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Inspection on 13/06/05 for The Good Companions

Also see our care home review for The Good Companions for more information

This inspection was carried out on 13th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home carries out in-depth assessments of people before admission to the home to ensure their individual needs could be met and the correct level of care given. The care planning systems were excellent and all residents were given the opportunity to be involved in the care planning process if they wished. The care staff were given all the information required to provide a high level of care for people. All healthcare needs were met, with an up to date record of all professional healthcare visits and external appointments. Residents said they were able to see the doctor or nurse when they wanted and all appointments were made promptly. There was a daily programme of activities and the home has it`s own transport for outings all year round. Residents said there was always plenty going on but they did not have to join in if they did not want to. Efforts were made to ensure that a nutritious and varied menu was provided with a choice at each meal.

What has improved since the last inspection?

Decoration in the home is ongoing with one bedroom being completely refurbished since the last inspection and another about to be started.

What the care home could do better:

Discussions with the manager and staff confirmed that they are continually striving to improve the level of care given to the residents. Care is taken to ensure the running of the home is always in the best interests of the people living in the home.

CARE HOMES FOR OLDER PEOPLE The Good Companions Criffel Street Silloth Cumbria CA5 4BT Lead Inspector Margaret Drury Unannounced 13 June 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 Good Companions F58 F10 s62105 good companions v232504 130605 ui stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Good Companions Address Criffel Street Silloth Cumbria CA5 4BT 016973 31553 016973 31553 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) Good Companions Cumbria Ltd Jacqueline Derrane Care Home 39 Category(ies) of OP - Old Age registration, with number DE(E) - Dementia over 65 of places PD - Physical Disability The Good Companions F58 F10 s62105 good companions v232504 130605 ui stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service must at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 2. The home is registered for a maximum of 39 service users to include: - up to 39 service users in the category of OP (Old Age, not falling within any other category) - up to 5 service users in the category of DE(E) (Dementia over 65 years of age) - one service user in the category of PD (Physical disability under 65 years of age 3. The staffing levels for the home must meet the Residential Staffing Forum Care Staffing Formula for Older People) Date of last inspection 7 December 2004 Brief Description of the Service: The Good Companions is owned by Good Companions Cumbria Ltd with Mr Mark Newby being the responsible individual. The home is run on a day to day basis by Mrs Jacci Derrane. The home is situated in Silloth, a seaside town overlooking the Solway Firth. The Good Companions is an older property that has been adapted and extended for its present use as a care home. Accomodation for service users is on three floors that are served by a passenger lift and stair lifts. All of the bedrooms are for single occupancy, with all but two having en-suite toilet and wash basin. There are three lounges and a large dining-room and a smoking area for those residents wishing to smoke. The toilets and bathrooms are equipped to assist people with disability. There are well kept gardens around the building and car parking facilities are provided. The Good Companions F58 F10 s62105 good companions v232504 130605 ui stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of the home, and took place over one day. During the inspection, time was spent talking with the manager, administrator and care staff on duty, looking at records to do with the day to day running of the home and the care of residents. Time was spent with of the residents individually and in groups, and all parts of the home were looked at. What the service does well: What has improved since the last inspection? Decoration in the home is ongoing with one bedroom being completely refurbished since the last inspection and another about to be started. The Good Companions F58 F10 s62105 good companions v232504 130605 ui stage 4.doc Version 1.30 Page 6 What they could do better: 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 Good Companions F58 F10 s62105 good companions v232504 130605 ui stage 4.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 Good Companions F58 F10 s62105 good companions v232504 130605 ui stage 4.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 home’s information pack, which included the Statement of Purpose, was extremely informative and provided all prospective residents and their families with the information required to make an informed decision about admission to the home. EVIDENCE: The information pack contained a copy of the Statement of Purpose, service user guide, terms and conditions, the complaints procedure and a copy of the latest inspection report. The pack contained very useful information about the care and services provided by the home. There was a clear admission procedure to the home, which included a full assessment of needs and capabilities being carried out to ensure the home could adequately meet the individual needs. Residents said that family and friends could visit at anytime and they were always made welcome and offered refreshments. The Good Companions F58 F10 s62105 good companions v232504 130605 ui stage 4.