CARE HOMES FOR OLDER PEOPLE
White Rose Court 40-42 Clifton Avenue Sheffield South Yorkshire S9 4BA Lead Inspector
Jayne Barnett-Middleton. Unannounced Inspection 09:50 15 March 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 White Rose Court DS0000003027.V268813.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. White Rose Court DS0000003027.V268813.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service White Rose Court Address 40-42 Clifton Avenue Sheffield South Yorkshire S9 4BA 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) 0114 244 2310 0114 261 9410 Fisherbell Limited Mr Phillip John Spencer Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places White Rose Court DS0000003027.V268813.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 11th May 2005 Brief Description of the Service: Whiterose court is an older adapted building with a modern extentions providing accommodation on two floors accessable by stairs and lift. The home provides both single and double bedrooms and comfortable lounge and dining areas. The home is registered to provide care for 21 older people over the age of 65, for both short term and long term stays.The home is situated in a residential area close to amenities and public transport. White Rose Court DS0000003027.V268813.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out from 9.50 am to 2.00 pm. Most of the residents were seen during the inspection. Seven residents, three staff and the manager were spoken to. A sample of records was examined and a partial inspection of the building was carried out. The inspector wishes to thank the manager, staff and residents for their time and co-operation throughout the inspection process. What the service does well: What has improved since the last inspection?
Staff were observed to be caring for residents in a manner that respected their individual needs, privacy and dignity. Fire exits were clear and free from obstruction, ensuring that a safe evacuation could take place in the event of a fire.
White Rose Court DS0000003027.V268813.R01.S.doc Version 5.0 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. White Rose Court DS0000003027.V268813.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 White Rose Court DS0000003027.V268813.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. Needs assessments were available on the residents files checked. They contained appropriate information about the residents care needs, which ensured that the service was able to meet individual needs. EVIDENCE: Three residents care files were checked and each contained a full needs assessment which had been carried out for the resident prior to their admission. The manager from the home also visited prospective residents prior to their stay. This confirmed that the service was appropriate for the resident, and provided staff with the information to formulate an individual plan of care. White Rose Court DS0000003027.V268813.R01.S.doc Version 5.0 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 the following standard(s): 7,8,9 and 10. Care plans were in place for all residents. They very detailed and included all of the required information. Residents received personal support, which promoted their privacy, dignity and independence. Resident’s physical and emotional needs were met. There was evidence that a range of healthcare professionals regularly visited the home to meet the resident’s healthcare needs. A policy and procedure to ensure that staff adhered to the safe administration of medication was in place. EVIDENCE: The care plan format was of a good standard. The format included all of the required information and the layout was accessible and information easy to track. Three care plans were checked. All detailed the specific actions required by staff to ensure that the residents care needs were met.
White Rose Court DS0000003027.V268813.R01.S.doc Version 5.0 Page 10 Records of healthcare visits were maintained and these evidenced that healthcare professionals, e.g. general practitioner and chiropodist were visiting residents on a regular basis. Residents said that their healthcare needs were met commenting, “We are very well looked after”. There was a policy and procedure to ensure that staff adhered to safe practices regarding medication and the protection of residents. Medication was checked on a sample basis. The systems in place were well managed and medication had been administered appropriately maintaining resident’s health, safety and welfare. Throughout the day staff were observed to treat residents with dignity and respect. All residents seen were well cared for, they were clean, hair and nails had been attended to and male residents were shaved. White Rose Court DS0000003027.V268813.R01.S.doc Version 5.0 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 the following standard(s): 12,14 and 15. Routines within the home were flexible and residents were encouraged to spend their day as they wished. A programme of activities was in place that was appropriate for the needs of the residents. A good choice of menu was offered and specific dietary needs were catered for. Residents were satisfied with the choice and quality of food offered. EVIDENCE: Residents confirmed that the routines within the home were flexible and that they could spend their day as they wished. One resident described their morning routine, commenting “ the staff bring me a cup of tea and give me time to come round before breakfast.” An activities co-ordinator was employed and regular activities including bingo, quizzes and sing-a-longs were available. On the day residents were observed to be joining in the activities provided, watching television or chatting to other residents. White Rose Court DS0000003027.V268813.R01.S.doc Version 5.0 Page 12 A good choice of menu was offered. The lunchtime meal observed, demonstrated that a good choice of meal was available. Residents were satisfied with the quality of food commenting, “Its nice” and “Its very good, I used to be a cook”. White Rose Court DS0000003027.V268813.