Inspection on 11/11/05 for Clair Francis Retirement Home

This inspection was carried out on 11th November 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Clair Francis Retirement Home 06/10/08

Clair Francis Retirement Home 18/05/07

Clair Francis Retirement Home 26/05/06

Clair Francis Retirement Home 15/07/05

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 Clair Francis Retirement Home 237/239 Park Road Peterborough PE1 2UT Lead Inspector Joanne Pawson Unannounced Inspection 11th November 2005 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 Clair Francis Retirement Home DS0000062899.V260190.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. Clair Francis Retirement Home DS0000062899.V260190.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Clair Francis Retirement Home Address 237/239 Park Road Peterborough PE1 2UT 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 8947 8603 Mr Karim Bhanji Mrs Christina Elizabeth Bentley Care Home 28 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (28) of places Clair Francis Retirement Home DS0000062899.V260190.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th July 2005 Brief Description of the Service: Clair Francis was originally two separate houses, which have been connected by a two-storey extension. They are turn of the 19th century buildings, which have been adapted to provide suitable accommodation for 28 older people. The home is situated in a quiet residential area of Peterborough, close to the park, local amenities and transport routes. The home has large well-tended gardens. Clair Francis Retirement Home DS0000062899.V260190.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the home’s second inspection for the year 2005/6. It was unannounced and conducted by one inspector over three hours at the home who interviewed residents, members of staff and the managers. The inspector undertook a brief tour of the home, checked medication and viewed a range of documents. As a result of this inspection three requirements and three recommendations have been made. What the service does well: What has improved since the last inspection? What they could do better: The home must ensure accurate recording and administration of medication for all residents. Residents may benefit from a range of activities being offered taking into consideration their interests, preferences and capacities. The rota must be clear record of who is working each shift within the home. During the previous inspection it was noted that not all the intumescient strips were visible due to being painted over. The manager stated that they have not all been replaced. This must be done by the 15th December to prevent residents from being put at risk. Clair Francis Retirement Home DS0000062899.V260190.R01.S.doc Version 5.0 Page 6 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. Clair Francis Retirement Home DS0000062899.V260190.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 Clair Francis Retirement Home DS0000062899.V260190.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): EVIDENCE: These standards were not inspected during this inspection. Standards 1,3 and 5 were met at the previous inspection. The home does not offer intermediate care (standard 6). Clair Francis Retirement Home DS0000062899.V260190.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The staff have the basic information needed to meet the residents needs. The medication procedure is not being followed by all staff. This could put the residents health at risk. EVIDENCE: There is a basic care plan for each resident. The care plan could be extended to include likes and dislikes, past history and more detailed information about residents needs. Evidence was seen of residents receiving the appropriate health care from professionals. The medication administration records were inspected and found to be inaccurate. Records for 23 residents were inspected and it was found that 17 of them contained omissions and/or errors. An immediate requirement was left stating that there must be accurate recording and administration of medication as of the 11th November 2005. Residents stated that staff treat them with respect when assisting them with personal care. Clair Francis Retirement Home DS0000062899.V260190.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): 2,3,3,3 Activities have been limited due to staff shortages. The appointment of an activities co-ordinator would increase the range of activities in the home and the local community. This would further residents fulfilment. EVIDENCE: The manager stated that there have not been many activities in the last few months due to staff shortages and the use of agency staff to cover vacancies. One resident stated that she did not want to take part in activities but really enjoyed watching the birds on the bird table that had been placed outside of the conservatory so that residents could see it. One resident stated that she enjoyed reading books from the homes library. All residents are asked their food likes and dislikes. If a resident does not like what is on the main menu they can choose an alternative. All of the residents spoken to stated that they enjoyed the food. One resident said’ there is always plenty of food and drink’. During the morning of the inspection residents were offered a hot drink and two jugs of squash were on the sideboard in the lounge areas for residents to help themselves. There were bowls of fresh fruit available. Clair Francis Retirement Home DS0000062899.V260190.