Care Home: Courtlands

Similar services:

• Henry Nihill House
• Birchwood
• The Infirmary
• Orchard House Nursing Home
• St Josephs Rest Home
• Red Court Nursing Home
• Spinney (The)
• Queen Elizabeth House

What the care home does well The care provided was individualised and client-centered. Staff were aware of the individual preferences of residents and their specific care needs. There was regular and frequent interaction between staff and residents. Residents and their relatives indicated that they had been treated with respect and they were happy with the care provided for residents. The arrangements for the provision of meals were satisfactory and residents were noted to be enjoying their meals. Home-grown vegetables were available for use in the home. Staff responsible for cooking had been taught how to cook special meals for a resident from an ethnic minority. This was to ensure that the resident was made to feel more at home. The premises were well maintained, clean and felt homely. Bedrooms were well furnished and appeared cosy. The gardens were attractive and well maintained. This ensures that residents live in pleasant surroundings. Staff interviewed were knowledgeable regarding their roles and responsibilities and there was good teamwork. Over 50 % of care staff (77%) have the required NVQ qualifications. The registered provider and senior carer were knowledgeable regarding the management of the home and care of residents. This ensures that residents are appropriately cared for by. The "expert by experience" commented that although there seemed to be a lot of care activity going on during the day, staff appeared calm, competent and there was no rush or bustle. She further noted that staff worked very well together and were `people orientated` rather than merely `task orientated`. What has improved since the last inspection? Care plans prepared were comprehensive and addressed the holistic needs of residents. All care staff had been provided with training in moving and handling. Refresher training had also been organised. The gas installations safety inspection had been carried out. What the care home could do better: The registered person must ensure that comprehensive pre-admission assessments (including risk assessments) are carried out on service usersadmitted into the home. This is to ensure that staff are fully informed of the condition and care needs of prospective residents. All residents (or their representatives) must be consulted and agree with their care plans. Evidence that this has been done could be in the form of signed care plans. This ensures that the care provided is appropriate. The registered person must ensure that the home has a procedure for close supervision. This is required to ensure that staff are fully informed of action to be taken when caring for a resident requiring close (or closer) supervision. Daily checks must be made to ensure that medication charts are accurate and the daily temperature of the area where medication is stored is recorded and maintained at no higher than 25C. This is necessary to ensure that medication is stored correctly. All care staff must have training in the care of residents with dementia and in food hygiene. This ensures that staff are adequately trained to perform their duties. The home must have effective quality assurance and monitoring systems. This must include a published report of the results of a recent consumer survey and an annual development plan for the home. This is to ensure that the service is regularly evaluated and responsive to feedback received. To ensure staff are fully aware of action to be taken in the event of a fire, at least one of the fire drills organised during a twelve month period must be held after dark. In addition, the emergency lighting must be checked weekly unless the manufacturer indicates otherwise. It is recommended that the registered person should organise outings for residents who are able to participate in them. This provides an opportunity for residents to enjoy an outing. To ensure that all fire safety arrangements are in place, the registered person should contact the LFEPA to request that a fire safety inspection be carried out. CARE HOMES FOR OLDER PEOPLE Courtlands 24 Northumberland Road New Barnet Hertfordshire EN5 1ED Lead Inspector Daniel Lim Key Unannounced Inspection 5th November 2007 10:00 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 Courtlands DS0000010402.V350775.R01.S.doc Version 5.2 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. Courtlands DS0000010402.V350775.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Courtlands Address 24 Northumberland Road New Barnet Hertfordshire EN5 1ED 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) 020 8440 1625 020 8440 2626 The Gannon Family Partnership Mrs Olivia Emily Gannon, Mr Stephen David Gannon, Mrs Claire Patricia Stanley, Mrs Anne Marie Probert Mrs Yogaiswaree Desscan Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (11) of places Courtlands DS0000010402.V350775.