygiene and safety risk. 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 J52J01_s986_The Cottage_v229547_260705.doc Version 1.30 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 J52J01_s986_The Cottage_v229547_260705.doc Version 1.30 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 The Statement of Purpose and Service Users’ Guide do not include all the required information. The individual plans of care do not contain sufficient information to reflect the care and support needs of the service users. EVIDENCE: The home’s Statement of Purpose and Service Users’ Guide both need to be amended to ensure all the information outlined in the Care Homes Regulations 2001, including Schedule 1, and the National Minimum Standards is included in these documents. At present a number of pieces of information are missing from both documents. Although there are pre-admission assessments in the files examined they were not seen to be translated into workable plans of care. Prior to their admission service users are invited to visit The Cottage and stay for a meal if they wish. The Cottage does not offer intermediate care. The Cottage J52J01_s986_The Cottage_v229547_260705.doc Version 1.30 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 Although monthly reviews are taking place the individual plans of care all need a complete review to ensure they clearly reflect the current care and health needs of the service user. They must be updated when any changes occur and also show that the service user or their representative has contributed to and agreed the plan. The medication records are accurately maintained but it is important that the medicine storage cupboards are securely locked and storage for controlled drugs and a record book obtained. Service users were seen to be treated with respect and consideration and their dignity upheld by staff. EVIDENCE: The individual service users files include detailed monthly reviews and some examples of good information, such as nutritional assessments and life histories. However the five files examined did not contain clear and up to date care plans showing how each service user’s assessed needs were being met. One plan appeared to consist of an incomplete transfer care plan from the service user’s previous care home; received when the person moved to The Cottage more than two years ago. Other files did not include moving and handling plans and changing needs identified in the reviews were not reflected in the plans. One service user’s weight chart recorded an apparent gain of over two and a half stone between November 2004 and February 2005, yet the The Cottage J52J01_s986_The Cottage_v229547_260705.doc Version 1.30 Page 10 monthly review states that there was ‘no change’ to this person’s weight. Not all reviews showed evidence that the service user or their representative had been involved in developing their plan of care or in the reviews. There was evidence that the District Nurses and other health care professionals are involved in the care of service users where appropriate. Pressure relieving cushions and mattresses were seen to be in use. However there was no evidence in the files examined of service users access to routine examinations such as chiropodists, opticians and dentists. When service users are seen by a health care professional this visit and the outcome must be recorded in their individual file. The medication administration process was inspected. The Medication Administration Record (MAR) sheets were seen to be accurately completed and there is a ‘brought forward’ system in place to keep a check on quantities. The cupboards storing the medications must be kept locked, as well as being situated in a lockable room. Suitable storage and recording needs to be provided for any controlled drugs prescribed. When a service user selfadministers any of their own medication then it must be stored in a lockable space in the service user’s own room. It was clear from observation and discussion that service users privacy and dignity is respected at all times. This was reflected in the interaction between service users and staff. The Cottage J52J01_s986_The Cottage_v229547_260705.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13 & 15 The individual plans of care do not all include information about the person’s leisure interests. During the inspection it was clear that visitors are welcomed to the home. The meals are well prepared and tasty with sufficient choice. The ladies and gentlemen who commented all said how much they enjoy their meals. EVIDENCE: Only one of the plans of care examined included information concerning the individual’s preferred leisure and social interests. This information should be recorded to ensure people’s preferences can be met, wherever possible. Visitors were seen to be welcomed into the home and this was confirmed through conversation with a visitor. Lunch was taken during the inspection and was enjoyable and tasty. The menu included a choice of two main courses and two desserts. The service users who commented said how much they enjoy their meals and the meal was seen to be taken at a leisurely pace. A member of staff was observed assisting a service user to eat in an appropriate and calm manner. The Cottage J52J01_s986_The Cottage_v229547_260705.doc Version 1.30 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) None of these standards