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): 16,18 The home has a satisfactory complaints procedure. Staff are aware of the procedure to be followed to protect residents from abuse. EVIDENCE: During the previous inspection residents stated that they were not aware of the complaints procedure. The manager has positioned a notice in all of the resident’s bedroom next to the light switch stating that if they are not happy with any aspect of their care they can complain to the manager. Resident should also be made aware that they could complain to the Commission if they feel it appropriate. Staff spoken to were aware of the procedures to follow if they suspected the abuse of a resident. Clair Francis Retirement Home DS0000062899.V260190.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): The environment continues to provide residents with an attractive and homely place to live, with the equipment the need to help their independence. EVIDENCE: There is a programme of routine maintenance and renewal. The paintwork continues to be chipped and worn. The proprietor has stated that it will be replaced during 2006. Grounds are kept tidy and clean with the exception of two old armchairs outside a lounge window. A carer did not know why they had been placed there. The patio area outside the conservatory is bright and cheerful. Communal space includes three lounge areas on the ground floor, a small lounge on the first floor, two dining rooms and a conservatory. There is a large well-maintained garden. The home provides grab rails, raised toilet seats; bath hoists and a passenger lift to promote residents’ independence. There is a call system in every room so that the residents can summon help if necessary. There are accessible Clair Francis Retirement Home DS0000062899.V260190.R01.S.doc Version 5.0 Page 13 toilets and bathrooms for residents to use, which are close to the lounge and dining areas. Clair Francis Retirement Home DS0000062899.V260190.R01.S.doc Version 5.0 Page 14 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 It is not clear from the rota if there are sufficient numbers of staff on duty at all times to meet the needs of the residents. EVIDENCE: The rota did not clearly indicate if staff shortages had been covered by agency staff. During the previous inspection it was stated that there must be at least three members of care staff on shift during the normal waking times of the residents. The rota was unclear as to whether this requirement had been met. The manager stated that agency staff were used to cover staff shortages. Not all paperwork was available in the home at the time of the inspection to evidence this. It is a requirement to ensure there is a clear record of who has worked in the home for each shift. Staff were seen talking to residents and treated them with dignity and respect. The manager confirmed that care staff are not being allowed to work in the home before the receipt of satisfactory POVA First. Clair Francis Retirement Home DS0000062899.V260190.R01.S.doc Version 5.0 Page 15 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): 31,32,33,37,38 The manager is competent and experienced to run the home. Regular health and safety checks are being carried out to ensure the safety of the residents. However the replacement of intumescient strips has not been completed and this could lead to residents being at risk if there was a fire. EVIDENCE: Regular staff meetings are taking place. A notice was seen asking residents to join a residents committee. The manager stated that no residents had expressed an interest in joining. Regular testing of the fire alarms and emergency lighting are being carried out. During the previous inspection the inspector left an immediate requirement for the replacement of intumescient strips on fire doors that had been painted over. The manager stated that this has not been completed. This could place service users at risk. This must be Clair Francis Retirement Home DS0000062899.V260190.R01.S.doc Version 5.0 Page 16 completed by 15th December 2005. Failure to do so may result in the commission taking further enforcement action. The inspector has contacted the Fire Service and requested an inspection of the home to assess whether it meets the fire regulations requirements. Clair Francis Retirement Home DS0000062899.V260190.R01.S.doc Version 5.0 Page 17 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 2 Clair Francis Retirement Home DS0000062899.V260190.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement The registered person must ensure the accurate administration and recording of all medication. An immediate requirement was left stating that this must be actioned by 11th November 2005. Consult service users about their social interests and make arrangements to enable them to engage in local, social and community activities and to visit or maintain contact with their families and friends. Badly chipped woodwork around the home must be repaired and repainted A minimum of three staff must be on duty at all times during the daytime. The rota must clearly state who has worked each shift. All fire doors must be checked to ensure that they close properly and that their intumescient strips are robust. This was a requirement from the previous inspection. Failure to meet this requirement may DS0000062899.V260190.R01.S.doc Timescale for action 11/11/05 2. OP12 16(2)(m) 01/01/06 1. 2. OP19 OP27 23(2)(d) 18(1)(a) 15/07/06 15/07/05 3. OP38 23(4) 15/12/05 Clair Francis Retirement Home Version 5.0 Page 19 lead the commission to taking enforcement action. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 4. Refer to Standard OP7 OP19 Good Practice Recommendations Details of residents social histories and likes and dislikes should be clearly recorded in their plans of care Kick plates should be installed on doors to protect the woodwork Clair Francis Retirement Home DS0000062899.V260190.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE 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 Clair Francis Retirement Home DS0000062899.V260190.R01.S.doc Version 5.0 Page 21 - 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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