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th July 2006 Brief Description of the Service: Courtlands is a family run private care home registered to provide care for a maximum of eleven older people. The stated aim of the home is to provide a high quality of care for residents and to treat them with respect and dignity and assist them in reaching their full potential. The home is an attractive large semi-detached two storey Edwardian house. The office, kitchen, laundry room and lounge are on the ground floor. There are three bedrooms on the ground floor. One of them is a shared bedroom. Five bedrooms are located on the first floor. Two of these are shared. Bathrooms and toilets are located on both floors. There is a staff room / second office on the top floor. A chair lift provides access to the first floor. There are 2 hoists to assist in transfers and to aid some residents in getting in and out of the baths. There is a ramp leading to the garden and another to the front door. There is a small paved area at the front of the building and a large garden at the back. There is also a patio at the back of the house. The communal lounge / diner is comfortably furnished with the dining tables at one end overlooking the garden. The home is situated in a residential area of Whetstone and within easy reach of public transport, shops and leisure amenities located in New Barnet. The fees charged by the home are £580 per week. The home has a registered manager who has received the Registered manager’s award (RMA). The provider must make information about the service available (including reports) to service users and other stakeholders. Courtlands DS0000010402.V350775.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out on 5th November 2007 and took a total of seven hours to complete. A second visit was made to the home on 8 November to view documents not available on the first day. During the inspection, the inspector was accompanied by an “expert by experience” (An interviewer who has experience of being a service user). The inspector and the “expert by experience” were assisted by the registered provider of the home (Mrs Olivia Gannon) and the senior carer. The inspector and the “expert by experience” were able to interview a total of seven residents and two relatives. The feedback received from them indicated that they were satisfied with the care provided. Completed questionnaires were also received from one resident and five relatives. The comments made regarding the home were all positive and indicated that the respondents were satisfied with the care provided. The home’s visiting community nurse was interviewed. She indicated that the healthcare needs of their clients had been met and staff maintained good liaison with her. A record of compliments received from residents and their relatives had also been kept. Statutory records were examined. These included four residents’ case records, the maintenance records, accident records, complaints’ record, financial records and fire records of the home. These records were on the whole, well maintained. Four staff on duty were interviewed on a range of topics associated with their work. They were noted to be knowledgeable. Staff records, including supervision records, evidence of CRB disclosures, references and training records were examined. The minutes of staff and residents’ meeting were also examined. These indicated that changes had been communicated and residents and staff had been consulted regarding the management of the home. The premises including bedrooms, bathrooms, lounge / dining room, laundry, kitchen, dry store, garden and other communal areas were inspected. These areas were clean and well maintained. The completed Annual Quality Assurance Assessment form (AQAA) was also received by CSCI. Information provided in the assessment was used for this inspection. What the service does well: The care provided was individualised and client-centered. Staff were aware of the individual preferences of residents and their specific care needs. Courtlands DS0000010402.V350775.R01.S.doc Version 5.2 Page 6 There was regular and frequent interaction between staff and residents. Residents and their relatives indicated that they had been treated with respect and they were happy with the care provided for residents. The arrangements for the provision of meals were satisfactory and residents were noted to be enjoying their meals. Home-grown vegetables were available for use in the home. Staff responsible for cooking had been taught how to cook special meals for a resident from an ethnic minority. This was to ensure that the resident was made to feel more at home. The premises were well maintained, clean and felt homely. Bedrooms were well furnished and appeared cosy. The gardens were attractive and well maintained. This ensures that residents live in pleasant surroundings. Staff interviewed were knowledgeable regarding their roles and responsibilities and there was good teamwork. Over 50 of care staff (77 ) have the required NVQ qualifications. The registered provider and senior carer were knowledgeable regarding the management of the home and care of residents. This ensures that residents are appropriately cared for by. The “expert by experience” commented that although there seemed to be a lot of care activity going on during the day, staff appeared calm, competent and there was no rush or bustle. She further noted that staff worked very well together and were ‘people orientated’ rather than merely ‘task orientated’. What has improved since the last inspection? What they could do better: The registered person must ensure that comprehensive pre-admission assessments (including risk assessments) are carried out on service users Courtlands DS0000010402.V350775.R01.S.doc Version 5.2 Page 7 admitted into the home. This is to ensure that staff are fully informed of the condition and care needs of prospective residents. All residents (or their representatives) must be consulted and agree with their care plans. Evidence that this has been done could be in the form of signed care plans. This ensures that the care provided is appropriate. The registered person must ensure that the home has a procedure for close supervision. This is required to ensure that staff are fully informed of action to be taken when caring for a resident requiring close (or closer) supervision. Daily checks must be made to ensure that medication charts are accurate and the daily temperature of the area where medication is stored is recorded and maintained at no higher than 25C. This is necessary to ensure that medication is stored correctly. All care staff must have training in the care of