were inspected on this occasion. EVIDENCE: The Cottage J52J01_s986_The Cottage_v229547_260705.doc Version 1.30 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, 21 & 23 Maintenance records are not being kept although the house and grounds appeared to reasonably well maintained. The toilet and bathing facilities and the private accommodation meet the standards. EVIDENCE: Although routine maintenance is being carried out there are no records kept to confirm this. The home provides private rooms and washing and toilet facilities which all meet the current environmental National Minimum Standards. The Cottage J52J01_s986_The Cottage_v229547_260705.doc Version 1.30 Page 14 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, 28, 29 & 30 All the standards relating to staffing levels and staff qualifications and recruitment were seen to be met. EVIDENCE: The staffing rotas were examined and showed that there are sufficient staff on duty to meet the needs of the service users and ensure the smooth running of the home. At the time of the inspection six care staff had achieved NVQ level 2 in care, one of these staff members has also achieved NVQ level 3 in care. This means that half of the care staff are now qualified. The owner and manager said that they were expecting a new group of staff to begin the qualification in September 2005. The staff files showed that a satisfactory recruitment procedure is being followed. New staff undergo a six week structured induction period and follow this up with an approved foundation training programme. The Cottage J52J01_s986_The Cottage_v229547_260705.doc Version 1.30 Page 15 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) 33 & 38 The home’s quality assurance systems need further development to ensure they result in useful information which the home can use as the basis for service quality improvements. Staff need to attend two fire safety lectures each year and the Legionella testing for the water supply was still outstanding. Both these issues were raised at the last inspection in February 2005. The use of the kitchen as a thoroughfare and for carrying out tasks constitutes a risk to both health and safety. EVIDENCE: There is a relatives’ quality assurance questionnaire in place but this is to be further developed to produce better information. Other areas of quality assurance were discussed and will be looked at to improve the process and outcomes. The Cottage J52J01_s986_The Cottage_v229547_260705.doc Version 1.30 Page 16 Not all staff have undertaken sufficient fire safety training yet, to ensure they are all aware of the procedures to be followed in the event of a fire. The water supply testing for Legionella had not been done, although the management said this was in hand. The kitchen is quite small and is used as a thoroughfare, as well as regularly having a large number of staff congregating in there. People walking through and carrying out tasks in the kitchen without wearing protective clothing and washing their hands constitutes a health and hygiene risk. The number of people using the kitchen and passing through it also poses a potential risk to staff safety. The Cottage J52J01_s986_The Cottage_v229547_260705.doc Version 1.30 Page 17 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 1 x 1 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 x 3 x 3 x x x 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 Standard No 16 17 18 Score x x x x x 2 x x x x 1 The Cottage J52J01_s986_The Cottage_v229547_260705.doc Version 1.30 Page 18 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 OP 01 Regulation 4&5& Schedule 1 15 Requirement The statement of purpose and service users guide must contain all the information required by the Care Home Regulations 2001. Each service user must have an up to date plan of care based on the Social Services or the homes own needs assessment. Each service users plan of care must reflect their individual care needs and be agreed with the service user or their representative. The plans of care must show how all of the individuals health care needs are being met. All medications must be securely stored and accurate and verifiable stock control records be kept. Suitable facilities for storing and recording of controlled drugs must be available. All staff must have two fire lectures each year. Timescale for action 31/10/05 2. OP 03 31/10/05 3. OP 07 15 31/10/05 4. 5. OP 08 OP 09 12(1)(a) 13(2) 31/10/05 31/10/05 6. OP 38 23(4)(d) 31/12/05 The Cottage J52J01_s986_The Cottage_v229547_260705.doc Version 1.30 Page 19 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. 3. 4. Refer to Standard OP 12 OP 19 OP 33 OP 38 Good Practice Recommendations Service users leisure and social preferences should be recorded in each persons individual plan of care. Records of routine maintenance to the house and grounds should be kept. The quality assurance systems need further development in order to obtain useful information. The use of the kitchen for purposes other than the preparation of meals needs to be addressed. The Cottage J52J01_s986_The Cottage_v229547_260705.doc Version 1.30 Page 20 Commission for Social Care Inspection 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 J52J01_s986_The Cottage_v229547_260705.doc Version 1.30 Page 21 - 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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