Inspection on 06/02/06 for Faldonside Lodge Residential Home

This inspection was carried out on 6th February 2006.

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

The inspector 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 19/06/07

Faldonside Lodge Residential Home 04/04/06

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 Announced Inspection 6th 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 Faldonside Lodge Residential Home DS0000065222.V282804.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.V282804.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.V282804.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21 June 2005 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.V282804.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and took place during the day of 6 February 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. This was the first inspection of the home since Mrs Soobrayen took over as the home’s owner in December 2005. The main focus of this inspection was to see how well the change of ownership had gone and also to look at the plans Mrs Soobrayen had for the future development of the home. Mrs Soobrayen completed a pre-inspection questionnaire that provided information about the home and returned it to the Commission before this inspection started. Nine residents and 4 relatives completed Commission questionnaires. There were 11 residents living at the home on the day of inspection. All of the residents were seen and most were spoken to during the day. Some residents were spoken to in private. A visiting relative was also seen and spoken to. On the day of inspection, various records were seen and a tour of the building took place. Three staff were spoken to in private and the opportunity was taken to speak with a visiting district nurse. Overall, this inspection found that the standard of care at this home was good although some concerns were raised about some practices regarding medicines. The inspection of the medication standard (NMS 9) was conducted simultaneously by Pharmacist Inspector Mr M Andrews. He found there to be inadequacies in the security of medicines and that the home is failing to keep necessary records of medicines received at the home on behalf of service users and records of medicines removed for disposal. Therefore the home is currently both unable to account for medicines or demonstrate that prescribed medicines have been administered in line with prescribed instructions. During inspection, the inspector issued an Immediate Requirement form requiring that urgent remedial action is taken to resolve these issues. In addition, the inspector noted that some medication records in use to record the administration of medicines do not accurately reflect the medication regime currently prescribed for service users. Although there was documentary evidence to confirm that two members of staff had been on recent medication training, for others there was no such Faldonside Lodge Residential Home DS0000065222.V282804.R01.S.doc Version 5.1 Page 6 evidence therefore it cannot be confirmed that all members of staff authorised to access, handle and administer medicines have received appropriate training. Although the registered person has recently put in place some additional medicine policy documentation, it was recommended that all medicine policy documentation available is reviewed and rationalised ensuring more detailed policy guidance is available for reference by members of staff. A full medication inspection report has been sent to the provider alongside this report and is available subject to request. What the service does well: What has improved since the last inspection? What they could do better: The way the home looks after and records the administration and use of medicines needs to improve. Staff need to attend further adult abuse awareness training so that they are fully informed of these important issues. The number of hours staff are employed on a shift needs to be reviewed and reduced as in some cases this is excessive. Please contact the provider for advice of actions taken in response to this Faldonside Lodge Residential Home DS0000065222.V282804.R01.S.doc Version 5.1 Page 7 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.V282804.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.V282804.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): These standards were not inspected on this occasion. EVIDENCE: Faldonside Lodge Residential Home DS0000065222.V282804.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): 7, 8, 9 & 10 Each resident has a plan of care that sets out their needs and how they are to be met. The health care needs of residents are well met. Poor practice was seen in respect of the control and recording of medicines. Residents are treated with respect and their right to dignity and privacy protected. EVIDENCE: Two care plans were looked at in detail and Mrs Soobrayen described the work she has already done to improve the care planning and recording practices. Both care plans clearly identified the physical, health and emotional needs of the resident and how they should be met. Each care plan included risk assessment and risk reduction plans that were relevant to the individual resident. Each care plan seen had a page that served as a written agreement for who the resident felt could and should have access to their plan. Only 1 of the 2 care plans seen had this page completed, however this is regarded as good practice and efforts should be made to ensure all residents make their Faldonside Lodge Residential Home DS0000065222.V282804.R01.S.doc Version 5.1 Page 11 wishes in this regard clear. Staff stated that they found the care plans clearer and easy to use. Each care plan had a record of all visits and interventions from health professionals. During this inspection a visiting district nurse attended the home and the opportunity was taken to speak with her. Positive comments were received regarding the care given