Inspection on 07/08/07 for Biffins

This inspection was carried out on 7th August 2007.

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 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 13/07/06

Biffins 06/12/05

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 Pauline Marshall Unannounced Inspection 7th August 2007 08:50 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.V346855.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. Biffins DS0000044339.V346855.R01.S.doc Version 5.2 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.V346855.R01.S.doc Version 5.2 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 13th July 2006 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 the twin bedrooms. The home has a large lounge/dining area and a large garden. All prospective residents are provided with a Statement of Purpose and Service User Guide that supplies them with up to date information on the home. Fees range from £362.46 to £445.00 and there are additional charges for hairdressing, chiropodist, newspapers and private telephone and Sky TV. Biffins DS0000044339.V346855.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that lasted for five hours and twenty minutes. The process included a tour of the premises, a random selection of resident and staff files and discussions with residents, staff a visiting relative, the hairdresser and the owner/manager. As part of this inspection surveys were sent to ten residents, ten relatives’ six health and social care professionals and ten care staff to obtain their views on the service the home provides. At the date of writing this report one resident, three relatives, no health and social care professionals and two care staff surveys had been returned. Comments were mostly positive and included “staff are helpful, cheerful and friendly and always know the situation with my relative”. “Staff make visitors feel welcome and I am totally satisfied with the service”. Staff surveys said that “their views are listened to and carried out and they really enjoy working at Biffins”. Twenty-four of the thirty-eight standards were inspected. What the service does well: Biffins provides people who want to live in the home with good up to date information about what it has to offer. The home will make sure that they can meet people’s needs before they move in. The homes care plan paperwork is very clear and tells staff how to look after people. Biffins gives people information on how to complain if they want to. The home is clean and tidy. Biffins DS0000044339.V346855.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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 summary of this inspection report can be made available in other formats on request. Biffins DS0000044339.V346855.R01.S.doc Version 5.2 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.V346855.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides prospective residents and their families with good information and carries out a thorough assessment of needs prior to any admission. No intermediate care is provided. EVIDENCE: The Statement of Purpose and Service User Guide provided for inspection were dated June 2004 and contain some out of date information. The owner/manager said that these documents had been reviewed in August 2006 and an up to date version is supplied to all prospective residents. The owner/manager visits prospective residents in their home prior to admission and encourages them together with their family to visit the home as Biffins DS0000044339.V346855.R01.S.doc Version 5.2 Page 9 part of the admission process. The owner/manager undertakes a thorough pre-admission assessment to establish that Biffins can meet their needs. A review is held one month after admission to ensure that everyone is satisfied with the arrangements. The three care files examined contained evidence of thorough assessments of needs having taken place. Residents spoken with confirmed that the owner/manager visited them at home and completed a needs assessment. Biffins does not provide intermediate care. Biffins DS0000044339.V346855.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are set out in their care plans and their health and social care needs are fully met. Medication policy and practice is good and residents are treated with dignity and respect. EVIDENCE: Three care files were examined and each provided clear information on the level of intervention required by staff. The daily notes were well written and informative. Each of the care files examined had evidence of regular reviews. Residents spoken with confirmed that they understood their care plan and that they were always involved in its review. Risk assessments had been carried out and included management plans. The care plans examined contained full details of residents’ health care visits that included the outcomes and identified any actions to be taken. Residents Biffins DS0000044339.V346855.R01.S.doc Version 5.2 Page 11 spoken with confirmed that health care at the home is good and that staff respond well to all health issues. Medication policy and practice in the home is good and an observation of staff administering medication confirmed this. Staff administering medication had received training and there were specimen signatures available with the administration records. The medication and the administration records examined were satisfactory. Residents and relatives’ surveys received included comments that “residents are well cared for and staff always know their status”. “Staff treats residents respectfully, they are cheerful and friendly, and provide plenty of personal attention”. Residents spoken with said how they felt well treated by staff and always in a dignified manner; an observation of staff interaction with residents confirmed this. Biffins DS0000044339.V346855.