residents with dementia and in food hygiene. This ensures that staff are adequately trained to perform their duties. The home must have effective quality assurance and monitoring systems. This must include a published report of the results of a recent consumer survey and an annual development plan for the home. This is to ensure that the service is regularly evaluated and responsive to feedback received. To ensure staff are fully aware of action to be taken in the event of a fire, at least one of the fire drills organised during a twelve month period must be held after dark. In addition, the emergency lighting must be checked weekly unless the manufacturer indicates otherwise. It is recommended that the registered person should organise outings for residents who are able to participate in them. This provides an opportunity for residents to enjoy an outing. To ensure that all fire safety arrangements are in place, the registered person should contact the LFEPA to request that a fire safety inspection be carried out. 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 Courtlands DS0000010402.V350775.R01.S.doc Version 5.2 Page 8 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Courtlands DS0000010402.V350775.R01.S.doc Version 5.2 Page 9 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 Courtlands DS0000010402.V350775.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 People who use this service experience an adequate outcome in this area. This judgement has been made from evidence gathered both during and before the visit to this service. Evidence suggests that people who use the service can be assured that they will be assessed to ensure that their needs can be met by the home. These are generally undertaken satisfactorily. However, further improvements are required in specific areas to ensure that the required standard regarding these assessments is fully met. EVIDENCE: The feedback received from residents and relatives interviewed was that residents had been treated with respect and they were satisfied with the care provided by the home. Comments received included, Courtlands DS0000010402.V350775.R01.S.doc Version 5.2 Page 11 “‘The staff are very good to me. I’ve been here more than 2 years and this is my home’ “It is very peaceful here although there’s always someone to talk to and something going on. I’ve known about this place for a long time. It was hard living on my own and it is so nice not to have to cook for myself” “..meticulous attention always given and information passed to next of kin immediately” The case records of two new residents who were admitted into the home since the last inspection were examined. Assessments had been carried out prior to their admission. These included details of the individual’s preferences, personal care needs, cultural background, mental state, medical and social background. However, other essential information such as a moving & handling assessment and a falls risk assessment were not recorded in one of them. These deficiencies were discussed with the registered provider and the senior carer. A requirement is made to ensure that comprehensive assessments are documented before residents are admitted. This is to ensure that staff are fully informed of the condition of prospective residents and the care arrangements, which need to be in place to meet the needs of residents. The registered provider informed the inspector that she was careful to ensure that only residents who can be properly cared for are admitted. The home does not provide intermediate care. Courtlands DS0000010402.V350775.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 People who use this service experience a good outcome in this area. This judgement has been made from evidence gathered both during and before the visit to this service. Personal support provided was responsive to the individual preferences of people who use the service. Residents’ individual plans record their personal and healthcare needs and how they will be delivered. The service was client centered, sensitive and responsive to the changing needs of residents. Risks to residents had been identified. All residents interviewed were happy with the care provided. Further improvements are required in certain areas identified. EVIDENCE: All residents and two relatives who were interviewed indicated that they were satisfied with the care provided. One of the relatives made the following comments regarding the care provided: Courtlands DS0000010402.V350775.R01.S.doc Version 5.2 Page 13 “‘Individual care is provided…any queries I might have are dealt with straight away. I’m not made to feel I am being too fussy’ The home’s visiting community nurse was interviewed. She indicated that the healthcare needs of her clients had been met and staff maintained good liaison with her. She was also able to confirm that her instructions regarding the specific healthcare of residents had been followed. The case records examined contained details of how the healthcare needs of residents had been met and included appointments with doctors, dentists, optician and chiropodists. Residents interviewed indicated that they had access to the doctor and other healthcare professionals when required. The GP visits regularly and his reviews are recorded. The case records examined contained comprehensive care plans. These care plans had been regularly reviewed. However, they had not been signed to indicate that residents (or their representatives) had been consulted and agree with them. To ensure that all residents (or their representatives / relatives) have been consulted and agree to the care plans prepared, a requirement is made for all care plans to be signed. The case records of a resident who was at risk of falling was examined. Appropriate care plans and risk assessments had been prepared and staff interviewed were aware