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Inspection on 27/11/05 for Crouched Friars Residential Home

Also see our care home review for Crouched Friars Residential Home for more information

This inspection was carried out on 27th November 2005.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home continues to operate to a good level with the service users consistently reporting that they enjoy living at the home and feel the staff are capable, kind and respectful in carrying out their duties.

What has improved since the last inspection?

The new manager has settled into her role and established some significant progress in staff training, supervision and the presentation of the home.

What the care home could do better:

Overall the home is performing at increasingly improved levels, however the manager is encouraged to continue to develop initiatives in good practice which will benefit the service users.

CARE HOMES FOR OLDER PEOPLE Crouched Friars Residential Home 103-107 Crouch Street Colchester Essex CO3 3HA Lead Inspector Sara Naylor-Wild Unannounced Inspection 27th November 2005 11:30 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.V263084.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Crouched Friars Residential Home DS0000017799.V263084.R01.S.doc Version 5.0 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.V263084.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 56 persons) The registered manager in association with the Responsible Individual devises and attains a programme of development, at the end of which she is able to demonstrate her full awareness of the responsibilities of the role, by 1st April 2005 28th May 2005 Date of last inspection Brief Description of the Service: Crouched Friars is a period property offering 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. Crouched Friars Residential Home DS0000017799.V263084.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on 27th November and 2nd December 2005. The inspector was assisted by the deputy Manager throughout the initial inspection day, with follow up discussions held with the manager, Ms Engutsamy on the second date. A large proportion of the National Minimum Standards (NMS) were considered at the last inspection in May 2005, therefore this visit focused on those standards not already assessed and the general progress of the home. 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 contacting your local CSCI office. Crouched Friars Residential Home DS0000017799.V263084.R01.S.doc Version 5.0 Page 6 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.V263084.R01.S.doc Version 5.0 Page 7 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): 2. Service users benefit from a contract or terms and conditions agreement with the home. EVIDENCE: The service users’ files sampled contained examples of terms and conditions agreements between them and the home, which met the listed expectations of NMS 2. Crouched Friars Residential Home DS0000017799.V263084.R01.S.doc Version 5.0 Page 8 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): 9 and 11. Medication is administered in accordance with national guidance and legislation. The wishes of service users in respect of their terminal care and following death are sought by the home. EVIDENCE: During the inspection visit staff were observed dispensing medication. The procedure followed was satisfactory, and ensured that service users’ safety was maintained. Other aspects of the recording and keeping of medication was also considered. The home maintains a medication storeroom, with good levels of secure storage for both general and controlled drugs. Records of drug delivery and returns were kept in good order. The inspector was not aware of any assessment of service users’ ability to manage their own medication or statements relating to the permissions given to the home to manage their drugs in their stead. The manager should consider this at service users’ reviews. Crouched Friars Residential Home DS0000017799.V263084.R01.S.doc Version 5.0 Page 9 The sample of service users’ files seen during the inspection provided evidence of the home’s attempts to gain insight into the individual’s wishes relating to death and dying. Crouched Friars Residential Home DS0000017799.V263084.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not fully revisited on this inspection. EVIDENCE: Although the full scope of these standards was not revisited on this occasion, discussions with service users highlighted some issues with the provision of a shop trolley at the home. The practice of taking a trolley stocked with a small selection of toiletries and sweets around the lounges to service users had been in place for some time. However, service users were disappointed that this practice had ceased and felt they missed out on the choice and opportunity offered. This was discussed with the manager, who explained that the trolley had become unfeasible due to the small turnover of stock and sell by dates, etc. However, an alternative arrangement had been made and service users were aware of this. She was advised to revisit this with the service user group. Crouched Friars Residential Home DS0000017799.V263084.R01.S.doc Version 5.0 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17. The home promotes advocacy services and supports service users in accessing their civil rights. EVIDENCE: The opportunity to use an advocacy service was promoted