to residents and the competence of staff to follow any instructions given. The inspection of the medication standard (NMS 9) was conducted simultaneously by Pharmacist Inspector Mr M Andrews. He found there to be inadequacies in the security of medicines and that the home is failing to keep necessary records of medicines received at the home on behalf of service users and records of medicines removed for disposal. Therefore the home is currently both unable to account for medicines or demonstrate that prescribed medicines have been administered in line with prescribed instructions. During inspection, the inspector issued an Immediate Requirement form requiring that urgent remedial action is taken to resolve these issues. In addition, the inspector noted that some medication records in use to record the administration of medicines do not accurately reflect the medication regime currently prescribed for service users. Although there was documentary evidence to confirm that two members of staff had been on recent medication training, for others there was no such evidence therefore it cannot be confirmed that all members of staff authorised to access, handle and administer medicines have received appropriate training. Although the registered person has recently put in place some additional medicine policy documentation, it was recommended that all medicine policy documentation available is reviewed and rationalised ensuring more detailed policy guidance is available for reference by members of staff. Interaction between staff and residents was observed. In all instances, residents were spoken to respectfully and appropriately. Residents stated that they felt well cared for and very warm and complimentary comments were made about Mrs Soobrayen and the staff team. Faldonside Lodge Residential Home DS0000065222.V282804.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 & 15 Residents are able to maintain contact with relatives and friends as they wish. Residents receive a varied and nutritious diet that reflects their needs and preferences. EVIDENCE: During the course of this inspection a visitor was seen and spoken to. All returned questionnaires confirmed that visitors can see residents in private and feel welcomed by staff. Mrs Soobrayen provided copies of the homes menus and these showed that the diet offered is varied and nutritious. Although the menus do not detail alternatives available, Mrs Soobrayen confirmed that residents are offered other dishes if they do not like what is on the menu. The cook was seen and spoken to during this inspection. She confirmed that all foods are freshly prepared and fresh produce is used wherever possible. The lunch provided to residents on the day of inspection looked wholesome and well presented. Residents confirmed that they enjoyed their lunch and very little was returned on plates. Faldonside Lodge Residential Home DS0000065222.V282804.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The home has a complaints procedure in place that is well known to residents and visitors. Residents are protected from abuse by staff who know about adult abuse matters. Further training needs to be arranged to ensure all recently recruited staff are also knowledgeable. EVIDENCE: The home’s complaints procedure is clearly displayed in the entrance hall. It is also displayed in each of the residents’ bedrooms and a copy included in the resident information pack in each bedroom. The procedure was well known to residents and relatives. Residents felt that they were able to raise any concern with Mrs Soobrayen and were confident she would take it seriously and deal with it appropriately. All staff are subject to Criminal Records Bureau and Protection of Vulnerable Adults (CRB/POVA) checks. Evidence was seen within staff files that staff have received training in regard to adult abuse. One member of staff had received training in 2003 and a completed questionnaire to assess understanding was in her file. More recently recruited staff have not received training at this home and Mrs Soobrayen stated that she is looking to join a training cluster so that there will be more opportunity for staff to access training such as this. It is recommended that staff attend further adult abuse awareness training as soon as possible. See recommendations. Faldonside Lodge Residential Home DS0000065222.V282804.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 The home is well maintained and safe for residents and visitors. All areas of the home are kept clean and tidy. No unpleasant odours were detected. EVIDENCE: A tour of the building was undertaken and various maintenance records were seen. These showed that the home is well maintained. Records demonstrated that arrangements are in hand to ensure that all equipment and installations are subject to service and maintenance contracts. The home was very clean and tidy on the day of inspection and there were no unpleasant odours detected. Mrs Soobrayen has reviewed practice around infection control and steps have been taken to reduce the risk of cross infection. Faldonside Lodge Residential Home DS0000065222.V282804.R01.S.doc Version 5.1 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 Staff are employed in sufficient numbers to meet the needs of the residents. Some staff are working very long shifts that may affect their competence. Residents are in safe hands. The home has a robust recruitment process that protects residents. Staff receive training that is appropriate to their role. EVIDENCE: The staff rota for the week of inspection was seen. This showed that at least 2 care staff were on duty between 07:00 and 22:00. A member of staff providing sleep-in cover supported a waking night staff. An additional member of staff was employed to do catering duties. There was evidence that some staff were working shifts of 14 or 15 hours duration on a regular basis. Mrs Soobrayen explained that this was due to contractual agreements made by the previous owner of the home. The