Inspection on 28/02/06 for Falcon House

This inspection was carried out on 28th February 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

Falcon House 15/12/06

Falcon House 14/02/05

Falcon House 24/06/04

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 Falcon House George Green Little Hallingbury Bishops Stortford Essex CM22 7PP Lead Inspector Sharon Thomas Unannounced Inspection 28th February 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 Falcon House DS0000017815.V286629.R01.S.doc Version 5.1 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. Falcon House DS0000017815.V286629.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Falcon House Address George Green Little Hallingbury Bishops Stortford Essex CM22 7PP 01279 658393 01279 758646 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) Mr Noel Gordon Griffiths Catherine Garrett Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Falcon House DS0000017815.V286629.R01.S.doc Version 5.1 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 19 persons) 5th September 2005 Date of last inspection Brief Description of the Service: Falcon House is a large detached house located on the outskirts of the village of Little Hallingbury. The home provides accommodation for 19 older people (age 65 or older). The home provides care to meet the needs of people with low to high dependency needs. It has been adapted to meet the needs of residents with limited mobility. Falcon House provides personal and social care to those who live there. All bathrooms and toilets are fully equipped to provide a safe environment and promote independence. The home is well decorated and furnished throughout and the atmosphere is calm and relaxed. Falcon House benefits from a stable, knowledgeable, and skilled staff team. The proprietor, manager and the staff have a strong commitment to enabling residents to maintain the lifestyle that they had previously experienced before living in the home. The management and staff work hard to create a homely atmosphere, where choices are valued, and rights are preserved. The home aims to provide care that has positive outcomes for the residents. The staff team benefit from an extensive training and development programme and they were observed interacting with the residents in a sensitive and respectful manner. Falcon House DS0000017815.V286629.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on, and took 4.5 hours. Eleven of the thirty-eight National Minimum Standards were inspected: all eleven were well met within the home. For the purpose of this report the individuals living in the home spoken with on the day stated that they would prefer to be called residents. The inspection process included: discussions with the manager, two members of staff, and two residents. The tour of the premises included observation of five bedrooms, all of the bathrooms and toilets, all of the communal areas, the kitchen and the laundry. There was an opportunity to spend a considerable period of time observing the care being provided by the staff. The inspection included the examination of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). The home was warm, clean and tidy. The residents spoke highly of the care that they receive in Falcon House and spoke highly of the efforts of the staff, their commments may be found throughout the report. The home was decorated and furnished to a high standard and was clean, comfortable and had a homely atmosphere. The residents spoken with held the home in high esteem and made many positive comments regarding the atmosphere and dedication of all of the owner, manager and staff. The home aims and is successful in providing good quality care that promotes the rights and independence of the individuals living in the home. Falcon House promotes ensures privacy and the dignity of the person. Choice and autonomy are central to the care provided to the residents. What the service does well: The home provides a warm and homely atmosphere for residents. The home has created a family atmosphere that is relaxed and calm. Falcon House has a good caring staff team, and has a low staff turnover; staff that have left have done so for genuine reasons, such as retirement. The staff group in the home are enthusiastic, knowledgeable and skilled. Falcon House DS0000017815.V286629.R01.S.doc Version 5.1 Page 6 All of the residents spoken with on the day stated that the manager and staff were ‘kind and caring’ and the home was ‘very nice’. Residents reported that relatives and visitors are welcomed into the home at all times. Much of the activities provided in the home are designed to provide stimulation for residents and to promote physical exercise and interaction with the other residents and staff. The staff on duty were observed to talk continually with the residents and involve them as they went about their work through out the day. The home has succeeded in achieving its aims of: independence, choice, and care that provides dignity and respect. It is well decorated and maintained, and provides the residents with a team of well-trained, professional and caring staff. The home is committed to providing an environment that is ‘owned’ by the residents who live there and this concept is central to the high quality care that is provided to residents. What has improved since the last inspection? The home ensures that did a pre-admission assessment is contained in the care plan files The home now ensures that all residents have a photograph in their care plan files. The home has ensured that care plans now contain a risk assessment for the newest admission into the home. The care plans sampled have been developed to contain details relating to oral health care. The home has ensured that all staff in the home will receive Adult Abuse training. Falcon House DS0000017815.V286629.R01.S.doc Version 5.1 Page 7 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. Falcon House DS0000017815.V286629.R01.S.doc Version 5.1 Page 8 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 Falcon House DS0000017815.V286629.R01.S.doc Version 5.1 Page 9 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): None of the above standards were examined – please see previous inspection report. EVIDENCE: Falcon House DS0000017815.V286629.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8&9 The residents’ healthcare needs are well met in Falcon House. The home has appropriate systems in place that ensures the safe administration of medication. EVIDENCE: The three care plans that were examined all contained clear and detailed instructions for the delivery of personal care for residents. Oral and foot care were detailed. Routine health checks offered such as optician, dentist, and podiatrist were well documented. The home provided residents with access to aids and equipment to address their healthcare needs and issues. The manager confirmed that the home is well supported by the local primary healthcare team. Two residents stated that they were confident that staff would “phone for the GP if they were ill” and that “the staff keep an eye on me if I am poorly”. The manager has a registered nursing background and stated that many of the carers come from a healthcare background. This has the benefit that some healthcare issues are picked up speedily and dealt with in a preventative manner. Falcon House DS0000017815.V286629.R01.S.doc Version 5.1 Page 11 The medication used in the home is securely locked and stored. The records of the administration, receipt, and disposal of medication are accurate and well maintained as are the records of controlled medication. The staff spoken with that are responsible for giving medication confirmed that they had received appropriate training and support, and are confident that they ensure the safety of the residents when administering medication. Through discussion with staff it was clear that they were knowledgeable regarding side effects of medication, the policies and procedures and the importance of accurate recording. The manager reported that they had a good working relationship with the pharmacist, and is able to contact him to seek advice if required. Falcon House DS0000017815.V286629.