Inspection on 14/07/06 for Crouched Friars Residential Home

This inspection was carried out on 14th July 2006.

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

Crouched Friars Residential Home 17/07/08

Crouched Friars Residential Home 20/06/07

Crouched Friars Residential Home 27/11/05

Crouched Friars Residential Home 28/05/05

Crouched Friars Residential Home 11/11/04

Crouched Friars Residential Home 30/06/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Crouched Friars Residential Home 103-107 Crouch Street Colchester Essex CO3 3HA Lead Inspector Jenny Elliott Key Unannounced Inspection 14th July 2006 09:30 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 Crouched Friars Residential Home DS0000017799.V302488.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. Crouched Friars Residential Home DS0000017799.V302488.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Crouched Friars Residential Home Address 103-107 Crouch Street Colchester Essex CO3 3HA 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) 01206 572647 01206 763622 Weldglobe Limited Mrs Lutchmee Engutsamy Care Home 56 Category(ies) of Old age, not falling within any other category registration, with number (56) of places Crouched Friars Residential Home DS0000017799.V302488.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 56 persons) 27th November 2005 Date of last inspection Brief Description of the Service: Crouched Friars is a period property that has been extended to offer care to 56 older people on three floors. The upper floors are accessed via a passenger lift. Most of the bedrooms are single occupancy and all have en-suite facilities. There are several communal areas offering a choice for service users, and a large pleasant garden at the rear of the property with a summerhouse for service users use. The property is situated close to Colchester town centre and has access to local amenities, including libraries, shops, post office and public transport. The fees charged by the home range from £367 to £570 per week. In addition to the weekly fee, service users pay £4 for hairdressing and £12 for the chiropodist where those services are used. Crouched Friars Residential Home DS0000017799.V302488.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The evidence contained in this report was gathered from discussion with service users and staff at the home, questionnaires completed by service users, relatives and professionals visiting the home, information provided to the Commission for Social Care Inspection (CSCI) since the last report and an unannounced visit to the home on 14th July 2006. What the service does well: What has improved since the last inspection? Two requirements for improvement were made at the last inspection. These were to review care plans and to ensure that information held in respect of the fitness of staff was complete. Both of these requirements were fully met at this inspection. In addition the home had provided training for senior carers with responsibility for supervising staff. The quality of supervision had improved since the last inspection and included clear guidance for staff. Crouched Friars Residential Home DS0000017799.V302488.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Crouched Friars Residential Home DS0000017799.V302488.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 Crouched Friars Residential Home DS0000017799.V302488.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The information provided to and about prospective service users was adequate. EVIDENCE: The information provided by the home continues to meet national minimum standards. The pre-admission assessment for one service user was seen. The format was limited but generally linked well to the needs of people who require care due to their age. The format does not allow for information about people’s interests, past life or emotional and social wellbeing (other than a tick box) to be included or assessed in detail. The assessment seen related to someone whose greater needs arose from another condition (other than age) and was, therefore, more limited in respect of the usefulness of the information to inform a plan of care. Crouched Friars Residential Home DS0000017799.V302488.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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home had plans of care to support their needs. The home meets the health needs of people living at the home well, including the administration of medication. EVIDENCE: The records of three service users were inspected in detail. Each of these contained a plan of care that identified their primary care needs and provided basic information about how these should be provided. The plans did not include information about the social and emotional needs of people. The plans had been reviewed on a monthly basis, and there was evidence that plans had been changed to reflect changing needs. More detail in the action required to meet the identified needs would better reflect the particular preferences service users had in respect of how they wished their care needs to be carried out, this is particularly important in relation to comments on records such as ‘can be difficult’ or ‘mood can change’. There were no associated notes that Crouched Friars Residential Home DS0000017799.V302488.R01.S.doc Version 5.2 Page 10 reflected why this might be or what action should be taken to manage the changes in behaviour. Daily record notes were basic containing information such as ‘slept well’ or ‘small diet taken’; these provide little information in respect of the review of care plans. Questionnaires had been received from service users and their relatives prior to the inspection. These were positive about the care provided in the home. Discussions with service users during a visit to the home were also positive about care provided by staff. Staff were observed with one person, who was bedridden and with whom the inspector was unable to communicate verbally, making that person comfortable, and talking with them in caring manner. This person’s records also provided evidence that the home was working proactively with health agencies to maximise their quality of life. The inspector spoke with another person who, although couldn’t clearly discuss the quality of the care they received, said they liked to have ‘a joke and a laugh’ with staff, and presented as being content with their environment. The records inspected at the home, and notifications of incidents sent to CSCI, demonstrate that health professionals, including district nurses and GPs are contacted in a timely manner where there were concerns about a person’s health. The administration of medication was not observed during the visit to the home. Records relating to administration, and the storage of medication were inspected and found to be satisfactory. It was apparent from the appearance of people living at the home that clothes were well cared for and that for people who required help with dressing time had been taken to ensure that their dignity had been maintained through their appearance. The inspector paid close attention to the quality of interaction between staff and service users during the visit to the home, at all times this was friendly but respectful, and service users were given time to respond to questions posed by staff. Social records indicated that the friends and families of service users visited the home. Relatives said they were made to feel welcome by the home when they visited. Crouched Friars Residential Home DS0000017799.V302488.