Inspection on 18/05/07 for Clair Francis Retirement Home

This inspection was carried out on 18th May 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 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 26/05/06

Clair Francis Retirement Home 11/11/05

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 Key Unannounced Inspection 18th May 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Clair Francis Retirement Home DS0000062899.V341193.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. Clair Francis Retirement Home DS0000062899.V341193.R01.S.doc Version 5.2 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) 01733 312670 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.V341193.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th September 2006 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 gardens. The fees at the time of the inspection were for private residents £380 per week and for funded residents £372 per week. The fee for residents with dementia is £416. The most recent inspection report is placed on the table next to the visitors book in the corridor joining the two houses. Clair Francis Retirement Home DS0000062899.V341193.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection that took place on Friday 18th May 2007. There were 21 people living in the home on the day of the inspection. The manager was present for the inspection and the deputy was present for the majority of the time. Methods used for the inspection included speaking to people who live at the home and staff, files and other records were seen and a tour of the home was undertaken. Twelve surveys from people living in the home were returned to the commission. What the service does well: What has improved since the last inspection? What they could do better: A system for monitoring the weight of people who live in the home must be put in place to ensure they are not at risk from being underweight. The manager must ensure that all new staff have two references before commencing employment. This will help to ensure the right people are employed. Clair Francis Retirement Home DS0000062899.V341193.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Clair Francis Retirement Home DS0000062899.V341193.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 Clair Francis Retirement Home DS0000062899.V341193.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): 1,3,5,6 Quality in this outcome area is good. Residents have the information they need to make an informed choice about moving into the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All residents have full assessments by care managers and/or the home manager before moving into the home to ensure the home is able to meet their needs. The manager stated that any one thinking of moving into the home are welcome to come and visit and have a meal if they wish to. One of the people living in the home said that she had come to visit for half a day and had lunch and been given a leaflet about the home before deciding to move in. There is an up to date statement of purpose and service user guide. This contains all the information needed to make an informed choice to move into Clair Francis Retirement Home DS0000062899.V341193.R01.S.doc Version 5.2 Page 9 the home. A selection of files of the people that live in the home were inspected. All of them had a contract of care and statement of terms and conditions of residence. The home does not offer intermediate care. Clair Francis Retirement Home DS0000062899.V341193.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): 7,8,9,10,11 Quality in this outcome area is good. The health care needs of service users are met while maintaining their privacy and dignity and their wishes during final illness and for after death are known and respected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All the people living in the home have a care plan which contains information about them such as what they prefer to be known as, medical history, current medical issues and treatment, summary of their needs and how they should be met by the staff and other important information that the staff need so that they know how to meet their needs if the way that they prefer. In some parts of the care plans tracked, areas of needs were identified such as one person in the home becomes confused at times but it does not tell the staff what action to take to follow. Where needs are identified a care plan Clair Francis Retirement Home DS0000062899.V341193.R01.S.doc Version 5.2 Page 11 should also state how that needs can be met. This will help to ensure all staff are working in the same way with the people living in the home. The care plans are being reviewed monthly to ensure they are up to date. The care plans showed that where issues have been identified the relevant health care professionals have been contacted. When written care plans must be dated so that it can be identified if all the information is current. At least one person living in the home is not being weighed on a regular basis, as no suitable scales are available. Where nutrional risk screening tools are showing that people living in the home may be at risk form being underweight this must be assessed regularly and the necessary equipment provided to do this must be made available. The relative of one person living in the home stated that the manager keeps them informed of any changes such as GP visits and they are always made to feel welcome when visiting. Eight of the surveys returned to the commission from people living in the home stated that they always receive the medical support they receive, three said usually and one said sometimes. The medication administration sheets were inspected and found to be accurate. The people living in the home confirmed that the staff treated them with dignity and respect by doing things like always knocking on their bedroom doors before entering and keeping them covered up when helping them with personal care. One of the people living in the home stated’ staff are always polite’. One of the people living in the home had asked the manager to put a notice on her bedroom door. The notice said ‘strictly no admittance to my room without my consent and authorisation’. The manager stated that all staff adhered to this. The manager and deputy stated that they feel they care for people who live in the home who are dying with the care, sensitivity and respect. They are currently putting a booklet together for people who live in the home about what to expect in the last stages of life and what support they can offer. The booklet will also help families with the practicalities after death so that they can discuss the dying persons wishes. If someone living in the home does not have any family with them in the last stages of their life the home always ensure that a member of staff are with them at all times. The relatives and friends of a person who is dying are able to stay with them and the home supports them to do this by providing meals and drinks. Clair Francis Retirement Home DS0000062899.V341193.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 excellent. The home has a full and varied activities programme and resident’s needs are met in a flexible way. