Inspection on 19/06/07 for Faldonside Lodge Residential Home

This inspection was carried out on 19th June 2007.

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

Faldonside Lodge Residential Home 04/04/06

Faldonside Lodge Residential Home 06/02/06

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 Faldonside Lodge Residential Home 25 Cliff Avenue Cromer Norfolk NR27 0AN Lead Inspector Mrs Geraldine Allen Unannounced Inspection 19th June 2007 09:00 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 Faldonside Lodge Residential Home DS0000065222.V343801.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. Faldonside Lodge Residential Home DS0000065222.V343801.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Faldonside Lodge Residential Home Address 25 Cliff Avenue Cromer Norfolk NR27 0AN 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) 01263 512838 01263 515950 Mrs Janeghee Soobrayen Mrs Janeghee Soobrayen Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (11) of places Faldonside Lodge Residential Home DS0000065222.V343801.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th April 2006 Brief Description of the Service: Faldonside Lodge is a care home providing personal care and accommodation for up to 11 older people. The home is owned and managed by Mrs Janeghee Soobrayen. Faldonside Lodge was built around the turn of the century and is a large, adapted house in a residential area not too far from the town and sea in Cromer. The home is close to all local amenities. Accommodation is provided on the ground, first and mezzanine floors in two shared and seven single rooms. Two of the single bedrooms have en-suite facilities. There is a stair climber to assist access to the first and mezzanine floors. The home has pleasant gardens to the rear of the home that provide sheltered sitting areas. Mrs Soobrayen confirmed that the fee range was £275 - £350 per week, dependent on individual need and accommodation. People are advised verbally of the fee payable before the resident moves into the home. All residents receive a contract shortly after moving into the home. Additional costs are shown in the Statement of Purpose and Service User Guide and include such items as hairdressing, private chiropody and newspapers. Faldonside Lodge Residential Home DS0000065222.V343801.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place during the day of 19th June 2007. Information and evidence was obtained from various sources. Prior to the inspection, Mrs Soobrayen completed a questionnaire, detailing information about the day-to-day running of the home. Four visitors to the service completed and returned questionnaires to the Commission, although no people using the service returned a questionnaire. On the day of inspection, further information was obtained by looking at various documents, speaking with people using the service, staff, visiting health professionals and visitors. Practice was observed and a tour of the building was made with a member of staff. Mrs Soobrayen was not available until later in the day and in her absence staff on duty provided information. Overall, this inspection found evidence that people enjoy a good quality of life in a pleasant environment. People using the service spoke about “kind and caring” staff. People also said they were happy and felt well cared for. Comments received from visitors who completed questionnaires included “new management and staff seem caring and eager to please”. There were some expressions regarding communication difficulties because of the number of overseas staff. However, people using the service were very clear that they were able to understand staff very well. Requirements made at the last inspection had been met. As a result of this inspection 1 requirement and 6 good practice recommendations have been made. What the service does well: What has improved since the last inspection? Faldonside Lodge Residential Home DS0000065222.V343801.R01.S.doc Version 5.2 Page 6 The home has made improvements to the way it looks after, administers and records medicines. Staff were knowledgeable about dealing with medicines and followed good practice. Mrs Soobrayen informs the Commission about any event at the home that may have an effect on people living there. Staff are receiving training about adult abuse. This means that people living at the home can feel safe and secure. 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. The summary of this inspection report can be made available in other formats on request. Faldonside Lodge Residential Home DS0000065222.V343801.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 Faldonside Lodge Residential Home DS0000065222.V343801.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service had an assessment of their needs before moving into the home to ensure the home can meet their needs. The home does not provide intermediate care. EVIDENCE: All residents had an assessment of their needs completed before they moved into the home. These documents were seen and provided a holistic approach to the person’s needs. Mrs Soobrayen said she had been completing all preadmission assessments to date but intends to start training senior staff to undertake this role from the next application received. This home does not provide intermediate care. Faldonside Lodge Residential Home DS0000065222.V343801.