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 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home did not plan social interaction to meet the assessed needs or aspirations of people living there. The social interaction observed during the site visit was generally good. The food provided by the home, and the mealtime ambience was good. EVIDENCE: The home accommodates people with a diverse range of care and social needs. The inspector also came across two service users with different religious beliefs. The care plan of one of these people said that they received communion at the home, although this was not supported by that persons ‘social diary’. The manager was aware of the beliefs of the other person but it was not clear whether they were encouraged to make contact with or meet people from outside the home who shared similar beliefs. Throughout the inspection staff were observed talking to people living at the home whilst carrying out their duties. One service user and member of staff were heard discussing what was being made in the kitchen whilst they were Crouched Friars Residential Home DS0000017799.V302488.R01.S.doc Version 5.2 Page 12 moving from one area of the home to another. Although there was little time to sit and talk to service users, this interaction did provide some social stimulation. During the visit to the home, the inspector was aware of two games of bingo being played. At the first a number of service users were involved in the game, holding their own cards even where they appeared somewhat confused about the game. These people seemed to be enjoying the activity. There was far less involvement from service users in the second game and it was not apparent that this was the most suitable activity for those people to be engaged in. Social diaries included other activities such as keep fit, hairdresser and one service user had an advocate. As has already been mentioned, care plans did not address the social and emotional needs of people living at the home. Service users records did not contain information about their personal history that would help the service to identify with service users activities and interests that they could continue with the home. The inspector saw the main meal of the day served in one of the dining rooms. The dining room had a pleasant atmosphere, and the meal was served once everyone was seated. There was a choice of food available, and it was evident that service users had made choices the previous day. People living at the home were complimentary about the food, one said the food was ‘fine’ another that they were ‘looking forward to lunch’ and another who was very pleased with the food, and presented as being happy generally, said ‘you can have chish and fips[sic] or egg and chips or whatever you want.’ Fresh fruit was seen in the rooms visited and another service user told the inspector ‘staff come round with fruit after dinner’. During the visit to the home one service user told the inspector that they were having difficulty eating some vegetables and that they were going to talk to the chef about cooking them differently. The chef was seen visiting that person in their room to discuss this and the service user confirmed after their meal that their request had been followed through. Crouched Friars Residential Home DS0000017799.V302488.R01.S.doc Version 5.2 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 the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home responds well to and keeps good records of formal complaints. The home did not always receive informal comments well or clearly record and advise those raising concerns of action taken. Systems, processes and practice in the home help to protect service users from abuse. EVIDENCE: The Commission had not received any complaints about this service. The service reported that they had received three formal complaints. Relatives reported a high level of satisfaction with the service, but two relatives reported that when they had raised issues with staff they had not been addressed quickly. The complaints log maintained by the home held good records including action taken in response to complaints. Records were also maintained of concerns and complaints made verbally to staff. The manner in which these were recorded did not make it easy to identify action that had been taken, as the concern and action taken were not necessarily on the same page. Notes from service user meetings were inspected. It was pleasing to note that action taken in response to issues raised at one meeting, were fed back at the next Crouched Friars Residential Home DS0000017799.V302488.R01.S.doc Version 5.2 Page 14 meeting. The notes for one meeting however, suggested that when service users raised issues, the immediate response of staff chairing the meeting was to justify the area that was raised as a concern. This approach was not reflected in subsequent meeting notes, where there was a more open and accepting tone to the notes. Care must be taken to ensure that service users are not put off from raising concerns by the manner in which they are accepted by the home. The home’s recruitment practice, induction of new staff, supervision of staff, and commitment to training were good. These practices help to protect service users from abuse. There had been no protection of vulnerable adults issues raised in connection with this service since the previous inspection. Crouched Friars Residential Home DS0000017799.V302488.