Inspection on 01/12/05 for The Cottage Residential Home

This inspection was carried out on 1st December 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Cottage Residential Home 04/06/07

The Cottage Residential Home 19/06/06

The Cottage Residential Home 01/07/05

The Cottage Residential Home 16/12/04

The Cottage Residential Home 31/08/04

The Cottage Residential Home 26/02/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE The Cottage Residential Home Nocton Hall Nocton Lincs LN4 2BA Lead Inspector Mr David Bacon Unannounced Inspection 1st December 2005 08:30 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 Residential Home DS0000056118.V270019.R01.S.doc Version 5.0 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 Residential Home DS0000056118.V270019.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Cottage Residential Home Address Nocton Hall Nocton Lincs LN4 2BA 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) 01526 320887 01526 323055 BSB Care Limited Mrs Sharon Sills Care Home 26 Category(ies) of Dementia - over 65 years of age (26), Old age, registration, with number not falling within any other category (26) of places The Cottage Residential Home DS0000056118.V270019.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st July 2005 Brief Description of the Service: The Cottage Residential Home is a period converted two storey building situated seven miles from the south of the city of Lincoln in the grounds of Nocton Hall. The home provides personal care for up to 26 residents over the age of 65 years of age. The home is approached by a long tree lined driveway and is not on a bus route but is within walking distance of the village of Nocton. Car parking is available to the front of the home. There are gardens surrounding the property, which are on one level and easily accessible for pedestrians and wheelchair users. There are also garden chairs and tables at the front of the home. Accommodation is provided on both ground and first floors. The first floor is served by a shaft lift. The Cottage Residential Home DS0000056118.V270019.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and it took place over 4 hours. The inspector spoke with three service users, two service users representatives, one Community Nurse, five staff members as well as the home manager. The main method of inspection was called “case tracking”. This involved selecting 2 residents and tracking the care they received through the checking of records, discussion with them or their representatives and the homes care staff. Also, a tour of the premises was conducted and staff records were inspected. What the service does well: What has improved since the last inspection? What they could do better: Minor adjustments are required with the maintenance of some administrative systems, including staff records which did not detail that all checks had been undertaken prior to an individual commencing work within the home or that staff had received a formal induction. Also, records of all medicines administered to service users must be maintained. An updated risk assessment of the premises is now needed and action must be taken to ensure overall health and safety. For example, regarding fire safety and to minimise risks to service users prone to wandering. The Cottage Residential Home DS0000056118.V270019.R01.S.doc Version 5.0 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 Residential Home DS0000056118.V270019.R01.S.doc Version 5.0 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 Residential Home DS0000056118.V270019.R01.S.doc Version 5.0 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 the following standard(s): 1, 2, 3, 4, 5, 6 Satisfactory policies and procedures are in place for the guidance of care staff during the introduction of service users to the home. Information is provided to prospective service users to enable them to make informed choices about the homes facilities and services. EVIDENCE: A statement of purpose and service users guide have been produced, which detail the services provided by the home, the aims and objectives and these are made available to service users and displayed in the home. Service users are provided with written terms and conditions of residence contracts and signed copies of these are maintained. Written confirmation is not currently sent to service users where the home is able to meet their individual care needs. It is acknowledged that the manager was unaware of the need to do this. Admission policies and procedures are in place, giving guidance to staff. The care records viewed evidenced that an assessment of each service users care The Cottage Residential Home DS0000056118.V270019.R01.S.doc Version 5.0 Page 9 needs had been undertaken. The completed risk assessments identified any risks and the manager evidenced that service users or their representatives were being consulted with regarding their care plan. The service users and representatives spoken with confirmed that they were satisfied with the homes admission arrangements. Comments included: “Well, we looked round but I had heard before about the place, they were very helpful and answered any questions”. “We were told about the home and had a god look round, there was no pressure to make a decision”. “I had a look round for my loved one and the staff were very welcoming and informative”. The Cottage