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each person who uses the service had a care plan that outlined the care they need and how it should be provided. Care plans were kept under review. Evidence was obtained that staff liaise appropriately with health professionals. Staff followed safe procedure and practice when dealing with medicines. People received personal care in private and were treated with dignity. EVIDENCE: Two care plans were looked at in detail. The care plans were well written and gave good information about each person’s needs and how they should be met. There was evidence of monthly care plan reviews and an annual review of care. The life histories need to be developed more to include significant events and anniversaries in the person’s life. The brief description sheet would benefit from having a photograph attached given the purpose of this document. Faldonside Lodge Residential Home DS0000065222.V343801.R01.S.doc Version 5.2 Page 10 A visiting District Nurse was spoken to. She said that staff referred to health professionals in an appropriate and in a timely way. The nurse said the care at the home was regarded as good. She said staff were always available to assist them when they visited the service. Medication records were seen. The recording and use of “when necessary” medicines were discussed with staff on duty and it was suggested that a care plan should be developed to keep with the administration charts to provide guidance to staff about when these medicines should be administered. A member of staff was observed dispensing medicines at lunchtime. Good practice was seen. It was confirmed that no controlled medicines were in use at the time of inspection. Mrs Soobrayen said she has still not obtained a controlled medicines register and she was advised to do so to ensure it was available should it be required in the future. Staff were providing personal care throughout the day and their practice was observed. All personal care was provided behind closed doors to protect privacy and dignity. Faldonside Lodge Residential Home DS0000065222.V343801.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service said they were able to make choices and live their lives as they wished. Visitors felt welcomed at the home and were able to visit in private. People receive a diet that is varied and nutritious and meet their specific dietary needs. EVIDENCE: Five people living at the home were spoken to. A recently admitted resident said she was well looked after and was still settling into the home. People were joined at lunchtime and spoken with at length. They said days do not feel long and they are not bored as they can pursue their interests. They said that days sometimes feel the same but only occasionally. Two residents were particularly chatty and enjoyed friendly banter. They talked about life in the home and said they were very happy. They said staff were good and looked after them well. People said activities were available if they wanted to join in. One resident said he enjoyed watching sport on TV in his own room. A visitor was seen in the home. People said their visitors can visit when they wish and staff always made them feel welcome. Faldonside Lodge Residential Home DS0000065222.V343801.R01.S.doc Version 5.2 Page 12 People said the food was always good and tasty. They said there was plenty available and confirmed they were offered alternatives if they didn’t want what was on the menu. Staff confirmed that drinks and snacks were available at all times. One resident said he didn’t need to have anything else to eat, as the quantity at meal times was sufficient. The practice at lunchtime was observed. People were eating in the dining room, lounge or their own rooms. Soft diets were being provided for some residents and it was noted that the components of the meal were liquidised separately. Drinks were encouraged during the meal. The cook said most vegetables were frozen but were always steamed to protect their nutritional value. All meals are home made. The kitchen was very clean and tidy. People said they were able to make choices about their daily life and were very confident staff would always respect these. Faldonside Lodge Residential Home DS0000065222.V343801.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure that is prominently displayed and well know by residents and visitors. Staff are trained about abuse awareness and the home follows good recruitment procedures to help protect people from abuse. EVIDENCE: One complaint had been received by the Commission and forwarded to Mrs Soobrayen to investigate. This was completed thoroughly and in accordance with the service’s complaints procedure. The complaints procedure was prominently displayed in the entrance hall. People said they would speak to Mrs Soobrayen or another member of staff if they had any concerns. The complaints procedure was well known to visitors to the home. Staff confirmed they had received vulnerable adults training. Mrs Soobrayen said she is due to attend a 3-day adult abuse course in July and all staff will attend after this. People are protected by good staff recruitment procedures that include Criminal Records Bureau and Protection Of Vulnerable Adults disclosures and a minimum of 2 written references. Faldonside Lodge Residential Home DS0000065222.V343801.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well maintained and in a good state of decoration. All areas seen were clean and tidy. No unpleasant odours were detected. EVIDENCE: A tour of the premises was undertaken with a member of staff. All areas of the home were clean and tidy, with no unpleasant odours noted. Various aids were in place to help people move about the home and also to maintain independence. Bedrooms seen were highly personalised and in a good state of décor. 1 bedroom door was propped open using a cushion because the resident liked the door open at all times. This needs to be replaced by an automatic, magnetic door closer to ensure fire safety. Staff are required to undertake cleaning duties and this took place during the afternoon of the inspection. Night staff clean communal areas. Faldonside Lodge Residential Home DS0000065222.V343801.R01.S.doc Version 5.2 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient staff were employed to meet the needs of residents. Staff had received training that is appropriate to the needs of people using the service. New staff had received induction training that complied with Common Induction Standards. EVIDENCE: A copy of the staff rota for the week of inspection was made by hand. This showed that 2 care staff are employed between 08:00 and 20:00. One carer was employed over night, with Mrs Soobrayen living on the premises and available to provide support and guidance as necessary. The cook was employed 5 days per week, with Mrs Soobrayen cooking on the cooks days off. There were no other ancillary staff employed and care staff undertook. 