CARE HOMES FOR OLDER PEOPLE
Faldonside Lodge Residential Home 25 Cliff Avenue Cromer Norfolk NR27 0AN Lead Inspector
Mrs Geraldine Allen Unannounced Inspection 4th April 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 Faldonside Lodge Residential Home DS0000065222.V288507.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. Faldonside Lodge Residential Home DS0000065222.V288507.R01.S.doc Version 5.1 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.V288507.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 6th February 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. Faldonside Lodge Residential Home DS0000065222.V288507.R01.S.doc Version 5.1 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 4 April 2006. Not all of the National Minimum Standards were inspected on this occasion and, where a standard has been inspected, the complete range of sub elements, as set out in the National Minimum Standards, may not have been assessed. The main focus of this inspection was to assess progress since the last inspection in February 2006. Mrs Soobrayen completed and returned a pre-inspection questionnaire prior to this inspection. Three completed comment cards were received from relatives. There were 10 residents at the home on the day of inspection. Six residents were spoken to either in private or in a communal part of the home. Three staff were spoken to together and also in private. A visitor was seen but it was not possible to speak in private. Overall, this inspection showed progress in many areas although the Pharmacist Inspector raised some concerns. Residents receive good care by staff who are committed to providing appropriate care. The inspection of the medication standard was conducted simultaneously by Pharmacist Inspector Mr M Andrews to follow up on issues raised during the inspection of 02/02/06. He found overall that the home had made efforts to resolve the issues previously identified as of immediate concern and that progress was slowly being made to improve medication practice at the home. Whilst the home had started to record the receipt and disposal of medicines on behalf of service users there were still some inadequacies in the recording. It remains of concern that some medicines no longer prescribed by the GP were recorded on the MAR charts as if active prescriptions including one entry where the incorrect medicine was being recorded. An audit of medication during the inspection revealed some minor discrepancies, which suggested records may have been completed by staff when medicines were not actually given. Also, because the exact doses of some medicines administered were not being recorded not all medicines could be fully accounted for. There are therefore unresolved and outstanding requirements relating to the homes medication record-keeping practices. Recommendations relating to the auditing of medication and records were again also made. Faldonside Lodge Residential Home DS0000065222.V288507.R01.S.doc Version 5.1 Page 6 The home has still not made arrangements for the provision of formal medication training for members of staff yet to be trained and therefore this remains of concern. What the service does well: What has improved since the last inspection? What they could do better:
The home needs to make sure that it obtains the views of as many people as possible to ensure that they provide the service that people need and expect. Mrs Soobrayen is keen to receive the views and opinions of people and needs to develop ways to assess the information she gets and use it to make plans for improvement. There remain some concerns about the way medicines are dispensed and recorded although improvement has been made since the last inspection. The home is not currently advising the Commission about significant events affecting the residents and home. It has been agreed that the necessary documentation will be forwarded to Mrs Soobrayen so that the home will comply in the future.
Faldonside Lodge Residential Home DS0000065222.V288507.R01.S.doc Version 5.1 Page 7 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. Faldonside Lodge Residential Home DS0000065222.V288507.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 Faldonside Lodge Residential Home DS0000065222.V288507.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): 1, 3 & 6 The home needs to make sure that it obtains the views of as many people as possible to ensure that they provide the service that people need and expect. Mrs Soobrayen is keen to receive the views and opinions of people and needs to develop ways to assess the information she gets and use it to make plans for improvement. There remain some concerns about the way medicines are dispensed and recorded although improvement has been made since the last inspection. The home is not currently advising the Commission about significant events affecting the residents and home. It has been agreed that the necessary documentation will be forwarded to Mrs Soobrayen so that the home will comply in the future. EVIDENCE: Faldonside Lodge Residential Home DS0000065222.V288507.R01.S.doc Version 5.1 Page 10 Mrs Soobrayen advised that the current fee levels range between £259.00 and £378.00 dependent on individual needs. Mrs Soobrayen confirmed that fee levels and additional charges payable, i.e. hairdresser, private chiropody, etc. are advised to potential residents and/or their representatives at the time of the needs assessment. A copy of the amended Statement of Purpose and Service User Guide were provided. Both documents have been updated by Mrs Soobrayen to reflect her ownership. . All residents have their own copies in their rooms and these were seen and known of by the residents. A copy of the pre-admission assessment that will be used by Mrs Soobrayen was provided. This document clearly has its origins in health and Mrs Soobrayen is aware that it will need to be amended and adapted to be more appropriate to this client group. . Issues around senior staff using this document were also considered. Mrs Soobrayen stated that she intends to amend the document based on experience of its use. She anticipates using the assessment for the first time very shortly. See recommendations. The home does not provide intermediate care. Faldonside Lodge Residential Home DS0000065222.V288507.R01.S.doc Version 5.1 Page 