Inspection on 06/12/05 for Biffins

This inspection was carried out on 6th December 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Biffins 02/07/08

Biffins 07/08/07

Biffins 13/07/06

Biffins 01/07/05

Biffins 15/12/04

Biffins 20/09/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Biffins 18 Thorpedene Gardens Shoeburyness Essex SS3 9JB Lead Inspector Christine Bennett Unannounced Inspection 6th December 2005 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Biffins DS0000044339.V270686.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. Biffins DS0000044339.V270686.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Biffins Address 18 Thorpedene Gardens Shoeburyness Essex SS3 9JB 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) 01702 292120 faizaljoomun@yahoo.co.uk Mrs Bibi Sehnaz Bano Joomun Mr Mohammed Faizal Joomun Mr Mohammed Faizal Joomun Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places Biffins DS0000044339.V270686.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Total number of service users not to exceed 14. Service users to be older persons over the age of 65 years. Date of last inspection 1st July 2005 Brief Description of the Service: Biffins is a care home for older people over 65 years of age and can accommodate 14 people. It is situated in a residential area of Shoeburyness with easy access to shops and other amenities. There are good bus and train links to the area. The home has accommodation on two floors and there is a passenger lift to enable access to both floors. There are 10 single bedrooms and 2 twin bedrooms, although only 1 resident is occupying each of these rooms. The home has a large lounge/dining area and a large garden. Biffins DS0000044339.V270686.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, which took place on 6th December, 2005 over 7 hours. The inspection process included discussion with the manager, four members of staff, and two relatives. The day was spent amongst the residents who live in the home and discussion took place with three of them. A tour of the premises was undertaken and an inspection of sample records and policies. What the service does well: What has improved since the last inspection? The home has now got a fax machine, which helps speed up communication. The manager has commenced NVQ level 4 in management and has also done other training in order to keep himself updated. The home has recently started completing nutritional charts for residents to make sure people are thriving. The manager has purchased a new carpet for the hall, lounge and dining area, which will be laid in the new year. One of the care staff has been put in charge of activities in the home, and will be doing some extra hours to develop this area, and the atmosphere in the home had improved with more interaction between residents. Biffins DS0000044339.V270686.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. Biffins DS0000044339.V270686.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 Biffins DS0000044339.V270686.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 The home’s Statement of Purpose provides the information required for a prospective resident to make an informed decision. EVIDENCE: The home has a Statement of Purpose, which has sufficient information about the services it provides. This enables a resident to make an informed decision as to whether the home will be able to meet their needs. Contracts of residency were seen in individual care plans. Biffins DS0000044339.V270686.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, 9 Care plans do not contain sufficient information to ensure residents get optimum care. Medication at the home is not managed well enough to promote good health. EVIDENCE: Care plans in the home have recently been reviewed to clarify the care needs of the residents. Two care plans were looked at but they failed to identify all the risks relating to the individuals and therefore had no management plan in place for the risks. Daily records had improved and generally gave good information as to how a resident had spent their day. Both the residents and relatives were very complimentary about the care that was given in the home. One relative said, “It’s lovely and warm, I wouldn’t change anything”, and a resident said, “it’s quite a good life, the staff are very pleased to be able to help. This is my home now”. The systems for administering medication were checked. Ten members of staff had received training in medication in April 2005, but there were shortfalls in the recording, which meant it was not possible to check the accuracy of medication held by the home. Liquid medication had not been dated on opening. This was discussed with the manager at inspection who agreed that amendments need to be made to ensure the safety of residents. Biffins DS0000044339.V270686.R01.S.doc Version 5.0 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 the following standard(s): 12, 13, 14, 15 The home is endeavouring to improve the occupation of residents, and provides a varied menu allowing people to exercise choice over what they eat. EVIDENCE: The manager has recently appointed a member of the care staff to be responsible for activities in the home, allowing her extra hours to develop this role. The member of staff is enthusiastic and said that some of the residents are looking forward to more social involvement. The manager confirmed that at present residents are offered light exercise twice a week, and he has tried to involve the community by getting the local police and priest to come to chat to residents. One lady was knitting in the lounge and another resident enjoys watching the sport on his TV in his room. There was more social interaction seen between the residents and this created a better atmosphere in the home. The home has a four weekly menu with a choice of food. One resident in the home said, “The food suits me”, and a relative said, “the food is good, they go out of their way to find things they like”. Nutritional charts have recently been introduced and a fluid chart is kept for an individual with a catheter to ensure adequate fluids are taken. Biffins DS0000044339.V270686.R01.S.doc Version 5.0 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 the following standard(s): A robust complaints procedure and training in Adult Protection issues protects residents from abuse. EVIDENCE: The home has a complaints procedure, which is clearly displayed in the home. There has been one complaint since the last inspection and this had