Residential Home DS0000056118.V270019.R01.S.doc Version 5.0 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 Service users are treated with dignity and respect and care records provide staff with sufficient information overall to meet service users care needs although minor adjustments are required with the recording of medicines administered. EVIDENCE: The service users and representatives spoken with were satisfied overall with standards of care within the home. Comments included: “I know how to complain but I couldn’t about this place, they really are very good, a nice bunch”. “I am happy here overall, I’ve not been here long but for me its good”. “They treat you with respect and you can do just as you please”. A care plan is completed for each service user and information within these document each individuals assessed care needs and how these are met. Care records are generally updated daily and reviewed each month. Information regarding service users likes and preferences are included. The care plans viewed evidenced where residents were seen by health care professionals in relation to their health care needs. The community nurse spoken with was satisfied with standards of care and that care staff followed The Cottage Residential Home DS0000056118.V270019.R01.S.doc Version 5.0 Page 11 any given instruction or advice. Comments included: “We have no concerns about the home, they seem to look after everyone very well and they contact us for advice”. During the visit members of staff were seen to treat residents with respect and sensitivity when delivering personal care. A record is maintained of medicines as receipted into the building and as disposed of although there were gaps in the signing of some medicines where administered. Medicines are stored appropriately and staff administering medication receive training regarding this subject matter. The Cottage Residential Home DS0000056118.V270019.R01.S.doc Version 5.0 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): 13, 14 Service users are supported to express their views regarding life within the home, the care they receive and they can spend their time as they like and maintain and develop any community links as they prefer. The relatives and friends of service users are made welcome by staff. EVIDENCE: Service users confirmed that they are consulted with about their likes and dislikes and they have opportunities to express their views at informal residents meetings, on a daily basis and through monthly questionnaires which are sent to each service user or their representative. The service users and representatives spoken with confirmed that there was no restriction as to how residents spend their time and that staff respected their individual wishes and preferences. Comments included: “Well, we do what we like and there’s not a problem, seriously it’s like your own home”. “You can do just as you choose, perhaps some of them can’t properly choose for themselves though as they’re not able”. “They make everyone welcome as far as I know, you can speak with them which has given me great piece of mind”. The Cottage Residential Home DS0000056118.V270019.R01.S.doc Version 5.0 Page 13 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 The service users spoken with feel able to express their views regarding the care they receive and complaint guidelines are in place regarding this. Staff are aware of the homes abuse and whistle blowing policies and procedures. EVIDENCE: Complaint policies and procedures are in place and information regarding these is provided to service users and displayed in the home. No complaints have been received by the CSCI or the home since the last inspection. The service users and representative spoken with said that they felt able to voice any opinions regarding the home and that any comments would be acted upon. Comments included: “I’ve got no complaints but they would listen if you had to say anything”. “You don’t have to complain, you would only have to say, I’m sure”. “We’ve not needed to complain but there is information about that somewhere”. The care staff spoken with confirmed that they attend abuse awareness training and policies and procedures regarding complaints, whistle blowing and abuse are in place. The Cottage Residential Home DS0000056118.V270019.R01.S.doc Version 5.0 Page 14 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, 20, 22, 24, 25, The standard of the physical environment is good, with the organisation ensuring the maintenance of each area of the home. All private and communal space is suitable for the residents, homely and comfortable. EVIDENCE: The service users and representatives spoken with were satisfied with the physical environment. Comments included: “I’ve no complaints abut it, its comfortable enough”. “Yes, it’s kept clean and tidy each day”. Service users can gain access to all areas of the home. Service users personal accommodation was viewed, which was cleanly decorated and demonstrated where service users had personalised their room. Furniture is of a domestic style and is in good order. The home was clean, comfortable, tidy and well presented and there were no unpleasant odours. Designated cleaning staff are employed who attend specific training in relation to their roles. The Cottage Residential Home DS0000056118.V270019.R01.S.doc Version 5.0 Page 15 The manager confirmed that