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, 10 & 11 The home had a clear and consistent care planning system, which ensured residents ’health and social needs were met in a way that promoted their privacy, dignity and independence. EVIDENCE: The care plans contained information about residents’ care needs and also included a full assessment of moving and handling needs. The plans were updated monthly with the manager completing a care profile audit every two months. Details of healthcare needs and professional visits were recorded and residents said that they only had to request a G.P. visit and the appointment was made promptly. The care staff spoke to the residents in a courteous and polite manner and always knocked before entering bedrooms. Residents said that the staff always gave personal care in a way that preserved their privacy and dignity whilst encouraging independence. The Good Companions F58 F10 s62105 good companions v232504 130605 ui stage 4.doc Version 1.30 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13, 14 & 15 Social activities were well-organised, creative and provided entertainment and stimulation for people living in the home. Links with the local community were good and meals were nutritious and balanced, offering a healthy and varied diet. EVIDENCE: Visitors were welcome at the home at any time and they were always offered refreshments during their visit. There was no restriction on the time a visit could take place. The home employed three activities co-ordinators and there was a daily programme of activities on offer to those who wished to join in. Residents said that they were always given the choice of taking part or not. The home had a mini bus that is used throughout the year and there was a visiting entertainer in the home on the day of the inspection. Links with the local community were maintained by outings with a local group and luncheon club. Residents said they decided themselves how they wished to spend their day. The menus were displayed in the home and there was a choice offered at each meal providing a well-balanced, nutritious diet. Special diets were catered for and one resident said her diabetic needs were met all the time. The Good Companions F58 F10 s62105 good companions v232504 130605 ui stage 4.doc Version 1.30 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 The home had a satisfactory complaints procedure with each resident given a copy. Residents felt they were able to approach the manager or any of the staff of they had anything to discuss. Staff understood adult protection issues, which protected residents from abuse. EVIDENCE: The complaints procedure is contained in the admission pack given to all those applying to live in the home. Although no resident had made a complaint they said they knew what the procedure was if ever they had to use it. They preferred to speak directly to the manager. The home has a protection of vulnerable adults policy, which includes whistle blowing. The Good Companions F58 F10 s62105 good companions v232504 130605 ui stage 4.doc Version 1.30 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 25 & 26 The standard of the environment within the home was good with an on-going programme of maintenance providing the residents with an attractive, homely and secure place to live. EVIDENCE: Since the last inspection the home had continued with the maintenance programme and one bedroom had been completely redecorated with another due to be started in the near future. Ongoing maintenance of the building and grounds ensured the residents had a safe and secure place to live. There were rails on the corridors, a passenger lift and stair lifts to enable people to move freely around the home. The gardens were well maintained and had recently been used for a garden party. Plans were in place to build a ramp from the lounge on the lower ground floor into the garden, which would give better access for the residents with a disability. Domestic arrangements in the home provided clean pleasant surroundings. The Good Companions F58 F10 s62105 good companions v232504 130605 ui stage 4.doc Version 1.30 Page 13 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 & 30 Residents were cared for by an experienced and trained staff group who were appointed following a detailed and thorough recruitment procedure. This ensured that there was maximum protection for people living in the home. EVIDENCE: There were five carers on duty during the inspection to care for thirty-seven residents, the home manager, care co-ordinator and administrator. There were also domestics, a cook and a kitchen assistant on duty. These staff were able to attend to the residents’ needs in a prompt manner, keep the home clean and provide meals and snacks during the day. Before new staff are appointed, an application form is completed, the person is invited for interview and two written references are sought No new staff are appointed until a satisfactory Criminal Record Bureau check has been completed. These measures contributed to the protection of residents. All staff training was up to date, which meant that staff were competent to do their job. Residents said that the staff were kind and helpful and looked after them very well. The Good Companions F58 F10 s62105 good companions v232504 130605 ui stage 4.doc Version 1.30 Page 14 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 34, 35 & 38 There was clear leadership, guidance and direction to the staff to enable them to give a consistently high level of care. The management practices ensured that the home was run in the best interests of residents. with ongoing internal quality audits covering all aspects of life in the home. Good financial procedures safeguarded residents’ finances and health and safety policies promoted residents safety. EVIDENCE: The manager was highly motivated and residents expressed their appreciation of her help and care. The staff group found the manager supportive and readily available for help and advice. Management supervision motivated the staff to undertake training, which assisted in the improvement of their skills and knowledge. There were ongoing internal quality audits covering all aspects of life in the home. Good financial procedures and records safeguarded residents’ finances and health and safety policies promoted residents welfare. The Good Companions F58 F10 s62105 good companions v232504 130605 ui stage 4.doc Version 1.30 Page 15 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 x x x x 3 3 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 3 3 3 x x 3 The Good Companions F58 F10 s62105 good companions v232504 130605 ui stage 4.doc Version 1.30 Page 16 NO 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 Regulation Requirement Timescale for action 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 Good Practice Recommendations The Good Companions F58 F10 s62105 good companions v232504 130605 ui stage 4.doc Version 1.30 Page 17 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith, Cumbria CA11 9BP 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. 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