3 Staff files were looked at in detail. These showed that good recruitment procedures were followed. All staff on duty were spoken to. They described the home’s recruitment process and also gave details of the training they had received. Staff demonstrated a commitment to further training and development. Faldonside Lodge Residential Home DS0000065222.V343801.R01.S.doc Version 5.2 Page 16 The arrangements for the shift on the day of inspection were discussed. Care staff said they were required to do cleaning as well as provide care but said the needs of residents always came first. Two recently appointed care staff had just finished doing their induction training. Common induction standards training booklets were seen and had been fully and well completed. Mrs Soobrayen said that a recently appointed member of staff from overseas was currently having English lessons and there had been a significant improvement in her communication skills as a result. Faldonside Lodge Residential Home DS0000065222.V343801.R01.S.doc Version 5.2 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 21, 33, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Mrs Soobrayen is suitably qualified and competent to own and manage the home. The home operates a quality assurance process that seeks the views of people who use and visit the service. The home has good procedures in place for looking after people’s personal allowances. Staff receive formal supervision but this is not as frequently as is required. People are protected by good health and safety procedures. EVIDENCE: Mrs Soobrayen is qualified, experienced and competent to run and manage the home. She has completed relevant training to ensure her practice is up to date. Faldonside Lodge Residential Home DS0000065222.V343801.R01.S.doc Version 5.2 Page 18 The homes quality assurance process was looked at. Questionnaires were most recently sent out to relatives in March 2007. The quality assurance selfassessment was in place and contained an action and improvement plan. Good records were seen indicating a thorough review. The last resident survey was dated March 2007. It was noted that the print was quite small. Two people had their money looked after by the home. Each person had their money paid directly into bank savings accounts in their own names. Some people had their personal allowances looked after by the home. The amounts held were checked against records and these were correct. Good storage arrangements and practice were seen. Mrs Soobrayen confirmed that supervision was only taking place 4 times per year and she was aware this needed to increase. The documentation being used was seen. Supervision sessions were themed and good recording was seen. Each member of staff had signed a supervision agreement. Staff supervision was discussed and staff confirmed this was not taking place very frequently. Various health and safety files were looked at. These provided evidence that the building, systems and appliances were well maintained. A new nurse call system was installed in May 2006. The fire safety folder was seen and contained the new fire safety guidance document, along with fire risk assessments. The fire panel was replaced in June 2006. There were good fire training records seen and these showed that monthly drills and practice take place covering various topics such as evacuation and equipment use. Faldonside Lodge Residential Home DS0000065222.V343801.R01.S.doc Version 5.2 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 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 X 3 X 3 2 X 2 Faldonside Lodge Residential Home DS0000065222.V343801.R01.S.doc Version 5.2 Page 20 No Are there any outstanding requirements from the last inspection? 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 OP36 Regulation 18 (2)(a) Timescale for action All staff must receive appropriate 18/09/07 supervision. This will ensure that staff work understand and work to the home’s policies and procedures. Requirement 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 OP7 Good Practice Recommendations The way in which the service obtains information about a person’s life should be reviewed so that important events and matters are known and understood. This will help staff to support people better. The service should, with permission from the person, include a photograph of the person on the description sheet. This will support the purpose of the document. People should have a care plan that advises staff when “as necessary” medicines should be given. The care plan should be kept with the medicine administration records. This will ensure people receive these medicines at the correct time. DS0000065222.V343801.R01.S.doc Version 5.2 Page 21 2. 3. OP7 OP9 Faldonside Lodge Residential Home 4 5 6 OP9 OP19 OP33 A controlled drug register should be obtained by the service as soon as possible. This will ensure it is available at short notice. A magnetic door holder should be fitted to all bedroom doors where people like to have their door open. This will ensure that fire safety is not compromised. The print used in the quality satisfaction questionnaires needs to be clearer and larger. This will mean that people using the service can complete the questionnaire without the need of help from staff or visitors. Faldonside Lodge Residential Home DS0000065222.V343801.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Faldonside Lodge Residential Home DS0000065222.V343801.R01.S.doc Version 5.2 Page 23 - 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. 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