11 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 Quality in this outcome area is good in respect of standards 7, 8 and 10. The quality outcome for standard 9 is adequate. This judgement has been made using available evidence including a visit to this service. Care plans provide good and full information about the resident and how their needs are to be met. There was good evidence that the home is pro-active in supporting residents who have health needs. There are still matters outstanding regarding pharmacy matters although there has been improvement in records and practice. Residents are treated with dignity and their privacy is respected. EVIDENCE: Faldonside Lodge Residential Home DS0000065222.V288507.R01.S.doc Version 5.1 Page 12 Two care plans were looked at in detail but only 1 of the residents was available to speak with for case tracking. The care plans have now been updated and provide a good picture of the needs of each resident and how they should be met. There was evidence that residents are involved with their care planning and also with the review process. 1 resident confirmed this. Staff confirmed that the care plans are working well and contained more detail about each resident. Staff were observed completing the daily record sheets in each care plan. Residents have access to their care plans and records held about them if they wish. There has been good liaison between health services and the home regarding the care needs of one specific resident. The home has been pro-active in seeking advice and support appropriately. The resident was seen and her condition is much improved from the last Commission visit in March 2006. Staff were aware of her specific needs and how they should be met. Mrs Soobrayen stated that training from the diabetic nurse and also input from a dietician were arranged for staff. The pharmacist inspected against standard 9. Please see page 6 of the report summary. Four requirements were made but overall there was evidence of progress towards compliance. There was evidence of staff receiving training regarding privacy and dignity during their induction and foundation. Staff also spoke about their practice and how they try to ensure these matters are protected. Care plan entries detail specific privacy and dignity issues and how staff are to deal with any conflict in this area. Residents felt they were treated respectfully and interaction between staff and residents was respectful and appropriate. Faldonside Lodge Residential Home DS0000065222.V288507.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Records and practice support residents to live as they wish as far as possible. There is emphasis on rights and how they are supported. Residents are treated as individuals. EVIDENCE: Residents care plans show care planned around individual needs. Residents confirmed that routines were present but they had a say about when and how they received support etc. Posters clearly state that residents can take part in activity as they wish. The service user guide explicitly refers to choice, preferences and respect. One resident regularly goes out to the local shops and attends coffee mornings at the local church. Outings are planned for better weather. Relatives and friends are welcomed. A visitor to the home was seen being offered refreshment and notices invite visitors to stay for lunch for a small contribution toward the amenity funds. Faldonside Lodge Residential Home DS0000065222.V288507.R01.S.doc Version 5.1 Page 14 The bedrooms seen contained a significant number of personal belongings and lists of possessions were seen on the care plans. The pre-inspection questionnaire shows that all residents have advocacy in the form of either relatives or friends. Residents can access records held about them if they wish. Records are taken to their own room to protect confidentiality. Most residents have signed access agreements. A dietician is involved in reviewing and amending the diet for 1 resident with specific needs. Residents were supported to eat discreetly and appropriately with their dignity being maintained. The home caters for diabetic and soft diets. Care plans contain nutrition sheets and daily records show what is being eaten. Faldonside Lodge Residential Home DS0000065222.V288507.R01.S.doc Version 5.1 Page 15 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has good complaints procedures in place that are known to all. The home is pro-active in seeking the views of service users. The home has sound adult protection practice. EVIDENCE: The complaints policy was looked at and is in line with good practice. Some updating of contact details with the Commission is needed. A copy of the complaints procedure is in each bedroom and is also displayed prominently. There was discussion about how any expressions of concern or complaint should be recorded and stored for future inspection purposes. Mrs Soobrayen has a very open approach and actively seeks the views of residents and visitors. Staff adult protection training is scheduled for May & June. One further training date is required to ensure all staff have attended by the end of the summer. New staff are subject to Criminal Records Bureau/Protection Of Vulnerable Adults (CRB/POVA) disclosure and this was seen on staff files. Staff have a good understanding of adult protection issues and were confident about whistle blowing. Faldonside Lodge Residential Home DS0000065222.V288507.R01.S.doc Version 5.1 Page 16 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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is safe, well maintained and suitable for purpose. The home was clean and tidy. There were no unpleasant odours. EVIDENCE: The record of maintenance and renewal was seen. The layout of the record needs to be clearer for ease of reference. See recommendations. A tour of the premises was undertaken against health & safety issues. All corridors were well lit and free of obstruction. The lounge was in a good state of décor and choices of seating were available. The dining room will be redecorated shortly. Carpets were in good condition and areas were clean and tidy. There were no chemicals seen in the communal parts of the building. The contractor has delayed the rewiring of the building and a new date for the work should be available within 2 – 3 weeks.
