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Inspection on 12/12/05 for Falcon House Care Home

Also see our care home review for Falcon House Care Home for more information

This inspection was carried out on 12th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

What has improved since the last inspection?

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE Falcon House Care Home 2 Middle Street Beeston Nottingham NG9 1FX Lead Inspector Paula Dutton Unannounced Inspection 12th December 2005 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 Falcon House Care Home DS0000008673.V271832.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. Falcon House Care Home DS0000008673.V271832.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Falcon House Care Home Address 2 Middle Street Beeston Nottingham NG9 1FX 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) 0115 922 8151 0115 922 3759 Caredene Limited Margaret Harris Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Falcon House Care Home DS0000008673.V271832.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd September 2005 Brief Description of the Service: Falcon house is a purpose-built modern establishment providing accommodation for up to 40 older people. Accommodation is offered on ground and first floor levels. The first floor can be accessed via a shaft lift which is slow moving. Individual and shared rooms offer ensuite facilities. The home is located in the centre of Beeston offering access to local shops and amenities. There is parking available to the rear of the premises. Bus routes operate along the road outside the home. Falcon House Care Home DS0000008673.V271832.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a period of four hours. The registered manager and the registered owner were available during this time. The inspection involved viewing the individual files for three residents, meeting residents, discussion with staff, a tour of the premises, viewing the accident record, observing residents interacting with staff and viewing the medication trolley. This method of gathering information is known as ‘case tracking’ which measures outcomes for residents. What the service does well: This is a well organised and managed service. There have been clear and measurable improvements achieved by the manager and her staff team over the last twelve months. The service offers a range of strengths which include the following: • • • • • • The manager has very good understanding of the needs of residents and has clear expectations of how to meet those needs. Staff have very clear understanding of their responsibilities and how to achieve good standards of care. Staff promote independence and maintain residents’ skills. Staff have positive and respectful communication with residents. Staff participate in a comprehensive training programme. The environment is very clean and tidy. Some comments were received from residents: • • • ‘Food is nice and we always have a choice at dinnertime and at teatime’. ‘Staff are very good at night. They bring me my tablets’. ‘The staff are very nice’ Some comments were viewed from relatives: • • ‘Thank you for all your help and making my stay so happy’. ‘Very good and many thanks for the excellent service given to my mother’. Falcon House Care Home DS0000008673.V271832.R01.S.doc Version 5.0 Page 6 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. Falcon House Care Home DS0000008673.V271832.R01.S.doc Version 5.0 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 Falcon House Care Home DS0000008673.V271832.R01.S.doc Version 5.0 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): 1, 3, 4, 5 Sufficient information is exchanged between the home and potential residents so that informed decisions can be achieved. EVIDENCE: The home provides a Statement of Purpose and Service Users’ Guide to prospective residents prior to admission and on admission. These are comprehensive documents detailing the aims and objectives of the service. Residents are able to read about the range of services offered by the home. This document includes recent results of a quality survey. This is good practice. A discussion took place with the manager about admissions in relation to the home’s registration details. The manager stated a review of the Statement of Purpose and the Service Users’ Guide is about to be completed. Three residents’ individual record files were viewed. All showed a detailed assessment of need had been completed prior to admission to inform a trial period. Falcon House Care Home DS0000008673.V271832.R01.S.doc Version 5.0 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 Residents’ personal and health care needs are effectively addressed. EVIDENCE: Three residents’ record files were viewed. These showed care plans and risk assessments had been completed giving clear instruction to staff as to how they should meet residents’ needs. Work has been undertaken to ensure all residents who are identified as at risk of falling have risk assessments. Evidence showed risk assessments highlighted the mobility activities presenting high risk and what actions to take to reduce the risk of accidents. The accident record book showed all falls were addressed appropriately and health care services were accessed where necessary. Observation took place of staff assisting residents to move. This was unhurried, with dignity and actively promoting residents’ independence. Staff offered gentle verbal prompts alongside visual prompts through gestures. This is good practice. Falcon House Care Home DS0000008673.V271832.R01.S.doc Version 5.0 Page 10 The home has provided senior staff with accredited training in safe administration of medications. The medication lockable trolley was viewed and three records were sampled. The home uses a monitored dosage system and Mediform charts. Entries in the Mediform records reflected the medication administered. Observation found staff administering medication ensured residents were prompted to take their medication appropriately. A discussion took place with the manager about the current practice of hand writing all medication and doses onto the individual Mediform records. The manager and staff stated this system is positive for the home and there have been no medication errors. All areas of the home were viewed. Staff were observed to interact with residents in a respectful manner. Residents commented about how satisfied they are with the staff. Observation found the staff were relaxed, good listeners, professional and humorous. It was clear staff had developed good relationships with residents. Falcon House Care Home DS0000008673.V271832.R01.S.doc Version 5.0 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, 15 Residents’ social, cultural and nutritional needs are met. EVIDENCE: A range of activities had been arranged for the Christmas period. Two residents expressed their delight with the pantomime entitled ‘Snow White’. A newsletter is available either displayed on communal noticeboards or received monthly with invoices. The dining area was pleasant and tables were set with table cloths and napkins. Three residents stated they enjoyed the meals provided. One resident stated there is always a choice of meal at dinner time and tea time. Two residents stated they always got enough to eat. Residents were observed asking staff for drinks which were provided in between meal times. A large open kitchen hatch was easily accessed by residents should they want to make requests at the kitchen. The two main meals served on the day of inspection were attractively presented and offered ample portions. Falcon House Care Home DS0000008673.V271832.R01.S.doc Version 5.0 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 Residents rights and interests are actively protected. EVIDENCE: The home offers a complaints policy and procedure which is displayed in the main hallway. The manager stated there have been no complaints over the last three months. The manager demonstrated a strong commitment to promoting the right of residents. The manager stated staff receive training in the prevention of abuse and the staff team have access to the Department of Health’s guidance document entitled ‘Adult Abuse’. Discussion with staff showed staff were aware of how to promote residents’ rights and independence. The home has been proactive in protecting the safety of residents in completing risk assessments for night time and for residents’ vulnerability. This is good practice. Falcon House Care Home DS0000008673.V271832.R01.S.doc Version 5.0 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 Residents reside in a pleasant, safe and well maintained environment. EVIDENCE: A tour of the premises found all areas of the home were very clean and tidy. Seven individual bedrooms were viewed. All were clean and residents’ personal property was neatly arranged on furniture. All areas of the premises were bright and had plenty of sunlight. The main lounge on the ground floor offers floor to ceiling windows with a view over the busy street leading into town centre. The main lounge offered furniture and fittings to create a homely environment. One resident’s clothing was viewed which showed clothing is appropriately labelled and returned to the resident. Falcon House Care Home DS0000008673.V271832.R01.S.doc Version 5.0 Page 14 The home has invested in a laundry system that cleans clothes at low temperatures to the standard necessary to prevent the spread of infection. The manager stated staff have completed infection control training this year. All bedrooms have an ensuite facility. Some bedrooms are shared rooms with one ensuite. Screening was available for privacy. All areas of the premises could be accessed by people with mobility impairments through level floors and hand rails on both sides of the corridors. There are two assisted baths – one on each floor. Falcon House Care Home DS0000008673.V271832.R01.S.doc Version 5.0 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 There are sufficient, competent staff available to ensure residents needs are met safely. EVIDENCE: A staff rota is maintained offering a record of the staffing in the home. The staffing includes 5 staff on for the morning shift, 5 staff on the afternoon and evening shift and three staff on duty awake all night. Planning has taken place to allow staff time to spend talking to residents. This is good practice. Staff were observed to communicate effectively with residents (see Standard 10). The manager stated the home recruits new staff by gaining copies of sources of identification including passports and driving licences. Evidence was seen of two staff record files of evidence taken in the process of applying for Criminal Record Bureau checks. The manager stated the home gains copies of documentation where the CRB has been completed by another body eg College. Evidence was also seen of two written references gained prior to employment commencing. The manager and staff have achieved a programme of training to include some staff completing National Vocational Qualifications. Mandatory training included moving and handling, infection control, food hygiene, fire and prevention of adult abuse. The manager and the deputy are completing an assessors’ award. This demonstrates a commitment to continual improvement and development of the staff skills mix. This is good practice. Falcon House Care Home DS0000008673.V271832.R01.S.doc Version 5.0 Page 16 Falcon House Care Home DS0000008673.V271832.R01.S.doc Version 5.0 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, 32, 34, 35, 36, 37, 38 Residents benefit from a well organised and managed service. EVIDENCE: The manager offers a professional approach to managing a quality service. The manager demonstrated a clear understanding of the needs of older people. Residents, relatives and staff were able to approach the manager with questions. Communication tools including a daily diary contribute to effective communication within the home. Formal and recorded supervision is completed for all staff which offers the opportunity to reflect on care practice. Evidence showed the manager and the senior team complete supervision and appraisals for staff. The home has recently renewed their Investors In People Award. Falcon House Care Home DS0000008673.V271832.R01.S.doc Version 5.0 Page 18 The manager does not become involved in the finances for residents. This is good practice. Small amounts of cash belonging to residents is kept in a safe. An example of money stored was viewed which demonstrated the home maintains accurate records of any money and transactions. Residents are invoiced individually for items for example hairdressing. Falcon House Care Home DS0000008673.V271832.R01.S.doc Version 5.0 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 3 X 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 4 3 3 3 3 3 3 3 4 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X 3 3 3 3 3 Falcon House Care Home DS0000008673.V271832.R01.S.doc Version 5.0 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. Standard OP29 Regulation 17, Schedule 4 Requirement Staff files must contain the information and documentation specified in Schedule 4 of the Regulations Timescale for action 21/10/05 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. 2. Refer to Standard OP27 OP38 Good Practice Recommendations The staffing arrangements should be reviewed to enable more time for residents and staff to chat. A detailed risk assessment should be undertaken to indicate the steps being taken to minimise the risk of injury from falls. Falcon House Care Home DS0000008673.V271832.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Falcon House Care Home DS0000008673.V271832.R01.S.doc Version 5.0 Page 22 - 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. 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