throughout the home on notice boards, and from discussions with staff and service users it was clear that this option was discussed. The manager should consider how individual’s mental capacity is assessed and the promotion and protection of their rights is recorded in care planning. Service users confirmed in discussions that they were supported in accessing their voting rights either through postal voting or escorted to the polling station. Crouched Friars Residential Home DS0000017799.V263084.R01.S.doc Version 5.0 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not fully assessed on this occasion. EVIDENCE: These standards were not fully revisited, however during the tour of the building the inspector was able to establish that the ongoing refurbishment and maintenance of the building has continued. Included in this was the removal of the stair gates on two stair wells, following recommendations of risk assessments. Crouched Friars Residential Home DS0000017799.V263084.R01.S.doc Version 5.0 Page 13 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 and 28. The numbers of staff on duty represent the outcomes of the residential forum calculations. The skill mix and experience of the staff group support service users’ needs. EVIDENCE: The planned rota demonstrated that staffing numbers were maintained at 6 care staff and person in charge during the waking shift. In addition there are auxiliary staff carrying out housekeeping, cooking and activities duties. Some vacancies had recently been recruited to including the supervisor’s vacancies, and these were undergoing an induction process. The number of staff holding and commencing NVQ 2 and above continues to increase and the manager reported that 3 new staff were commencing NVQ 2 with one doing NVQ 3. Crouched Friars Residential Home DS0000017799.V263084.R01.S.doc Version 5.0 Page 14 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): 36 and 38. A consistent staff supervision programme had been established. Quality assurance systems are in place. The evidence gathered at inspection demonstrates financial viability of the service. The records relating to health and safety were in good order. EVIDENCE: Since the previous inspection the manager had established a programme of supervision for all staff. The format had been revisited and new forms introduced, with a full published programme established for all line managers to carry out with staff. Crouched Friars Residential Home DS0000017799.V263084.R01.S.doc Version 5.0 Page 15 The home operates a quality assurance system which includes questionnaires provided to service users, staff, visitors and health professionals. They also operate regular staff and service users meetings for which minutes are maintained. The collation of the feedback from this information gathering had not been formalised previously, however the manager was able to advise the inspector of the outcomes of this work. The records relating to health and safety certificates for fire, electrical, gas, lift maintenance, etc were satisfactory. Crouched Friars Residential Home DS0000017799.V263084.R01.S.doc Version 5.0 Page 16 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 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 2 18 X X X X X X X X X STAFFING Standard No Score 27 3 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 3 X 3 X 3 Crouched Friars Residential Home DS0000017799.V263084.R01.S.doc Version 5.0 Page 17 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. Standard OP7 Regulation 15 Requirement The registered person must ensure that service users care plans are updated following review and that staffs daily records accurately reflect the successful implementation of the plan. The registered person must also ensure that service users or their representatives participate in the drawing up of care plans and sign off the completed document. This standard was not assessed at this inspection and is therefore carried forward to the next visit. The registered person must ensure that information held on staff files complies with Regulation 19, Schedule 2 of the Care Homes Regulations 2001. This standard was not assessed at this inspection and is therefore carried forward to the next visit. Crouched Friars Residential Home DS0000017799.V263084.R01.S.doc Version 5.0 Page 18 Timescale for action 31/03/06 2. OP29 19,Sch 2 31/03/06 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 OP10 Good Practice Recommendations The registered person should monitor staff practice and provide feedback to individuals on their performance. This standard was not assessed at this inspection and is therefore carried forward to the next visit. The registered person should develop the provision of activities in response to current good practice guidance. This standard was not assessed at this inspection and is therefore carried forward to the next visit. The registered person should develop the staff training programme to ensure it reflects the assessed needs of service users and skill shortfalls identified through staff supervision. This standard was not assessed at this inspection and is therefore carried forward to the next visit. 2. OP12 5. OP30 Crouched Friars Residential Home DS0000017799.V263084.R01.S.doc Version 5.0 Page 19 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.V263084.R01.S.doc Version 5.0 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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