been recorded in the complaints book. The outcome of the complaint should be recorded to show that the complainant was satisfied with the outcome. Two members of staff confirmed that they had recently attended Protection of Vulnerable Adult training and the procedure regarding any allegation of abuse is clearly displayed in the home. The manager confirmed that he too had recently attended POVA training. There have been no POVA issues in the home since the last inspection. Biffins DS0000044339.V270686.R01.S.doc Version 5.0 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 the following standard(s): 19, 26 Areas of the home require attention to ensure a safe environment for the residents. EVIDENCE: The manager is committed to improving the environment for the residents. A new carpet has been bought, which will be fitted in the lounge, dining area and the hallway. Water temperatures are still running too hot in communal washbasins and some residents’ bedrooms, despite the fitting of mixer valves. Water temperatures should be recorded weekly to monitor them and ensure the safety of residents. Eleven members of staff attended training in infection control this year and one of the care staff who is involved in the cooking at the weekends, confirmed that she has done food hygiene training. The home was clean with no unpleasant odours. Biffins DS0000044339.V270686.R01.S.doc Version 5.0 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 A thorough recruitment process offers protection to the residents. EVIDENCE: A staff file was examined for a new member of staff. The manager confirmed that he is waiting the return of the CRB check before giving her a commencement date. All other information relating to Schedule 2 was in place. Care staff spoken with confirmed that they feel there enough staff to fulfil their role. They said that the dependency of the residents has changed and only one resident was highly dependant. The arrangements for the morning staff are flexible, and if there is a need, the member of staff due off duty is prepared to stay. They also welcomed the input of the activities person for 3 mornings per week. None of the care staff work excessive hours or long shifts and they cover sickness and holidays, which means that agency staff are not used. This provides the residents with continuity of care and means the care staff are aware of their care needs. One member of staff spoke of a good team spirit among the staff. The home has subscribed to Mulberry training programme and the manager is a qualified nurse and provides training in specialist areas such as continence care. Three members of staff are just completing NVQ level 2 in care. Biffins DS0000044339.V270686.R01.S.doc Version 5.0 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 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, 33, 35, 36, 38 The manager is supported well by senior staff and has a good understanding of areas in which the home needs to improve, with plans in place to achieve this improvement. EVIDENCE: The manager is a qualified nurse who intends to do NVQ level 4 in management. He has undergone extensive further training in order to remain updated. He is supported by an assistant manager, who is on permanent night duty, and a supervisor during the day. Staff and residents were complimentary about the manager and said he is approachable and they feel any problems would be sorted out. The home has monthly meetings for the staff and an annual staff survey. There is a resident/relative survey in progress at the moment and the manager was advised to collate all the information and produce an annual development plan. The home must arrange for monthly visits as stipulated in regulation 26 as part of their quality assurance programme. Biffins DS0000044339.V270686.R01.S.doc Version 5.0 Page 15 The residents are encouraged to manage their finances independently where possible and the home only hold money for four residents. This money was checked and found to be accurate, and a relative confirmed that there had never been any discrepancies with their relative’s finances. Formal staff supervision at the home has lapsed and this was confirmed when speaking to staff. In order to protect the welfare of the residents, a lock should be fitted to the COSHH cupboard and weekly records must be kept to monitor the temperature at which water is delivered. Biffins DS0000044339.V270686.R01.S.doc Version 5.0 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 X 15 X 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 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 2 X 2 Biffins DS0000044339.V270686.R01.S.doc Version 5.0 Page 17 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. Standard OP7 Regulation 15 Requirement The registered person must prepare a written plan with consultation with the resident as to how their needs will be met. This refers to risk assessments and the management of risks This is a repeat requirement The registered person must make arrangements for the recording of medication to protect the safety of the residents The registered person shall continue to develop a plan for residents to engage in local, social and community activities. The registered person should keep the home in a good state of repair. This refers to the lounge carpet and water temperatures. This is a repeat requirement The registered person must maintain a quality assurance system for reviewing and improving the quality of care provided. This relates to sending in monthly reports on the conduct of the home to CSCI This is a repeat requirement DS0000044339.V270686.R01.S.doc Timescale for action 01/03/06 2. OP9 13(2) 01/03/06 3. OP13 16(2)(m) 01/04/06 4. OP19 23(2) 01/03/06 5. OP33 24, 26 01/02/06 Biffins Version 5.0 Page 18 6. OP36 18(2) 7. OP38 12 The registered person must ensure that persons working in the home are appropriately supervised The registered person must ensure the home is conducted to promote the health and welfare of the service user. This refers to the storage of COSHH substances. 01/03/06 01/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 12 16 Good Practice Recommendations It is recommended that the home continue to develop the activities programme It is recommended that the outcome of any complaint is recorded Biffins DS0000044339.V270686.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Biffins DS0000044339.V270686.R01.S.doc Version 5.0 Page 20 - 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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