Inspection on 07/02/06 for The Fountains Care Centre

This inspection was carried out on 7th February 2006.

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 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 Fountains Care Centre 10/10/06

The Fountains Care Centre 23/05/05

The Fountains Care Centre 02/03/05

Similar services:

Innova House Care Home

Portland College

Byars Care Home

Byars Care Home

St Marys Nursing Home

St Marys Nursing Home

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

CARE HOMES FOR OLDER PEOPLE The Fountains Care Centre Church Lane Tetney Lincs DN36 5JX Lead Inspector Kathryn Emmons Unannounced Inspection 09:15 8 February 2006 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Fountains Care Centre DS0000062766.V267406.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 Fountains Care Centre DS0000062766.V267406.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Fountains Care Centre Address Church Lane Tetney Lincs DN36 5JX 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) 01472 210456 01472 816456 fountainscare@aol.com Halcyon Care Limited Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (42), Physical disability (2) of places The Fountains Care Centre DS0000062766.V267406.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for one person in the Category PD as named in the Notice of Proposal to Register dated 20 October 2004 The home is registered for one person in the Category PD as named in the Notice of Proposal to Register dated 16 March 2005 23rd May 2005 Date of last inspection Brief Description of the Service: The Fountains Care Home is registered with the Commission for Social Care Inspection to provide nursing care and personal care to people over the age of 65 years and an individual with physical disabilities. The property is located in the village of Tetney in North East Lincolnshire, lying between Louth and Grimsby. It is a large detached building, standing in its own grounds and gardens. Car parking is to the side of the house. Accommodation is provided in mainly single rooms on the ground and first floor. Although there are two double rooms, these are kept for married couples or service users who specifically wish to share. There is a passenger lift to access the first floor. he homes brochure states that we are dedicated to providing you with the best care along with courteous, understanding and friendly attention to enable you to enjoy a high quality of life. The homes registered manager is Mrs Paula Teal. The Fountains Care Centre DS0000062766.V267406.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The homes manager assisted the inspector during the unannounced inspection. One inspector undertook the inspection spending seven and a quarter hours in the home .The inspector toured the building and spoke with the homes manager and staff. There were 39 residents living in the home and 7 were spoken with. Three relatives of residents were also spoken with. The main method of inspection used was called “case tracking” which involved selecting clients and tracking the care they receive through checking of their records, discussion with them, the care staff and observation of care practices. What the service does well: What has improved since the last inspection? What they could do better: All staff need to receive training in Adult Protection issues so that residents can be confident that their welfare is safeguarded. Records concerning progress of residents and the care they receive need to be in more detail so that a clear audit trail of the care can be identified, to ensure consistency in the care provided. The Fountains Care Centre DS0000062766.V267406.R01.S.doc Version 5.0 Page 6 Residents must only be admitted if the home has the correct category of registration. This ensures that the resident can be confident that the home has been assessed as being able to meet the care needs of the service user group the residents primary need is relevant to. The home needs to maintain a record of all the food provided. This provides a clear record of the dietary intake of each resident to assess if their nutritional needs are being met. 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 Fountains Care Centre DS0000062766.V267406.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 Fountains Care Centre DS0000062766.V267406.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): 3,4 Residents can be confident that their needs will be known to the home prior to their admission. Residents must only be admitted in respect of the homes categories of registration. This provides residents with information to make an informed decision regarding choosing to live at the home. EVIDENCE: Through case tracking and speaking to residents and their relatives it was established that residents are assessed prior to being admitted to the home. The manager confirmed that where possible the resident will be seen by the manager before being offered admission to the home. Where this is not possible the social worker or hospital staff provides a complete assessment. One relative spoken to was aware of the service user guide, and saw this document as the homes “brochure”. A copy of the service user guide is on display in one of the lounges. It was evidenced through case tracking that one resident had been admitted outside the homes categories of registration in that the resident was below the The Fountains Care Centre DS0000062766.V267406.R01.S.doc Version 5.0 Page 9 minimum age of admission to the home. An application for the relevant numbers of beds in this category is being made to CSCI. The Fountains Care Centre DS0000062766.V267406.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): 7.10 Care is delivered in a respectful manner. Care records do not always contain sufficient information to evidence that safe care is being delivered. It cannot be established that residents are involved in the compilation of their care plans. EVIDENCE: All residents have a service user plan profile, which contains assessments, care plans, risk assessments and other relevant records which evidence the care delivered and required. During the inspection 2 residents service user plans were inspected. One resident had been admitted 2 months previously and a completed file except for a photograph. Was in place . The resident confirmed that their care needs had been discussed with them but that they did not recall signing any records. The other resident case tracked had lived at the home for a week before being discharged. Assessments were in place for needs such as bed rails, dependency score and nutritional risk assessment but it was not clear who had produced the documents. No care plans were in place. Risk assessment documentation stated that care plans needed to be completed with 72 hours as per the homes procedure. This was not carried out. This was discussed with The Fountains Care Centre DS0000062766.V267406.R01.S.doc Version 5.0 Page 11 the manager who confirmed that recent discussion with trained staff had taken to place to advise them of the inadequate record keeping. Residents spoken with stated that they were treated “ with respect” and “spoken to nicely” and “they cant do enough for me”. One resident’s relative said “I know my mum is safe here and well looked after”. Observation by the inspector found that staff knocked on resident’s doors before entering and care was being delivered in a kind and dignified manner. On speaking with 2 care staff it was evidenced that staff were aware of the importance of maintaining residents dignity when delivering care. The Fountains Care Centre DS0000062766.V267406.