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a limited range of activities within the home and the local community. Residents are helped to exercise choice and control over their lives and they receive a healthy balanced diet in pleasant surroundings. EVIDENCE: A weekly programme for activities has been devised and one staff member works from 3pm-5pm each Wednesday afternoon, specifically to do activities with residents. Activities include, cards, bingo, drawing, dominoes, reminiscence, board games, hand massage and crafts. A record of who participated is kept in the kitchen in a folder. The home keeps a record of the activities residents have participated in but this was not fully completed. Residents spoken with said that they have enough to do and that they like time to themselves. The owner/manager said that the area of activities is constantly under review and that it is one of the main subjects of resident and staff meetings. Biffins DS0000044339.V346855.R01.S.doc Version 5.2 Page 13 The home has an open visiting policy and encourages as much family and friends contact as possible. The home does not provide many opportunities for residents to access the local community. The home does not employ a cook or domestic staff and the care staff on duty is responsible for preparing and cooking the meals, cleaning the home and doing the laundry. Residents meetings are held regularly and residents spoken with said they are frequently asked what they want to do and eat. Issues discussed at residents meetings were staffing, advocacy services, the environment, residents’ money and food. The home operates a four-week rolling menu that offers residents a choice of two main meals each day. One resident spoken with said there have been times when they did not want either option and that the staff would provide them with an alternative meal of their choosing. The homes food stocks were good and included a wide variety of different foodstuffs. The food looked and smelled appetizing and was plentiful and the tables were nicely laid out. Relatives’ surveys stated, “how good the home cooked food is”. Biffins DS0000044339.V346855.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ complaints will be listened to and acted upon and they are protected from abuse. EVIDENCE: The home has not received any complaints since the last inspection. The Complaints policy has recently been updated to reflect the changes in the CSCI procedures and it clearly explains the role of the CSCI. The home has a clear policy and procedure for safeguarding adults and this works within the Local Authority procedures. All staff have had training in safeguarding adults and staff sign the training record to confirm that they fully understand their role. The home has a flow chart displayed in the entrance hall. Staff spoken with and surveyed showed full awareness of the procedures and knowledge of the actions they should take should abuse be suspected. Biffins DS0000044339.V346855.R01.S.doc Version 5.2 Page 15 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, 24 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, well-maintained, clean and hygienic environment with their own personal possessions around them. EVIDENCE: The home has had new electric bath hoists in the upstairs and downstairs bathrooms. All bedroom doors have been fitted with door guards that automatically shut in the event of a fire. Water regulators have been fitted to all of the water outlets and each of the bedrooms has window restrictors fitted. The home is generally well maintained and the owner/manager said that he identifies when repairs or replacements are required and arranges them. One of the bedroom washbasin surrounds was in poor condition and the owner/manager said this had been identified and he evidenced that Biffins DS0000044339.V346855.R01.S.doc Version 5.2 Page 16 information was being sought to replace it. The staff sleep in room shower was used for the storage of pads making it unusable. Residents’ bedrooms contained many of their own personal possessions and the owner/manager said that he encourages residents to bring as many personal items as possible. Residents spoken with confirmed that they were able to bring items from their home providing their room could facilitate this. The home was clean, pleasant and hygienic. Biffins DS0000044339.V346855.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents would benefit from the recruitment of more staff to undertake catering and domestic duties. The staff are competent and have received training but they need updates and refresher courses to ensure that they are aware of up-to-date practice. The homes recruitment practice does not fully protect residents. EVIDENCE: The owner/manager said that he employs seventeen part time staff. On the day of the inspection there were three care staff on duty and they were responsible for the cleaning, cooking and laundry and one staff finished their duty at 1pm and this left two care staff on duty between 1pm and 4pm. The rota did not show who was responsible for the cook and domestic roles and staff spoken with said that this was decided at the start of each shift. The owner/manager was shown on the rota as working from 9am to 6.30pm on Monday, Wednesday and Friday and on call at all other times. Five staff have achieved NVQ training and two staff are nearing completion; a further three staff have just started their NVQ training. Biffins DS0000044339.V346855.R01.S.doc Version 5.2 Page 18 Three staff files were examined and all contained the relevant documentation with the exception of evidence of staff fitness. Many of the staff has worked at the home for several years; all new