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is provided in an environment that meets the needs of people living there. The health and safety of service users is promoted through good systems, training and care practice. EVIDENCE: Crouched Friars provides accommodation for up to 56 people. Although it is a fairly large home, the layout of the building gives an impression of smaller units and is not institutional. Accommodation is largely, but not wholly, in single rooms. There is some variation in the quality of accommodation provided to individuals, however it is felt that overall the accommodation is good. Some single rooms in the oldest part of the building are small with ensuite facilities that do not necessarily meet the needs of people living at the Crouched Friars Residential Home DS0000017799.V302488.R01.S.doc Version 5.2 Page 16 home. The home is on a number of levels but there is a lift in place to ensure people can move about the building. The front garden was tidy and well presented with a variety of flowering plants. The home has a generous sized rear garden. The rear garden was maintained to an adequate standard, but was not easily accessible by people who used wheelchairs, walking frames or other mobility aids. There was also little shade in the garden. The weather during the visit to the home was very sunny and hot, the only people seen to use the garden were staff. The home is situated in the centre of Colchester making it easy for service users, where suitable assistance is available, to access the town centre. Records relating to health and safety, including the routine maintenance and servicing of equipment were clear and up to date. The home employs staff whose sole responsibilities are domestic in nature, ensuring that care staff are not distracted from their core tasks. At the site visit the home was clean, free from odour and well maintained. The proprietor advised the inspector that there was a rolling programme in respect of external redecoration to the home. On the day of the site visit contractors were decorating external areas on the oldest part of the building. Staff had undertaken training in respect of infection control. Staff were observed wearing gloves and aprons when appropriate. None of the practices carried out by staff, and observed by the inspector gave rise to concerns about infection control measures. Crouched Friars Residential Home DS0000017799.V302488.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The number and skill mix of staff meets the needs of people living at the home. The training and supervision of staff employed at the home supports their ability to care for people living there. People living at the home are supported and protected by the home’s recruitment practice. EVIDENCE: The manager of the home has carried out an assessment of service user needs to identify minimum staffing levels using a recognised tool. The staffing levels at the home exceeded these minimum standards. It was evident through observation, that staff were able to carry out tasks in an unhurried manner and to engage with people living at the home in a meaningful, albeit limited, way. Staff were also observed responding promptly to service users calling for assistance from their rooms. There was though insufficient time to fully meet the social and emotional needs of people living at the home. The home employs dedicated domestic staff to ensure the home is maintained in a clean and hygienic state and that food is provided to a good standard. Crouched Friars Residential Home DS0000017799.V302488.R01.S.doc Version 5.2 Page 18 The home has a commitment to staff training. Mandatory and core training areas were routinely accessed including fire safety, food hygiene and moving and handling. Staff were also working through common induction standards for care staff and had attended training to raise awareness about the protection of vulnerable adults. Staff with supervisory responsibilities had attended training entitled ‘supervisory development’. Supervision notes and discussion with the manager demonstrated that the quality of supervision had improved. The notes suggested that staff took time to reflect on care principles appropriate to their work. The home had also identified training for staff whose first language was not English. Five care staff had completed a national vocational qualification (level 2) in care and three staff had applied to commence that course. Two staff were working towards the same qualification at level 3. Whilst this is short of the minimum level expected by national minimum standards, the home’s commitment to achieving this level of training for all staff, and planned approach to meeting it gives the Commission confidence that it will be met within the next twelve months. Recruitment records for two members of staff were inspected in detail. These held evidence that all checks as to their fitness for the work had been carried out. Crouched Friars Residential Home DS0000017799.V302488.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager of the home has the experience and level of qualification and competence necessary to run the home. The home is well run and promotes the safety and well being of people living there. EVIDENCE: The registered manager of the home has several years experience as a manager and senior carer and is qualified to National Vocational Qualification Level 4. The manager and provider have also attended training courses and seminars to develop and update their knowledge. The registered manager and provider work in an open manner with the Commission and this was evident in Crouched Friars Residential Home DS0000017799.V302488.R01.S.doc Version 5.2 Page 20 the manner of staff during the visit to the home and in the supervision and meeting notes held by the home. The home meets regularly with the District Nurse team to ensure that communication between the two bodies is of a good level, which further supports this atmosphere. The home has an elementary quality assurance system. The views of service users and other people who have links with the home, are sought through questionnaires. The answers are collated and put on display at the home. The questionnaires are limited to yes/no answers and therefore provide little opportunity for people to identify areas that are satisfactory, but could be improved. The home should also link in other areas of work that are measurable, for example responding to complaints, and service user meetings. The home ensures that staff are trained in respect of areas affecting the health and safety of service users. Good records are kept of the servicing and maintenance of equipment and services to the home. Crouched Friars Residential Home DS0000017799.V302488.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 X X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X X X X 3 Crouched Friars Residential Home DS0000017799.V302488.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. Standard OP7 OP12 OP14 Regulation 15 Requirement The service users plan, and practice at the home, must reflect the emotional and social needs that relate to service users’ health and welfare. The registered person must develop the services quality assurance process so that it meets current regulations. Timescale for action 30/09/06 2 OP33 24 31/10/06 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 OP3 Good Practice Recommendations The service should develop the format used for recording the assessed needs of prospective service users, so that it contains a fuller pen picture of the individual. Crouched Friars Residential Home DS0000017799.V302488.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Crouched Friars Residential Home DS0000017799.V302488.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!