any requirements placed upon the home following the most recent inspection visits from the fire safety officer and environmental health officer’s inspections have been met although fire safety tests were not undertaken as per fire safety regulations. Temperature restrictive valves are fitted to water outlets and radiator protective covers are being fitted to radiators. A risk assessment regarding legionella has been completed and a water tank test has recently been undertaken although this record was not available for inspection. The home has a shaft lift, one mobile hoist and one bathing hoist of which are serviced as required. The Cottage Residential Home DS0000056118.V270019.R01.S.doc Version 5.0 Page 16 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, 29, 30 Recruitment procedures are in place although these are not fully followed and records do not demonstrate that staff receive a formal induction when commencing work at the home. There are sufficient numbers of staff, appropriately deployed to allow them to care for the residents. EVIDENCE: The service users and representatives spoken with confirmed that the homes care staff met their individual care needs. The staff members spoken and home rota evidenced that there was sufficient numbers of staff deployed within the home. The staff records viewed were well maintained overall but did not fully evidence that appropriate recruitment procedures had been followed for each staff member recruited. For example, two references had not been obtained for one staff member and some identification and induction information was missing. The staff members spoken with confirmed that they had received an induction and sufficient training to enable them to carryout their roles. The Cottage Residential Home DS0000056118.V270019.R01.S.doc Version 5.0 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 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, 32, 33, 38 Service users are supported to express their views regarding life within the home and the care provided. The staff are trained to meet service users care needs. The premises are well maintained overall although not adequately risk assessed and some safety systems must be improved. EVIDENCE: The manager is experienced and is currently attending relevant management training. The service users, representatives, health professional and staff members spoken with were satisfied with the manager’s approach to the role. The Cottage Residential Home DS0000056118.V270019.R01.S.doc Version 5.0 Page 18 Residents meetings are held although records of these are not maintained. Quality satisfaction questionnaires are sent to service users and their representatives each month and action is taken as required. The home is well maintained and a risk assessment of the premises has previously been undertaken although this was not up to date. Some of the external doors are alarmed although these do not adequately minimise risks to service users who may be prone to wandering. The staff attend statutory training, which is ongoing. The Cottage Residential Home DS0000056118.V270019.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 2 3 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 X 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X 3 X 3 3 X STAFFING Standard No Score 27 3 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X X X 2 The Cottage Residential Home DS0000056118.V270019.R01.S.doc Version 5.0 Page 20 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 OP4 Regulation 14 (1) (d) Requirement The regisered person must confirm in writing to the service user where the home is able to meet their care needs. The registered person shall make arrangements for the recording, handling and safe administration of medicines. Therefore, all medicines must be signed for as administered. Confirmation is required that the home has complied with the most recent environmental health officer and fire officer reports and fire safety tests must be undertaken as per the Fire Safety Officers instructions. The registered person must ensure that the records specified in schedule 4 are maintained and available for inspection at all times. Staff must receive a full induction to give them the skills to promote and make proper provision for the health and welfare of service users. The registered person shall ensure that unnecessary risks to DS0000056118.V270019.R01.S.doc Timescale for action 31/01/06 2 OP9 13 (2) 14/12/05 3 OP19 23 (4) (5) 31/01/06 4 OP29 19 31/01/06 5 OP30 12 (1) (a) 31/01/06 6 OP38 12(1) 28/02/06 The Cottage Residential Home Version 5.0 Page 21 13 (4) (c) the health and safety of service users are identified and so far as possible eliminated. Therefore, a detailed risk assessment of the premises must be completed and action must be taken to minimise risks to service users prone to wandering (including design solutions). 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 OP37 Good Practice Recommendations It is recommended that the system used to store records is reviewed as 2 offices are being used and information was difficult to find. The Cottage Residential Home DS0000056118.V270019.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 Residential Home DS0000056118.V270019.R01.S.doc Version 5.0 Page 23 - 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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