staff works a probationary period prior to receiving their contracts of employment. One of the staff files examined for a worker that started work in October 2006 had a criminal records bureau check dated December 2006; there was no evidence that a POVA 1st check had been made. The owner/manager said that the worker was on a probationary period and that they never worked unsupervised until the criminal records bureau check was received. A discussion took place with the owner/manager around the importance of robust recruitment procedures to ensure that residents are not placed at risk. The homes staff has received training which includes moving and handling, food hygiene, first aid, infection control, fire, medication, adult safeguarding and funeral training. Training certificates were on the staff files examined, however these were old and some were out of date. Biffins DS0000044339.V346855.R01.S.doc Version 5.2 Page 19 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, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The owner/manager provides a stable environment for residents and staff and although the home has the residents’ interests at heart, the staffing, recruitment and training issues will impact on the home being able to provide a service that is in the residents’ best interests. Residents’ financial interests are safeguarded. Staff requires more frequent supervision sessions. The health, safety and welfare of residents and staff are promoted and protected. Biffins DS0000044339.V346855.R01.S.doc Version 5.2 Page 20 EVIDENCE: The owner/manager is a qualified nurse and was half way through the Registered Managers Award when the NVQ provider lost the business; he intends to re-commence in September 2007 as he was almost at completion of the award. The owner/manager obtains regular updates of information through the Internet and keeps his knowledge and skills updated by enrolling in various courses. Although the owner/manager is on duty for only three days each week, he is on call at all other times and lives within a five-minute drive from the home. A deputy manager who works permanent night shifts and a supervisor that works during the day supports the owner/manager. The staffing, recruitment and training issues mentioned earlier in this report have an impact on the outcomes for residents. The owner/manager is at the home on a regular basis and organises staff and resident meetings. Residents spoken with confirmed that they benefited from their meetings and that they were able to change things that they were not happy with. The owner/manager said that he had not yet received his Annual Quality Assurance Assessment documentation from the CSCI and had made enquiries with regard to obtaining one and that he would return this within the stated time. The homes own quality assurance system gathers survey forms from the residents, their relatives and other relevant people; the manager is in the process of compiling a report on his findings. Some of the policies and procedures sampled were due for review; the owner/manager said that he was in the process of updating all of the homes policies and had reviewed and amended some such as the complaints policy. The home holds small amounts of residents’ money and the three residents cash and transaction records examined were all found to be satisfactory. The three staff files examined contained some evidence that supervision does take place but this was not as often as set out in the standards. Staff spoken with confirmed that supervision does take place but one of the staff surveys returned said that “supervision is three monthly”. All safety certificates were in place and up to date. The homes last fire drill took place on 2/7/07 and the records evidenced that these took place on a regular basis. The home has a fire risk assessment in place that was reviewed on 3/7/07. The home sends it’s bedding and any soiled laundry to an outside Biffins DS0000044339.V346855.R01.S.doc Version 5.2 Page 21 contractor on a weekly basis; staff are responsible for the laundering of residents personal clothing. New water regulators and door guards have been fitted since the last inspection. The home has fitted a lock to the COSHH (Control of Substances Hazardous to Health) cupboard. Biffins DS0000044339.V346855.R01.S.doc Version 5.2 Page 22 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 3 X X N/A 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 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 2 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 3 Biffins DS0000044339.V346855.R01.S.doc Version 5.2 Page 23 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. 3. 4. Standard OP12 OP13 OP27 OP29 Regulation 16 (2) (m) 16(2)(m) 18(1)(a) Schedule 2 Requirement Sufficient activities must be provided by the home to meet residents’ needs and wishes. Residents must have the opportunity to participate in activities in the local community. There must be sufficient staff on duty to meet the assessed needs of the residents at all times. Staff cannot be employed at the care home unless all the information as required in schedule 2 has been obtained. This refers to the requirement that CRB/POVA checks are carried out prior to staff starting work and obtaining evidence of staff fitness. Timescale for action 30/11/07 30/11/07 30/11/07 30/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Biffins DS0000044339.V346855.R01.S.doc Version 5.2 Page 24 No. 1. Refer to Standard OP36 Good Practice Recommendations Staff should receive supervision at least six times each year. Biffins DS0000044339.V346855.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Biffins DS0000044339.V346855.R01.S.doc Version 5.2 Page 26 - 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!