Inspection on 15/07/05 for Clair Francis Retirement Home

This inspection was carried out on 15th July 2005.

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 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 11/11/05

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 Announced 15 July 2005 @ 09:00 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 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 I53 I03 S62899 CLAIR FRANCIS V228716 150705 STAGE 0.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Clair Francis Address 237/239 Park Road, Peterborough PE1 2UT Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01733 312670 01733 552132 clairfrancis@aol.com Mr Karim Bhanji Christina Bentley Care Home 28 Category(ies) of Dementia- over 65 years of age (3), Old age, registration, with number not falling into any other category (28) of places Clair Francis Retirement Home I53 I03 S62899 CLAIR FRANCIS V228716 150705 STAGE 0.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Not applicable Date of last inspection 22/03/2005 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 I53 I03 S62899 CLAIR FRANCIS V228716 150705 STAGE 0.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the home’s first inspection for the year 2005/6. It was announced. The inspectors spent a combined total of 11 hours at the home and interviewed nine residents, two visiting relatives, four members of staff and the manager. The inspectors undertook a brief tour of the home, checked medication storage and viewed a range of documents. As a result of this inspection five requirements and six recommendations have been made. What the service does well: 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 Clair Francis Retirement Home I53 I03 S62899 CLAIR FRANCIS V228716 150705 STAGE 0.doc Version 1.30 Page 6 contacting your local CSCI office. Clair Francis Retirement Home I53 I03 S62899 CLAIR FRANCIS V228716 150705 STAGE 0.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Clair Francis Retirement Home I53 I03 S62899 CLAIR FRANCIS V228716 150705 STAGE 0.doc Version 1.30 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 standard(s) 1,3,5 Information is available about the home, providing residents and prospective residents with details of the home’s services and enabling them to make an informed decision about where they live. Proper assessments are carried out before prospective residents enter the home so that they can be assured that their needs will be met. EVIDENCE: The home has a statement of purpose and service user guide that the inspectors have viewed on previous visits: these were satisfactory. A copy of the statement of purpose and the most recent inspection report are available in the main entrance to the home for residents and visitors to read. Prospective residents are assessed before they move in and all residents’ files checked by the inspectors contained completed pre-admission assessments carried out by a care manager or a staff member from the home. Visits to the home are actively encouraged and one resident told the inspector that, although she did not visit prior to moving in, her daughter did. Clair Francis Retirement Home I53 I03 S62899 CLAIR FRANCIS V228716 150705 STAGE 0.doc Version 1.30 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 standard(s) 7,8,10 The health care needs of residents are well met, and monitored, at the home. Staff work in such a way as to maximise and respect residents’ dignity and privacy. EVIDENCE: The inspectors viewed four residents’ care plans. The information they contained gave the reader a good understanding of the resident’s personal care needs. However some sections concerning residents’ social histories and their likes and dislikes had not been completed. There was evidence that residents had been involved in drawing up the plan, and also of regular review. Care plans are kept in residents’ bedrooms allowing them full access to the information. Residents’ health care needs are well met at the home and nutritional and pressure sore screening is undertaken regularly with each resident. One resident told the inspector that she saw the chiropodist five weeks ago, the dentist in May and the GP two weeks ago. The home has good links with the local PMS (personal medical service) team and has recently participated in a ‘Preventing Falls and Fractures In Care’ course run by the National Osteoporosis Society. Clair Francis Retirement Home I53 I03 S62899 CLAIR FRANCIS V228716 150705 STAGE 0.doc Version 1.30 Page 10 Staff interviewed by the inspectors gave good practical examples of how they maintain residents’ privacy and dignity when delivering personal care to them. One resident told the inspector: ‘I like my privacy so choose to spend the afternoons in my bedroom’. Clair Francis Retirement Home I53 I03 S62899 CLAIR FRANCIS V228716 150705 STAGE 0.