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has put an activities schedule together so that there is at least one activity organised for each day. The activities are varied to try to appeal to all of the people living in the home. On the day on the inspection the schedule stated ‘coffee morning’ however only two families had come to the coffee morning. One of the families commented that when the coffee mornings had started up there had been a few more families attending but recently only a few attended. One of the people who live in the home said that activities and games are regularly organised but not many want to take part. Of the twelve surveys returned from people who live in the home, four said there is always suitable activities arranged by the home, four said usually, one said sometimes and one said never. Clair Francis Retirement Home DS0000062899.V341193.R01.S.doc Version 5.2 Page 13 The activities record showed that in May there had been a reminiscence morning with photos, gardening, singer, golden oldies film afternoon, songs of praise, skittles, holy communion, quiz, quoits, nail care, pat dog, dominoes, walk to the park with tea and cakes in the café, piano playing and a birthday celebration. An entertainer had been in the home the previous day and several people living in the home commented how much they had enjoyed his singing. The accessible sports session was also mentioned by people living in the home and is an excellent example of how people of all abilities can get involved in an enjoyable activity. One lady living in the home stated that she had recently been out shopping with a carer and had really enjoyed it. Five of the surveys returned by people who live in the home stated that they always liked the meals, six said usually and one said sometimes. One person living in the home said she would like less minced meat. On the day of the inspection one person living in the home had told the cook that she had a sore mouth so the cook had prepared steamed fish for her so it would be easier to eat rather than the battered fish that was on the menu. Clair Francis Retirement Home DS0000062899.V341193.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): 16,17,18 Quality in this outcome area is good. Complaints are appropriately investigated and action taken if necessary. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a poster in all of the bedrooms which states ‘ if you have any worries or concerns or would like to make a complaint please ask to see the manager – Tina Bentley’. One person living in the home said’ I’ve got no complaints but if something was wrong and you complained they would put it right’. All of the surveys received back from people living in the home stated that they would know how to make a complaint. The complaints log was inspected. There has been two complaints received since the previous key inspection both of which had been appropriately investigated and any necessary action taken. Staff spoken to on the day of the inspection were aware of the procedure to be followed if they suspected any of the people living in the home had been abused in anyway. Clair Francis Retirement Home DS0000062899.V341193.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): 19,21,22,26 Quality in this outcome area is good. Clair Francis is clean, safe and well maintained with sufficient space and facilities to meet the needs of the people living in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The decoration of the home and purchase of new furniture have given the home a much fresher and cleaner appearance. The carpet in the main lounge has been replaced. Two bathrooms have had new flooring and new bath panels. Eight bedrooms have been redecorated and four have had new carpets. Both dining rooms have had new flooring, curtains and tables and chairs. There are plans to extend the home – steps must be taken to ensure minimal disruption for the people currently living in the home. Clair Francis Retirement Home DS0000062899.V341193.R01.S.doc Version 5.2 Page 16 Staff stated that they two wheelchairs had recently been purchased but more were required to meet the needs of the people who live in the home. Clair Francis Retirement Home DS0000062899.V341193.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 good. The manager recognises the importance of staff training in order provide a quality service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff commented that it would help them to stay up to date with best practice if the home could subscribe to magazines such as Journal of Dementia Care or nursing and residential times. 82 of the staff already have at least an NVQ 2 in care. Another three people have registered to start the NVQ2 and seven have applied to do an NVQ 3 in care. Three staff files were tracked and contained all of the necessary recruitment checks apart from one reference was missing. Interview notes are kept for all staff employed. The staff rota showed that there is always three staff on duty during normal waking hours of the people living in the home. Out of the twelve surveys returned to the commission from people who live in the home five said that there are always staff available when needed and seven said there is usually staff available when needed. Clair Francis Retirement Home DS0000062899.V341193.R01.S.doc Version 5.2 Page 18 All staff have attended mandatory training. Refresher food and hygiene training has been booked for June and July 2007 and moving and handling refresher at the beginning of June 2007. Clair Francis Retirement Home DS0000062899.V341193.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): 31,33,35,38 Quality in this outcome area is good. The home is run by a strong management team whom the people that live in the home and the staff find approachable. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has recently sent out quality assurance questionnaires to relatives of the people who live in the home and they have been asked to complete it with their relative. The manager stated that when she has received all of the completed questionnaires she will analyse the results and write a report and action plan. Clair Francis Retirement Home DS0000062899.V341193.R01.S.doc Version 5.2 Page 20 The people living in the home stated that they would speak to the manager if they wanted to discuss any issues. The fire alarm system testing records were inspected and found to be satisfactory. Fire training was completed in September 2006 and had been booked for mid June 2007. A fire risk assessment was completed in October 2003 but there was no evidence that this had been reviewed since. The manager stated that a fire trainer had reviewed it but that it had not been recorded. Clair Francis Retirement Home DS0000062899.V341193.R01.S.doc Version 5.2 Page 21 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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X 3 2 X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Clair Francis Retirement Home DS0000062899.V341193.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2. Standard OP22 OP29 Regulation 23(2)(n) 19(1)(b) Requirement Equipment to meet service user mobility and health needs must be provided. Two references must be received before staff commence work to ensure the right people for the job are employed. Timescale for action 01/08/07 01/07/07 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 Refer to Standard OP30 Good Practice Recommendations A subscription to relevant publications should be provided so that staff can stay up to date on good practise issues. Clair Francis Retirement Home DS0000062899.V341193.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 Clair Francis Retirement Home DS0000062899.V341193.R01.S.doc Version 5.2 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. 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