of the care to be provided. The weight of residents had been monitored and charts provided had been filled in. The case records of a resident identified as requiring close supervision because of her mental state was examined. Risk assessments and care plans had been prepared. However, there was no guidance or procedure for close supervision. This is required to ensure that staff are fully informed of action to be taken when caring for someone requiring close supervision. The senior carer explained that what the resident actually needed was “closer supervision”. She and the registered provider however, agreed to provide the necessary guidance. The medication charts were examined. These indicated that medication had been administered as prescribed. Two gaps were noted in one of the charts examined. This was brought to the attention of the registered provider. Prompt action was taken and the charts were signed by the staff member concerned. The temperature records of the room where medication was stored had been recorded. These were satisfactory. However, the temperatures had not been recorded since the beginning of November 2007. To ensure that medication is stored at the required temperature of no higher than 25C, the temperature must be monitored daily and recorded. Residents interviewed were able to confirm that they had been given their daily medication. Courtlands DS0000010402.V350775.R01.S.doc Version 5.2 Page 14 The inspector and “expert by experience” observed that staff were respectful towards residents and there was regular interaction with residents throughout the day. Courtlands DS0000010402.V350775.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 People who use this service experience an excellent outcome in this area. This judgement has been made from evidence gathered both during and before the visit to this service. The care provided was individualised and the preferences of residents were respected. Residents had been regularly consulted regarding the running of the home. The daily life, meal arrangements and routines of residents were well organised. The service had a strong commitment to enabling residents to remain as independent as possible and engage in meaningful activities. Personal and family relationships were being maintained. Meals were well balanced and catered for the cultural and dietary preferences of residents. EVIDENCE: The home had a varied programme of weekly social and therapeutic activities. The programme which was available for inspection included hand massage, religious services, exercise, aromatherapy, music, bingo, dominoes, Courtlands DS0000010402.V350775.R01.S.doc Version 5.2 Page 16 celebration of birthday parties, cultural festivals and provision of entertainers. Daily newspapers were available in the lounge. Residents interviewed were satisfied with the activities provided. The “expert by experience” noted that residents in the lounge were involved in various activities such as reading newspapers, having a manicure, exercising or just chatting. She was of the opinion that it felt like ‘home from home’. One relative who returned her completed questionnaire, suggested that outings should be organised for residents. This was discussed with the registered provider. She explained that the majority of residents were frail and would have difficulty going out on outings. She however, agreed to consider the possibility of organising outings for residents who are able to participate. The kitchen was clean and well equipped. A record of fridge and freezer temperatures had been kept. These were satisfactory. Staff were knowledgeable regarding special meals to be provided. This included meals for residents with diabetes. The menu which was examined, appeared varied and balanced. There was documented evidence that the ethnic dietary preferences of residents had been catered for. Meals provided included ethnic foods such as curries, rice and kosher food. A relative confirmed that staff responsible for cooking had been taught how to cook special meals for a resident from an ethnic minority. This, she stated was to ensure that the resident concerned was made to feel more at home. Residents interviewed indicated that they were satisfied with the meals provided. The registered provider stated that vegetables served were grown in the home’s own garden. Food hygiene training had been provided for staff and documented evidence was available in staff files. Two care staff when asked, stated that they had not received food hygiene training. This was discussed with senior carer and registered provider. For health and safety reasons, all staff who handle food must be provided with food hygiene training. Regular residents’ consultation meetings had been held and residents were encouraged to express their views by an independent visitor. Residents had been visited by their relatives. Two relatives interviewed indicated that they were welcomed at the home and staff maintained close liaison with them. Courtlands DS0000010402.V350775.