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): 15 Resident’s dietary preferences are catered for and residents can have confidence that they will receive specialised diets. Lack of food records result in lack of evidence that residents receive a nutritional balanced diet. EVIDENCE: Breakfast and lunchtime were observered by the inspector. It was evidenced that residents were able to choose what they had to eat and what quantity they had. Residents made positive comments regarding the food and said that the food was plentiful and a choice was always available. The home is able to evidence what a resident chose on a day-to-day basis, however these records were in minimal detail and are not kept after the day they refer to. It was not possible to assess if a resident was receiving an adequate dietary intake. The Fountains Care Centre DS0000062766.V267406.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 Systems are in place for issues of concern to be raised with the manager and registered provider. Training needs to be provided to provide staff with the skills to identify potential abuse. EVIDENCE: As part of the inspection an investigation of allegations made in respect of adult protection was undertaken. It was evidenced that not all staff had received training in adult protection and the registered manager who had already made provision for this training to take place had identified this. Staff spoken to, and given a scenario to discuss were clear on what constituted adult abuse and were clear what action they would take if they had concerns. An incident has previously occurred which should have been reported in accordance with adult protection but was not reported for a couple of days. The home has a complaints procedure in place and it was evidenced that a complaint, which had been made a month previously, had been investigated and responded to. Part of the complaint being investigated during the inspection was that when complaints had been made previously these had not been investigated. Due to no records being available it could not be evidenced when complaints had been received or if they had been investigated during the time period this allegation refers to. The Fountains Care Centre DS0000062766.V267406.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): 19,25,26 Residents live in a clean and tidy home with evidence of safe storage of equipment. Residents are protected by the homes procedure for responding to call bells. EVIDENCE: A tour of the premises evidenced a clean and tidy home with no adverse odours noted. Pathways outside the home and corridors inside were clear of potential hazards and there was room for residents to move freely. Equipment such as hoists and wheelchairs were stored in a safe manner. Hazard signs were on display for wet floors. Fire safety equipment was in place Residents who gave permission for their rooms to be viewed were satisfied with the décor and cleanliness. Domestic staff are employed to maintain the cleanliness of the home. The Fountains Care Centre DS0000062766.V267406.R01.S.doc Version 5.0 Page 15 Bathrooms were clean and tidy with specialised baths in some bathrooms. The call bell system was activated and responded to promptly. It was evidenced that the call bell system is monitored by checking the electronic readout of response times. The Fountains Care Centre DS0000062766.V267406.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): 30 Residents are cared for by a trained and enthusiastic care team who are aware of residents individual needs. EVIDENCE: Residents and relatives made positive comments regarding staff. One resident said “They are like friends to me” and another resident said “They are so kind and don’t seem to mind anything I ask for help with”. When speaking with staff they were able to give examples of the level of dependency of resident within the home and were clear on each residents individual care needs. Care staff were aware of care plans but said they usually gained current changes in residents care from the shift handover. One staff member said the home did provide training, which they found informative and gave them “more understanding of the conditions some residents have” The Fountains Care Centre DS0000062766.V267406.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 The home is well run by the manager, with good guidance and leadership for staff. Resident feel safe living at the home and are confident that the home is run in a professional manner. Record keeping is of a good standard and the health and safety and welfare of residents is promoted. EVIDENCE: Since the last inspection a new manager has been appointed at the home. The manager is Mrs Paula Teal who has been approved as the registered manager by CSCI. Residents and relatives spoke enthusiastically about Mrs Teal and said that the home was run in a calm and relaxed way and that the atmosphere in the home was very good. Residents made comments such as “Matron is lovely and always around to speak to “. Another resident said “I feel welcome here and can sleep knowing I am safe”. Staff spoken with said that the management style under the new manager was different and that they felt confident that the manager was focussed on The Fountains Care Centre DS0000062766.V267406.R01.S.doc Version 5.0 Page 18 continuing to improve the standards in the home. Staff said that Mrs Teal was “approachable and supportive” and that “I can speak to her and know she will not repeat what I say” the atmosphere in the home is seen by staff as professional but friendly with residents being given as much independence as possible and being involved in making decisions regarding the running of the home. Mrs Teal holds regular staff and resident meetings to capture the views of the running of the home and how the service can be improved. Mrs Teal is in the process of preparing the quality assurance process for the home. The home has a health and safety procedure manual and staff were clear on their responsibilities to maintain a safe environment. A record is maintained of all repairs and potential hazards and a maintainace person reviews this record on a daily basis. The Fountains Care Centre DS0000062766.V267406.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 x x 3 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 x 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 x x x x x 3 4 STAFFING Standard No Score 27 x 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x x x x 3 The Fountains Care Centre DS0000062766.V267406.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? no 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 4(1) Requirement Timescale for action 30/04/06 2 OP7 15 3 4 OP15 OP18 Schedule 4 (13) 13 (6) The registered person must ensure that all residents admitted to the home meet the categories of registration criteria. The registered person must 31/05/06 ensure the service user plan contains sufficient information which is accurate and up to date The registered person must 31/05/06 ensure a record is maintained of all food provided. The registered provider must 31/05/06 ensure that all staff have received training in adult protection issues. 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 Fountains Care Centre DS0000062766.V267406.R01.S.doc Version 5.0 Page 21 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 Fountains Care Centre DS0000062766.V267406.R01.S.doc Version 5.0 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. 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