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 and 18. The complaints procedure was clear and accessible. Residents felt confident that any concerns would be dealt with. There was an adult protection procedure in place at the home. Staff had an understanding of the procedures to be followed should they suspect any abuse at the home. EVIDENCE: The complaints procedure ensured that residents and their relatives were aware of how to make a complaint and who would deal with them. All residents spoke positively about the attitude of the manager and the staff team. They stated that they had no complaints, commenting that should they have any concerns the manager “ will always sort it out”. There was an adult protection policy and procedure that promoted the protection of service users from harm or abuse. The Staff were aware of the homes policy and the action to take should they suspect any abuse at the home. White Rose Court DS0000003027.V268813.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 and 26. The environment was safe reasonably well maintained, clean pleasant and hygienic. Several areas within the home were in need of redecoration and some furniture and carpets were in need of replacement. EVIDENCE: The home was clean, tidy and odour free. Areas seen were reasonably well maintained however some areas were due for redecoration, the easy chairs in the lounges had damaged and stained upholstery and the wooden legs were chipped. Some carpets were worn and ill fitting. The manager said that there were plans to refurbish parts of the home that will improve the environment for residents. Several bedrooms were checked and all were clean, pleasantly decorated and had been personalised by the resident.
White Rose Court DS0000003027.V268813.R01.S.doc Version 5.0 Page 15 All areas seen were clean and a good standard of cleanliness was observed. White Rose Court DS0000003027.V268813.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): 28,29 and 30. Residents spoke positively about the attitude of the staff and the service that they received. Staff had received training to meet the resident’s general and specific needs. Residents were protected by the homes recruitment policies and procedures EVIDENCE: Residents spoke highly of the staff team describing them as “smashing”, “they will do anything that you ask” and “they are good, they work very hard”. A training and induction programme for staff was in place enabling them to meet the assessed and changing needs of residents. Staff confirmed that they had attended various training courses that included food hygiene, adult protection, moving and handling and First aid. One member of staff who had recently commenced employment at the home confirmed that they had received the appropriate support and induction to enable them to safely care for residents. The manager confirmed that 50 of the staff team had achieved the NVQ level 2 in care and that the remaining staff was in process of undertaking the award. White Rose Court DS0000003027.V268813.R01.S.doc Version 5.0 Page 17 A robust recruitment policy and procedure was in place. Two files checked contained a good range of information including two references, declaration of health and qualifications/training. All staff employed had undertaken a Criminal Records Bureau Check at the enhanced level to promote the protection of service users. White Rose Court DS0000003027.V268813.R01.S.doc Version 5.0 Page 18 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 and 38. Residents and staff benefited from the ethos, leadership and management approach. The homes policies and procedures promoted the health, safety and welfare of service users and staff. EVIDENCE: The manager had many years experience within the caring profession that enabled him to contribute to the care of residents and communicate a clear sense of leadership to staff. Staff spoke positively about the manager describing him as “firm but fair”. The home was generally well maintained and all areas seen were clean and safe. The staff had received regular training to promote the health, safety and welfare of residents and their colleagues.
White Rose Court DS0000003027.V268813.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 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X 3 White Rose Court DS0000003027.V268813.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP19 OP19 Regulation 23 16 Requirement All parts of the home used by service users must be kept reasonably decorated All furniture and floor coverings in the care home must be in good condition therefore the easy chairs in the lounges must be replaced and the carpets in the areas identified. (Previous timescale 20/4/05 not met) Timescale for action 01/08/06 01/08/06 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 White Rose Court DS0000003027.V268813.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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