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 People who use this service experience a good outcome in this area. This judgement has been made from evidence gathered both during and before the visit to this service. The arrangements for responding to complaints and for adult protection were satisfactory. The home has an open culture that allows residents to express their views and concerns in a safe and understanding environment. This ensures that residents are well treated and protected from abuse. Residents and others involved with the service say they are happy with the service provision. EVIDENCE: The complaints record was examined. Complaints recorded had been promptly responded to. The home had a complaints procedure and the registered provider and her staff were aware of the procedure to follow when responding to allegations of abuse. There was documented evidence that staff had been provided with adult protection training and when interviewed, they were aware of the procedures to follow when responding to allegations or incidents of abuse. Courtlands DS0000010402.V350775.R01.S.doc Version 5.2 Page 18 The issue of equalities and diversity was discussed with staff. Staff indicated that they had been instructed to treat all residents sensitively and with respect regardless of disability, gender, race, religion or sexual orientation. The home had an equalities and diversity statement. All residents who were interviewed indicated that they had been treated with respect and dignity. A record of compliments received by the home had been kept. These indicated that relatives were satisfied with the care provided. Comments made in cards and letters sent to the home included the following: “love and care and attention were outstanding” “we shall always be grateful” “lovely staff” Courtlands DS0000010402.V350775.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23, 26 People who use this service experience a good outcome in this area. This judgement has been made from evidence gathered both during and before the visit to this service. The home provides a physical environment that is appropriate to the specific needs of the people who live there. It is clean, tidy and well maintained. Appropriate aids and equipment had been provided. The premises were homely, comfortable and cheerfully decorated. People who use the service can personalise their bedrooms. They stated that they were happy with the accommodation provided. EVIDENCE: Courtlands DS0000010402.V350775.R01.S.doc Version 5.2 Page 20 The bedrooms and communal areas inspected were clean, tidy, and well furnished. The home was well maintained and there is an ongoing programme of redecoration. Bedrooms inspected appeared cosy and had been personalised by residents with their own pictures and ornaments. Residents who were interviewed stated that their bedrooms had been kept clean. The gardens were attractive and seating had been provided. The gardener was noted to be busy trimming bushes and putting away some garden furniture for the winter. The laundry room was inspected and noted to be well equipped. Specialist equipment available included a chair lift, mobile hoist, ramps to the front door and garden. All rooms had call bells. One bath had a whirlpool facility. Both bathrooms in the home have power showers. All the zimmer frames had different coloured ribbons on them to help the residents identify their own. No offensive odours were detected Courtlands DS0000010402.V350775.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 People who use this service experience a good outcome. This judgement has been made from evidence gathered both during and before the visit to this service. People who use the service and their representatives had confidence in the staff who care for them. Rotas indicated that the staffing levels were good and staff had the required training. This ensures that residents are well cared for. The service had a good recruitment procedure that was followed in practice. Improvements are however, required in the area of staff training. EVIDENCE: Four staff who were on duty were interviewed on a range of topics associated with their work (such as fire safety, adult protection, equality & diversity, staffing arrangements, team work). They were noted to be knowledgeable regarding their roles and responsibilities. Staff stated that they had been instructed to treat all residents with respect and dignity regardless of their race, religion or sexual orientation. Residents who were interviewed indicated that staff were respectful and they had been well treated. This was reiterated in completed questionnaires received from relatives and by relatives interviewed. Courtlands DS0000010402.V350775.R01.S.doc Version 5.2 Page 22 The duty rota was examined. Staffing levels were as follows: - 3 carers during the morning shift - 3 carers during the afternoon and evening shifts and - 2 carers (one on waking duty). The manager was supernumerary. A maintenance person / gardener was also employed in the home. Staff indicated that they were able to perform their duties. No concerns regarding staffing levels were expressed by those interviewed. Seventy seven percent of care staff had the required NVQ L2 qualifications. Of these, 31 had Level 3 or Level 4. (This was indicated in the completed Annual Quality Assurance Assessment form returned to CSCI). The training records examined, indicated that staff had been provided with the required training (such as health & safety, moving & handling, administration of medication, first aid, fire training, food hygiene and adult protection). However, the inspector noted that 2 care staff had not received basic food hygiene training and training in the care of residents with dementia. These are required to ensure that staff are fully trained. Dementia training is required as two residents had mild dementia. The home had a low turnover of staff and most of the staff had worked there for more than 2 years. Recruitment records examined were well maintained and indicated that the required recruitment procedures (including obtaining of satisfactory CRB disclosures, evidence of identity and two references) had been followed. Supervision had been provided and these had been recorded. Staff employed had also been provided with a period of induction. Courtlands DS0000010402.V350775.