Commission takes the view that shift lengths in excess of 8 hours during the day should be the exception rather than accepted normal practice as there is an impact on the ability of staff to undertake their duties in a competent manner. It is recommended that staffing hours and lengths of duty are kept under review to ensure that residents and staff are safeguarded. See recommendations. Information provided by Mrs Soobrayen showed that most staff have completed National Vocational Qualifications (NVQ)to either level 2 or 3. The home is exceeding national Minimum Standards in this regard. Faldonside Lodge Residential Home DS0000065222.V282804.R01.S.doc Version 5.1 Page 16 Mrs Soobrayen has not yet been in a position requiring staff recruitment. As a result, the procedures used for the existing staff were reviewed and 2 staff files were looked at in detail. The staff files seen were in very good order and reflected recognised best practice including completed application forms with conviction disclosures, 2 references, full employment history, full personal details to facilitate CRB & POVA disclosure, training profile and supervision records. Mrs Soobrayen has identified some training issues that she intends to deal with in addition to statutory training requirements. These include infection control, safe handling of medicines and adult abuse awareness. A commitment to NVQ training will also continue. Faldonside Lodge Residential Home DS0000065222.V282804.R01.S.doc Version 5.1 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, 33, 35, 36 & 38 The home is owned and managed by a person who is competent to do so. The home has processes in place to seek the views of residents and visitors but these have not been implemented fully. Resident’s personal allowances are kept safely but procedures should be developed to reduce the risk of financial abuse occurring. Staff are well supervised. Residents, staff and visitors are protected by good health and safety practices. There needs to be a review and update of some information held to ensure it remains relevant. EVIDENCE: Mrs Soobrayen became the owner and manager of Faldonside Lodge in December 2005. This was following a successful application to become the Faldonside Lodge Residential Home DS0000065222.V282804.R01.S.doc Version 5.1 Page 18 registered person. Mrs Soobrayen is a qualified nurse with experience of managing a nursing home. The processes used to seek out the views of residents and visitors to the home were discussed. Mrs Soobrayen has had a residents meeting that was fully recorded. The record was seen and showed that issues around activities and food were discussed. An arranged meeting with relatives and friends had to be postponed but is to take place very soon. The home has a recorded quality assurance process in place that includes the distribution of questionnaires to residents and visitors. Some questionnaires were seen but had not been completed. The timing of this process was discussed and it is recommended that Mrs Soobrayen issues questionnaires after 3 – 4 months so that she can assess the views after a reasonable transition period. See recommendations. The arrangements for looking after resident’s monies were looked at. All monies are kept separately in a safe and receipts are obtained for all expenditure undertaken on behalf of the resident. Records of income, expenditure and running total are kept. The record would benefit from the inclusion of 2 signatures for each transaction wherever possible to reduce the risk of financial abuse It is also recommended that a regular audit takes place to ensure continuing good practice. See recommendations. Staff files showed that staff have received supervision that is being properly recorded. Mrs Soobrayen stated that she is to commence supervision of practical tasks followed by feedback to ensure best practice. Staff will also receive group supervision sessions and an annual performance review. Health and safety arrangements were reviewed and records in respect of fire safety, accidents, emergency lighting, Control of Substances Hazardous to Health, hot water temperatures, service records and portable electrical appliance testing were seen. The generic health and safety risk assessments were also looked at and it is recommended that they are reviewed and updated as necessary. See recommendations. Faldonside Lodge Residential Home DS0000065222.V282804.R01.S.doc Version 5.1 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 x 2 3 X 2 Faldonside Lodge Residential Home DS0000065222.V282804.R01.S.doc Version 5.1 Page 20 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. Timescale for action 13/02/06 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 3 Refer to Standard OP18 OP27 OP33 Good Practice Recommendations It is recommended that further adult abuse awareness training is provided as soon as possible. It is recommended that staff hours and lengths of shifts are kept under review to ensure residents and staff are safeguarded. It is recommended that quality assurance questionnaires are issued to residents and visitors to the home in approximately 3 – 4 months so that views can be sought after a transitional period. It is recommended that 2 signatures are obtained for all DS0000065222.V282804.R01.S.doc Version 5.1 Page 21 4 OP35 Faldonside Lodge Residential Home 5 6 OP35 OP38 transactions related to resident’s finances. It is recommended that a regular, monthly audit of residents personal finances takes place and is recorded. It is recommended that the generic health and safety risk assessments are reviewed and updated as necessary. Faldonside Lodge Residential Home DS0000065222.V282804.R01.S.doc Version 5.1 Page 22 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 © 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.V282804.R01.S.doc Version 5.1 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. 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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