Inspection on 26/05/06 for Clair Francis Retirement Home

This inspection was carried out on 26th May 2006.

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

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

Other inspections for this house

Clair Francis Retirement Home 06/10/08

Clair Francis Retirement Home 18/05/07

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 Unannounced Inspection 31st May 2006 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.V295574.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.V295574.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 01733 552132 clairfrancis@aol.comm 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.V295574.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th November 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. The fees at the time of the inspection were for private residents £350 per week and for funded residents £344 per week but the private funded residents fee’s are due to increase to £380 in July 2006. The fee for residents with dementia is £415. Clair Francis Retirement Home DS0000062899.V295574.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 26thMay 2006 for seven hours. Methods used for the inspection included speaking to the manager, staff and residents, observation of care, reading documentation and a tour of the home. Some requirements from the last inspection had not been met. 26 standards were inspected during this inspection only 50 met the national minimum standard. What the service does well: What has improved since the last inspection? What they could do better: The registered provider must ensure that there is adequate staffing at all times. On one occasion in the week previous to the inspection there were only two members of care staff on shift and no other staff in the building for 25 residents. This is not acceptable and places the residents at risk. Failure to Clair Francis Retirement Home DS0000062899.V295574.R01.S.doc Version 5.2 Page 6 provide adequate staff to meet the residents needs will result in the Commission taking enforcement action against the home. The general appearance and cleanliness of the environment could be improved. The manager stated that this had been due to electricians working in the home for four weeks. The fire service strongly recommended that the dorguards be replaced by automatic door releases as part of the fire alarm system. This has not been done and on the day of the inspection several of the battery operated dorguards were not working. 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.V295574.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.V295574.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have the information they need to make an informed choice about moving into the home. EVIDENCE: The inspector asked a resident why she had chosen the Clair Francis to move into. The resident stated that it was the only home with a vacancy but she had visited the home before moving in. 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. Clair Francis Retirement Home DS0000062899.V295574.R01.S.doc Version 5.2 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staff do not always treat residents in a way that promotes their privacy and dignity. EVIDENCE: The manager stated that all of the care plans are due to be updated to a new format by the end of June. Care plans have been written to encourage independence where possible for example one care plan tracked stated ‘to be encouraged to do as much as possible herself. Lay out clothes in order but may find that items get muddled and will need adjusting, discreetly monitor when dressing. Not all care plans are being reviewed regularly. One resident stated she had seen her care plan. There is a ‘getting to know you’ sheet in the care plans which includes details on family and cultural background, early life, employment, relationships and major life events. This gives staff information to discuss with the residents. Clair Francis Retirement Home DS0000062899.V295574.R01.S.doc Version 5.2 Page 10 Three members of staff were observed helping a resident in the lounge into a stand aid and transfer into a chair. The residents skirt was caught in the sling and her underwear and incontinence pad could be seen by other people in the room. Staff were unaware of this. More care needs to be taken when assisting residents to transfer to ensure their privacy and dignity is upheld. One member of the care staff was observed helping a resident through the communal lounge and told the other member of staff the lady she was helping had just had ‘her bowels wide open’. The manager agreed this was not acceptable and would discuss it with the member of staff concerned. Again this is not maintaining a resident’ dignity. One resident stated that she had not had any sleeping tablets supplied for the last three weeks so had not slept properly. The manager stated that this was due to administrative process changing the resident’s GP which was out of her control. The medication administration charts were inspected. There were several omissions of signing for medication but it is a great improvement on previous inspections. Any issues with supply of medication should be recorded on the medication charts. A