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 People who use this service experience good outcomes in this area. This judgement has been made from evidence gathered both during and before the visit to this service. The registered provider and senior carer had an understanding of the key principles and focus of the service. They were working to improve services and provide an increased quality of life for residents. There was a strong ethos of being open and transparent in the running of the home. The service was user focussed and worked in partnership with residents and their representatives. Arrangements were in place to promote the safety and welfare of residents in the home. However, further improvements are required. EVIDENCE: Courtlands DS0000010402.V350775.R01.S.doc Version 5.2 Page 24 The registered manager (Mrs Yogaiswaree Desscan) was away on holidays during the inspection. She had completed the RMA (Registered Manager’s Award). The registered provider indicated that the registered manager was fully supported by her and other members of The Gannon Family Partnership. There was evidence that staff and residents’ consultation meetings had been held. The minutes of these meetings were available for inspection. These indicated that relatives and staff had been kept informed of changes affecting the home. Fire records were checked. The fire risk assessment had been updated. The weekly fire alarm tests had been carried out and evidence was provided. The required fire training had been provided. Fire drills had been documented together with the names of staff who were present. However, none of the drills had been conducted after dark. To ensure that all staff are fully aware of the procedures, one of the drills must be carried out after dark. The emergency lighting had been checked by the home’s contractors about 6 months ago. However, no record of weekly checks had been recorded. To ensure the safety of residents in the event of a break in the mains electricity supply, the emergency lighting must be check weekly (unless the manufacturer indicate otherwise). The fire authorities had not inspected the home since 2005. To ensure that there are no deficiencies in the fire safety arrangements, the registered person should contact the LFEPA to request that a fire safety inspection be carried out. The registered provider agreed that this would be done. To ensure the safety and security of residents, window restrictors were in place and these were engaged. Safety inspections had also been carried out on the gas installations, stairlift, portable appliances and hoists. The home had a current certificate of insurance. The accounts of two residents whose money were kept by the home were examined and noted to be satisfactory. Receipts had been provided for items or services purchased on behalf of residents. Consultation regarding the views of residents had been carried out. However, no written report or development plan was available for inspection. This was discussed with the registered provider and senior carer. The registered person must ensure that the home has effective quality assurance and monitoring systems. This must include a published report of the results of a recent consumer survey and an annual development plan for the home. This is to ensure that the service is regularly evaluated and responsive to feedback received. Courtlands DS0000010402.V350775.R01.S.doc Version 5.2 Page 25 Courtlands DS0000010402.V350775.R01.S.doc Version 5.2 Page 26 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 2 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X 3 X X 3 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 3 X 2 X 3 X X 2 Courtlands DS0000010402.V350775.R01.S.doc Version 5.2 Page 27 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 OP3 Regulation 14(1) The registered person must ensure that comprehensive preadmission assessments (including risk assessments) are carried out on service users admitted into the home. This is to ensure that staff are fully informed of the condition and care needs of prospective residents. 2 OP7 15(1)(2) The registered person must provide evidence that residents (or their representatives) have been consulted and agree with their care plans. This evidence could be in the form of signed care plans. 3 OP7 12(1) 13(4)(c) 13/12/07 The registered person must ensure that the home has a procedure for close supervision. This is required to ensure that staff are fully informed of action Courtlands DS0000010402.V350775.R01.S.doc Version 5.2 Page 28 Requirement Timescale for action 13/12/07 31/12/07 to be taken when caring for a resident requiring close (or closer) supervision. 4 OP9 13(2) 13(4)(c) 13/12/07 The registered person must ensure that daily checks are made to ensure that medication charts are accurate and the daily temperature of the area where medication is stored is recorded and maintained at no higher than 25C. 01/02/08 The registered person must ensure that all care staff receive training in : - the care of residents with dementia. - food hygiene 6 OP33 24(1)(2) (3) 27/02/08 The registered person must ensure that the home has effective quality assurance and monitoring systems. This must include a published report of the results of a recent consumer survey and an annual development plan for the home. 31/01/08 OP38 23(4) The registered person must ensure that at least one of the fire drills organised during a twelve-month period is done after dark. 13/12/07 The registered person must ensure that the emergency lighting is checked weekly unless the manufacturer indicates otherwise. DS0000010402.V350775.R01.S.doc Version 5.2 Page 29 5 OP30 18(1)(c) 7 8 OP38 13(4)(c) 23(2)(c) Courtlands 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 OP12 2 OP38 Refer to Standard Good Practice Recommendations The registered person should organise outings for residents who are able to participate in them. The registered person should contact the LFEPA to request that a fire safety inspection be carried out. Courtlands DS0000010402.V350775.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Courtlands DS0000010402.V350775.R01.S.doc Version 5.2 Page 31 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!