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15 Although a number of in-house activities do take place, more must be done to ensure that residents have access to leisure and recreational facilities outside the home. The meals in the home are good, offering both choice and variety to residents. EVIDENCE: Activities do take place in the home and the inspectors viewed the activities file which showed that residents had played cards, quizzes, games, attended communion and reminisced. There was also a poster on display advertising future events such as a cream tea, a coffee morning, and a number of musical entertainers. However, apart from the occasional walk in the park, there are not many opportunities for stimulation through leisure and recreational activities outside the home and more should be done to promote this. The routines of daily living are flexible and residents are able to spend the day as they wish. One resident commented: ‘nobody pushes you, you can do what you like really’ another: ‘sometimes I like to stay up a bit later to watch TV’. Residents are able to entertain their guests. The inspectors interviewed two family members who were visiting their respective relatives on the day of inspection. Both confirmed that they were always made to feel most welcome by staff at the home. Clair Francis Retirement Home I53 I03 S62899 CLAIR FRANCIS V228716 150705 STAGE 0.doc Version 1.30 Page 12 The manager submitted a two-week menu as part of the pre-inspection information. This showed that residents receive a wholesome and balanced diet. Lunch on the day of inspection consisted of fried fish and chips or steamed fish with mushroom sauce and mashed potato, followed by trifle. Residents made many positive comments about the quality of the food. All meat, fish and vegetables are ordered fresh from local suppliers. The way breakfast is served has changed since the last inspection: it is now served communally in dining room (instead of being served individually to each resident in their bedroom). The manager stated that this was now more sociable for residents and that they were eating more as a result. Those residents who wish to breakfast in their room can still do so. Clair Francis Retirement Home I53 I03 S62899 CLAIR FRANCIS V228716 150705 STAGE 0.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The home has a satisfactory complaints procedure in place, however more could be done to promote it so that residents are fully aware of how to raise any concerns that they may have. EVIDENCE: Although a copy of the procedure for making a complaint is displayed on the wall in the entrance hall, most residents interviewed by the inspectors were unaware of it. In light of this, the manager agreed to issue residents with a copy of the procedure for their bedroom. The inspectors examined the complaints file and noted that there had only been one complaint dated 7 July 2003. The manager stated that most complaints are not recorded but passed on verbally and addressed there and then. The inspector recommended that a complaints/compliments book be set up as a way of recording, and monitoring, less serious complaints. Relatives interviewed by the inspectors said that they felt able to complain. Clair Francis Retirement Home I53 I03 S62899 CLAIR FRANCIS V228716 150705 STAGE 0.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25 The environment of the home provides residents with an attractive and homely place to live, with the equipment they need to help their independence. Badly chipped and marked woodwork, however, gives the home a rather shabby and neglected feel. EVIDENCE: The premises were viewed to be clean, comfortable with furnishings of good quality. A very homely atmosphere is achieved by the provision of old furniture, ornaments, plants and bookshelves. However, a lot of the internal woodwork is badly chipped and marked. The manager is well aware of this and stated that there were plans to strip down and repaint all the doors. The manager should also consider installing kick plates to prevent further damage to the woodwork. 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 Clair Francis Retirement Home I53 I03 S62899 CLAIR FRANCIS V228716 150705 STAGE 0.doc Version 1.30 Page 15 well-maintained garden with a patio area, garden seating and a raised plant bed. 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 residents can summon help if necessary. There are accessible toilets and bathrooms for residents to use, which are clearly marked, and close to lounge and dining room areas. Clair Francis Retirement Home I53 I03 S62899 CLAIR FRANCIS V228716 150705 STAGE 0.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 Training is good and residents are looked after by caring and competent staff, however staffing numbers must be maintained at a sufficient level to meet the needs of residents. The home’s recruitment and selections procedures are robust and ensure that residents are adequately protected. EVIDENCE: The inspectors received many positive comments from both relatives and residents about staff at the home including: ‘there always seem to be staff around and they really make an effort to talk to the residents’, ‘staff are very good and I can’t fault them’ and ‘I love being here, the staff are sociable, they’ll get you anything you want’. However two residents raised some concerns about a particular member of staff and this was discussed with the manager. Training for staff is good: more than 50 of staff are reported to hold an NVQ level 2 in care and staff also undertake additional training specific to the needs of older people such as Parkinson’s disease, dementia care and the protection of vulnerable adults. There