senior carer has been employed by the home who will be responsible for the ordering and auditing of medication. Clair Francis Retirement Home DS0000062899.V295574.R01.S.doc Version 5.2 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 the following standard(s): 12,13,14,15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Meaningful activities and trips out of the home are not being offered. EVIDENCE: One resident stated that she was not aware of any activities or trips out since living in the home. Another resident also stated that he would like to go out of the home as the last time he went out with staff was before Christmas. One member of staff said she was not aware of any activities taking place in the home during the last month when she was working. The manager stated that there had not been regular activities due to staffing shortages but that the proprietor had agreed to extra staff hours each week so they hoped to organise more activities in the future. The dining room table had been set for dinner with linen tablecloths and serviettes and a glass of sherry and juice for each resident. This made the dining room look very homely and welcoming for the residents. Residents stated that they enjoyed their food. Clair Francis Retirement Home DS0000062899.V295574.R01.S.doc Version 5.2 Page 12 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives are encouraged to discuss any concerns with the manager. EVIDENCE: All of the care staff spoken to said they would speak to the manager immediately if they suspected any of the residents had suffered abuse. The home has a complaints procedure. No complaints have been received by the home since the previous inspection. There is a poster in each resident’s room reminding them to discuss any concerns with the manager. A book for relatives to comment on any issues that need attention by the manager is provided next to the visitor’s book. However there are been no entries in it. Clair Francis Retirement Home DS0000062899.V295574.R01.S.doc Version 5.2 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Various areas of the home were in need of repair and cleaning. EVIDENCE: The carpets throughout the home looked like they had not been vacuumed for several days. The manager stated that the cleaner had not been at work for a few days. The gardens which can be seen from the lounge and conservatory areas are very overgrown. Therefore if residents wanted to go outside in the garden they would be restricted to the patio area. The woodwork on the doors and doorframes is still very chipped and gives the home a run down appearance. The toilet by Room 22 had a cupboard with aprons falling out of it and an empty mop and bucket and caution wet floor sign on it. Clair Francis Retirement Home DS0000062899.V295574.R01.S.doc Version 5.2 Page 14 Several of the dorguard units which release fire doors on the sounding of the fire alarm were found to not be working. The toilet opposite room 10 has half of the flooring missing exposing wooden floorboards. There was also four pieces of wood of the floor. This could be a hazard for residents. Incontinence pads were on top of a radiator cover in an upstairs corridor. In room 12 the window is broken and had been wedged open with a piece of wood. The bath panel is looking very worn in the bathroom next to room 12. There were also used towels left on the bath hoist and cleaning chemicals on the windowsill. All cleaning chemicals should be securely stored. One of the bathrooms upstairs had an out of order sign on it. The fire extinguisher in the upstairs corridor had been stored behind a table. This should be easily accessible in the case of a fire. The kitchen is in need of updating. Not all of the knobs on the oven have worked properly for a considerable amount of time. As the ignition switch is not working for the oven staff have to lean into the oven and manually light it. The area at the back of the sink and around the worktops looked dirty. Staff stated they have tried to clean it. The manager stated that there will be a new kitchen as part of the planned extension to the home so the provider is reluctant to spend money on the existing kitchen. The Food team at the Planning and environmental health services have been requested to inspect the kitchen to ensure its safety. One resident stated that she had not brought in any personal possessions or furniture as there was not room for it in her bedroom. The manager stated that it had been a decision of the residents family not to being in any extra furniture, but that she had brought in a television and photos. Clair Francis Retirement Home DS0000062899.V295574.R01.S.doc Version 5.2 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The staffing levels have at times been unacceptable to safely meet the residents needs. EVIDENCE: On Saturday the 27th May the rota shows that there was only two members of care staff on duty between 6pm and 8pm to meet the needs of 25 residents. This is not acceptable and places the residents at risk. The rota shows that there is normally four care staff on shift in the morning. On Sunday the 28th May there was only three members of staff on duty. The care staff and manger confirmed that they had asked the proprietor if they could arrange