Faldonside Lodge Residential Home DS0000065222.V288507.R01.S.doc Version 5.1 Page 17 Policies are in place for infection control, clinical waste and protective clothing. These were seen. All policies were reviewed and updated in January 2006. Risk assessments for electrical equipment were seen. Control Of Substances Hazardous to Health (COSHH) records were seen and data sheets were in place. All policies were based on recognised good practice. Faldonside Lodge Residential Home DS0000065222.V288507.R01.S.doc Version 5.1 Page 18 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are employed in sufficient numbers to meet the needs of residents. The home has exceeded the 50 qualified target. The home has good recruitment practice that safeguards residents. Training is provided to staff that is relevant to the client group. EVIDENCE: Staff rota’s were supplied. Staff confirmed that there are always 2 care staff on duty, in addition to a cook, during the day. Some staff confirmed that they work 12 hour shifts approximately once per week. Mrs Soobrayen stated that some staff prefer to work longer shifts because of transport and/or childcare issues but was aware she needed to keep the arrangement under review for health & safety reasons. She stated that days off were scheduled to ensure staff do not get over tired. The current staff who have not yet achieved NVQ do not wish to attend the course. The home currently exceeds 50 qualified. Faldonside Lodge Residential Home DS0000065222.V288507.R01.S.doc Version 5.1 Page 19 Two staff files were seen, one for a recently appointed staff. Both had full applications with health questionnaire, full work history. 2 written references and signed rehabilitation of offenders’ statements. The files also contained a completed interview questionnaire, photocopies of passport, full CRB/POVA disclosure & POVA 1st. There was evidence of overseas staff being subject to Home Office confirmation. Mrs Soobrayen is gradually building up training information on each staff file. Each file will contain certificates of training completed – this was seen on 1 file. Training needs are identified during supervision. The home is using the Malvern Partnership induction and foundation training pack. This was seen for the most recently appointed staff and they were up to date and timely. Training that will address the specific needs of residents will be provided in due course. Faldonside Lodge Residential Home DS0000065222.V288507.R01.S.doc Version 5.1 Page 20 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, 35, 37 & 38 Quality in this outcome area is good for standards 31, 33. 35 & 38. Quality outcome for standard 37 is adequate. This judgement has been made using available evidence including a visit to this service. Mrs Soobrayen is competent and experienced to run and manage the home. There is a good attitude towards seeking and responding to resident’s views. The scope needs to be widened to reflect the views of all stakeholders. The home operates good practice regarding resident’s monies that protects them from financial abuse. The home is not currently notifying the Commission of significant events. Records were generally in good order, up to date and legible. The content of records was appropriate. There are good health & safety practices at the home. Faldonside Lodge Residential Home DS0000065222.V288507.R01.S.doc Version 5.1 Page 21 EVIDENCE: Mrs Soobrayen stated that her course is progressing well and she is up to date with the submission of work. There is still some development work to do regarding quality assurance. Mrs Soobrayen expressed a wish to learn more about this subject, as it is not covered in great detail on her current course. She will look to attend a quality assurance management course. The home is open to seeking the views of residents and visitors but the scope needs to be widened. There was also discussion about analysis of the responses, how they should be summarised and the development of action plans. Mrs Soobrayen has a good grasp of the concepts. See recommendations. The financial records for residents personal allowances held by the home were seen and 2 full signatures are obtained in all circumstances. There was evidence of audit taking place. The practice used was seen and was appropriate. Regulation 37 was discussed and Mrs Soobrayen was not clear about this notification. This was explained and it was agreed a template would be forwarded for electrical advice. See requirements. Various health & safety records were seen. These included accident, fire, COSHH and generic risk assessment records. All were up to date and had been reviewed since January 2006. Fire records showed that a weekly alarm test takes place using a different call point. Staff confirmed recent fire training and this was recorded within the fire records. Faldonside Lodge Residential Home DS0000065222.V288507.R01.S.doc Version 5.1 Page 22 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 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 2 x 3 X 2 3 Faldonside Lodge Residential Home DS0000065222.V288507.R01.S.doc Version 5.1 Page 23 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 OP9 Regulation 13.2 Requirement The registered person must ensure that safe procedures are followed in respect of the safekeeping, control, administration and recording of medicines. See also the separate pharmacy report dated 6 February 2006. This is a repeated requirement. The registered person must ensure that the Commission is advised of all significant events as set out in this Regulation Timescale for action 17/04/06 2 OP37 37 13/04/06 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 2 Refer to Standard OP18 OP3 Good Practice Recommendations It is recommended that further adult abuse awareness training is provided as soon as possible. It is recommended that the present format for the preDS0000065222.V288507.R01.S.doc Version 5.1 Page 24 Faldonside Lodge Residential Home 3 4 OP19 OP33 admission assessment is kept under review to ensure it is relevant and supports the home to establish residents needs. It is recommended that the record of maintenance and renewal is kept in such a way that the date of completion is clearly seen. It is recommended that the scope of current quality assurance questionnaires is extended to all stakeholders. It is also recommended that the service provider access a quality assurance management course. Faldonside Lodge Residential Home DS0000065222.V288507.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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