are four care assistants on duty between 8am and 2pm and three care assistants on between 2pm and 10pm to support 25 residents. Two ‘waking’ night staff work between 10pm and 8pm. One resident told the inspectors that at weekends there sometimes wasn’t enough staff around. In light of this the inspectors viewed the staffing rota and noted several occasions where only two members of staff had been on duty. This number of staff is insufficient to meet the needs of twenty-five residents and an immediate requirement notice Clair Francis Retirement Home I53 I03 S62899 CLAIR FRANCIS V228716 150705 STAGE 0.doc Version 1.30 Page 17 stating that a minimum of three staff must on duty during the day was left with the manager. The inspectors checked a number of staff personnel files and they all contained appropriate CRB and POVA checks, references and work permits where required. The inspectors reminded the manager that employees should not routinely be starting work with just a POVA First check in place, unless in exceptional circumstances and having discussed it with the home’s inspectors. The manager interviews prospective employees on her on and the inspectors suggested that two people undertake this task to ensure consistency and fairness. Clair Francis Retirement Home I53 I03 S62899 CLAIR FRANCIS V228716 150705 STAGE 0.doc Version 1.30 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,36,38 The manager is competent and experienced to run the home and staff supervision has improved since the last inspection. However the failure to conduct regular fire systems and emergency lighting tests puts residents’ health and safety at risk. EVIDENCE: The home has a new manager who has been registered since February 2005. Feedback from both staff and residents about her management style and ability was generally very good. Regular staff meetings take place and staff reported these to be useful, and that concerns they raised were taken seriously. Residents meetings are not held, however, and the inspectors suggested that these are facilitated so that residents have an opportunity to feedback about the services they receive. Four senior staff members have recently completed a supervision course and most staff confirmed that they receive regular supervision, although the Clair Francis Retirement Home I53 I03 S62899 CLAIR FRANCIS V228716 150705 STAGE 0.doc Version 1.30 Page 19 domestic assistant reported that she never had. The manager stated supervision for this member of staff is planned for the future. Staff confirmed that they had received training in moving and handling, fire safety, first aid, risk assessment and food hygiene and training records viewed by the inspectors further evidenced this. The inspectors were particularly impressed by the domestic assistant’s knowledge of health and safety matters. However, the inspectors noted that a number of fire doors did not shut completely when released from their door guards and that a number of tumescent strips had been painted over, thereby rendering them ineffective. A check of the fire records showed that fire alarms and emergency lighting had not been tested as often as required. An immediate requirement notice was left with the manager in light of this. Clair Francis Retirement Home I53 I03 S62899 CLAIR FRANCIS V228716 150705 STAGE 0.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 4 COMPLAINTS AND PROTECTION 2 3 3 3 3 3 3 x 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 Standard No 16 17 18 Score 3 x x 3 x x x x 3 x 2 Clair Francis Retirement Home I53 I03 S62899 CLAIR FRANCIS V228716 150705 STAGE 0.doc Version 1.30 Page 21 no 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. 2. 3. Standard 19 27 38 Regulation 23(2)(d) 18(1)(a) 23(4) Requirement 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 day time All fire doors must be checked to ensure that they close properly and that their intumescent strips are robust. Fire alarms must be tested weekly Emergency lighting tests must be undertaken monthly Timescale for action 15 July 2006 Immediate and ongoing Immediate and ongoing Immediate and ongoing Immediate and ongoing 4. 5. 38 38 23(4) 23(4) 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. 3. Refer to Standard 7 12 16 Good Practice Recommendations Details of residents social histories and likes and dislikes should be clearly recorded in their plans of care Residents should be given more opportunties to participate in events and activties outside the home A copy of the complaints procedure should be issued to I53 I03 S62899 CLAIR FRANCIS V228716 150705 STAGE 0.doc Version 1.30 Page 22 Clair Francis Retirement Home 4. 5. 6. 19 29 33 each resident, in a fornat suitable to their needs Kick plates should be installed on doors to protect the woodwork Two people should interview all prospective employees to ensure consistency and fairness Residents meetings should be held. Clair Francis Retirement Home I53 I03 S62899 CLAIR FRANCIS V228716 150705 STAGE 0.doc Version 1.30 Page 23 Commission for Social Care Inspection 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 I53 I03 S62899 CLAIR FRANCIS V228716 150705 STAGE 0.doc Version 1.30 Page 24 - 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. 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