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 & 14 The home provides residents with variety and choice with regard to their daily lives. Their expectations and preferences with regard to lifestyle are well met, and the capacity of individual residents to make choices is central to the care provided in the home. EVIDENCE: The manager confirmed that the home does not act as appointee for any of the residents living there. Arrangements for residents to bring in possessions were discussed prior to admission, and records of possessions are available. The care plans examined indicated some personal preferences in terms of food, clothes and other daily choices. Routines in the home are flexible and residents’ individual choices where possible, are addressed. One resident commented that they felt that they were “free to come and go as I pleased”. Staff confirmed that they encouraged residents to leave the home with relatives, and encouraged relatives to attend events held in the home. The home was warm, clean and comfortable. Residents were using all areas of the home and commented that there “were no restrictions on them” and one resident stated that “although this is not my home it is as near to the real thing that I will ever get”. Resident choice is observed throughout the day and the staff were supporting choices made by residents rather than making choices for individuals. Staff were very clear regarding this issue and stated Falcon House DS0000017815.V286629.R01.S.doc Version 5.1 Page 13 that the policy of the home is that the care is resident led. The staff are pleasant, polite and professional with their dealings with the residents and provide care in a discreet and quiet manner. The atmosphere in the home is calm and soothing and is suitable to the residents needs. Falcon House DS0000017815.V286629.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Falcon House has appropriate systems in place that protect the residents who live there. EVIDENCE: The Protection of Vulnerable Adult abuse policy and procedure examined on the day was suitable for the purpose of protecting residents. The document had detail regarding the signs or types of abuse and contained clear and detailed information for staff. The home has a whistle blowing policy and procedure available to staff, that ensures their protection should they report bad practice. The training records reviewed on the day confirmed that all staff except the new staff had received adult abuse training. All staff will have received the training by the July 2006. The manager reported that the home had not had any reported allegations of abuse since the previous inspection. Falcon House DS0000017815.V286629.R01.S.doc Version 5.1 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): 26 The home was clean and hygienic; there are systems and facilities in place to prevent the spread of infection. EVIDENCE: On tour of the premises all areas of the home were clean, tidy and free from odour. The temperature of the hot water from the taps was being recorded on a weekly basis. The staff spoken with reported that they had received infection control training and had found this helpful in identifying risks. The laundry area was clean and well maintained; the washing machines have appropriate wash cycles to prevent cross infection. The home provides staff with policies and procedures and training regarding levels of hygiene and safe care practice. Falcon House DS0000017815.V286629.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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): 28, 29 & 30 There is a stable and loyal staff team, which ensure consisitency in the delivery of care. The recruitment procedure in the home was robust and ensured the safety and protection of the residents. Residents benefit from a well trained staff team. EVIDENCE: Falcon House provides staff with a full and appropriate annual training programme. Of the sixteen members of staff, ten have achieved their NVQ Level 2, three are currently studying for the qualification and there are plans to have the remaining three staff apply for the course this year. The staff spoken with and staff personnel records of the newest member of staff confirmed that all pre-recruitment checks are completed prior to employment. The staff file contained references, application form, Criminal reference Bureau check, personal identification, photograph and contract of terms and conditions for staff. The file of the one newly recruited employee confirmed that she had received a full induction programme, and had shadowed a senior care worker until she was assessed as fit to work alone. The manager is fully aware of all the checks that are needed prior to the employment of staff. Falcon House DS0000017815.V286629.R01.S.doc Version 5.1 Page 17 Falcon House DS0000017815.V286629.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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 The home is well run by a competent and skilled manager. The home has an effective system in place to ensure that the quality of the service is reviewed and monitored. EVIDENCE: The manager of Falcon House is competent, skilled and knowledgeable. Residents and staff spoken with on the day stated that they had a great deal of confidence with the manager and that they felt that “she was always available” and “you can go to her if you are not happy with something”. The staff spoken with reported that the manager was approachable and was always there to guide them in their practice. The home had an established quality assurance system in place. The residents and representatives are involved in the user surveys and the information Falcon House DS0000017815.V286629.R01.S.doc Version 5.1 Page 19 gathered from those surveys has been used to enhance residents’ lifestyles within the home. The home plans to survey the staff working in the home. Falcon House DS0000017815.V286629.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X X Falcon House DS0000017815.V286629.R01.S.doc Version 5.1 Page 21 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. Standard Regulation Requirement Timescale for 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. Refer to Standard Good Practice Recommendations Falcon House DS0000017815.V286629.R01.S.doc Version 5.1 Page 22 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. 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