agency staff to cover the 27th and 28th May but were told they could not. The proprietor stated that no one contacted him to request the agency cover. The inspector contacted the proprietor on the day of the inspection to confirm that there must be adequate staffing at all times to meet the needs of the residents. An immediate requirement was issued to the home stating that they must provide adequate staffing at all times. Failure to comply with this could lead to the Commission taking enforcement action. If staff require agency cover they have to complete a form and fax it to the proprietor to gain authorisation. A procedure must be put in place in the Clair Francis Retirement Home DS0000062899.V295574.R01.S.doc Version 5.2 Page 16 instance where staff can not contact the provider and need to arrange agency staff. Staff were observed singing and laughing with the residents which created a nice relaxed atmosphere in the home. One member of staff stated that she was due to attend a refresher training course on moving and handling in November 2005 but was told she could not do this due to staff shortages. The manager stated that it had been the trainer that cancelled the training. Care staff stated that when there are only three members of staff care staff in the morning it is a rush to help all of the residents. Clair Francis Retirement Home DS0000062899.V295574.R01.S.doc Version 5.2 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Processes are not in place to ensure the safety and welfare of residents and staff. EVIDENCE: All of the care staff spoken to said that both the manager and the deputy manager were approachable with any issues. Records show that care staff are not receiving regular supervision. When asked one member of that care staff was not aware what a supervision session was. The manager stated that supervisions were not up to date due to lack of time caused by staff shortages. Clair Francis Retirement Home DS0000062899.V295574.R01.S.doc Version 5.2 Page 18 Used gloves were seen in open bins in various places in the home. One member of staff was seen wearing an apron helping a resident from the toilet and then going to hep residents with lunch before changing her apron. A report in November 2005 from the Cambridgeshire Fire and Rescue Service stated ‘dorguard units are in extensive use in this property. The maintenance of these units with charged batteries can be a problem. It is strongly recommended that automatic door releases are installed as part of the fire alarm system. However on the day of the inspection the dorguard units were still in use. Three of the units were waiting for batteries to be renewed and would not hold the doors open and one unit was wedged onto a folded piece of carpet and when released the door did not close. This was reported to the fire service. The manager stated that there is no quality assurance system used at present but that she plans to do so in the future. Clair Francis Retirement Home DS0000062899.V295574.R01.S.doc Version 5.2 Page 19 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 2 2 3 3 2 2 1 STAFFING Standard No Score 27 1 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 1 X 1 Clair Francis Retirement Home DS0000062899.V295574.R01.S.doc Version 5.2 Page 20 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. Standard OP7 OP9 Regulation 15(2)(b) 13(2) Requirement Care plans should be reviewed on a regular basis. The registered person must ensure the accurate administration and recording of all medication. Any supply issues should be recorded on medication administration sheets. Timescale for action 01/07/06 01/07/06 3. OP10 12(4)(a) 4. OP12 16(2)(m) The registered person shall make 01/07/06 arrangements to ensure the care home is conducted in a manner which respects the privacy and dignity Consult service users about their 01/07/06 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. This was a requirement from the previous inspection. Failure to comply with this requirement may lead to the Commission taking enforcement action. All parts of the care home must DS0000062899.V295574.R01.S.doc 5. OP26 23(2)(d) 01/07/06 Page 21 Clair Francis Retirement Home Version 5.2 6 7. OP19 OP20 23 23 8. OP27 18(1)(a) be kept clean. The premises must be kept in a good state of repair. External grounds must be suitable and safe for use by service users and appropriately maintained. A minimum of three staff must be on duty at all times during the daytime. 01/08/06 01/07/06 26/05/06 9. 10. 11. OP33 OP36 OP38 24 18(2) 23(4) There must be a system for 01/08/06 regularly reviewing the quality of care provided. Care staff must have regular 01/08/06 supervisions. All fire doors must be checked to 01/07/06 ensure that they close properly. All dorguards must have batteries replaces as soon as needed. This was a requirement from the previous inspection. Failure to meet this requirement may 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.. Refer to Standard OP19 Good Practice Recommendations Kick plates should be installed on doors to protect the woodwork Clair Francis Retirement Home DS0000062899.V295574.R01.S.doc Version 5.2 Page 22 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. 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