CARE HOMES FOR OLDER PEOPLE
Faversham House 59 Church Road Urmston Manchester M41 9EJ Lead Inspector
Elizabeth Holt Unannounced 18 May 2005 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 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. Faversham House F55 F05 s6710 faverhsam house v227254 180505 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Faversham House Address 59 Church Road Urmston Manchester M41 9EJ 0161 748 5998 0161 748 5998 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Rachel Hind Mrs Rachel Hind CRH 20 Care home with nursing Category(ies) of OP Old age (0P) (19) registration, with number PD Physical disability (1) of places Faversham House F55 F05 s6710 faverhsam house v227254 180505 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: All service users shall be aged over 60 years and require nursing care. Minimum staffing levels as specified in the Notice issued under Section 25(3) of the Registered Homes Act and dated 18th August 2000, shall be maintained. 1 named service user in the category of PD (Physical Disability) may be accommodated within the overall number of registered places. When this service user leaves the home the place will revert to the previously registered category. Date of last inspection 29 September 2004 Brief Description of the Service: Faversham House is a care home providing nursing care and accomodation for up to 20 older people. The home is owned and managed by Mrs Rachel Hind. The home is located in the Urmston area of Manchester. Local shops, a market and other amenities are within a short distance of the home. A bus and rail service to the town centre are available from Urmston town centre. There is a small well maintained garden area to the rear and side of the property. Parking facilities for approximately five cars are available at the rear of the property. The home is a converted two storey property which includes a purpose built ground floor extension. Eight of the bedrooms are single and six of them are double. There are three communal toilets , two assisted bathrooms plus a large ground floor shower room. The communal space on the ground floor comprises of two lounges, one of which has a small dining table. Other residents dined from small individual tables.. Faversham House F55 F05 s6710 faverhsam house v227254 180505 stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced which took place over five and a half hours on Wednesday 18 May 2005. During the course of the inspection time was spent talking to a number of residents, visitors, the manager and some staff members. Time was spent examining records, including residents’ care plans, and staff files. A tour of the building was also carried out. On the day of the inspection Mrs Hind, the registered provider/manager was not on duty however she arrived to join the inspection and stayed until the end. As this inspection only looked at a limited number of standards, this report should be read together with the previous and any future reports to gain a full picture of how the service is meeting the needs of the residents living in the home What the service does well:
The manager carried out all pre admission assessments on prospective residents to enable her to feel confident that the home can meet their needs. A number of the residents spoke positively about the way in which particular staff members spoke to them and how “chatty and friendly” they were. One resident stated that “staff come in and have a good chat and we put the world to rights”. The registered provider/manager was clearly known by the residents and the staff and she demonstrated a good rapport with the residents and the staff . Mrs Hind clearly knew the residents and demonstrated a detailed knowledge of the conditions/diseases associated with old age. The atmosphere within the home was friendly and relaxed. Staff were observed being pleasant and polite with residents throughout the inspection. One resident commented more than once regarding the kindness of a particular nurse and that the home was “like a family”. The registered provider/manager was approachable and residents clearly knew Mrs Hind. Staff were observed feeding residents who required assistance in a discreet and pleasant manner. Communication was positive and care staff were observed having 1:1 interactions with residents in appropriate ways. The mealtime observed during the inspection was unhurried and residents
Faversham House F55 F05 s6710 faverhsam house v227254 180505 stage 4.doc Version 1.30 Page 6 commented that the quantity and quality of food was good. A recent admission to the home stated that his likes and dislikes were being taken into account and that the food was “tasty”. The manager commented on more than on occasion regarding the staff team who were well motivated to undertake further studies in order to assist them in meeting the needs of the service users accommodated. 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. Faversham House F55 F05 s6710 faverhsam house v227254 180505 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Faversham House F55 F05 s6710 faverhsam house v227254 180505 stage 4.doc Version 1.30 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 standard(s) 1 3, 4, 5 and 6. Service users are admitted to the home with accurate information and only after a full needs assessment is carried out by the registered manager. The home showed potential service users that it could meet their assessed needs. Opportunities for potential service users to visit the home to assess its quality, facilities and suitability were encouraged. EVIDENCE: The Statement of Purpose and Service User’s Guide were detailed and allowed prospective residents to make an informed choice about possible admission to the home. A detailed admission procedure was followed. This included a pre admission assessment to show that new residents needs are assessed and planned for. Following the pre admission assessment residents are informed in writing that the nursing home is able to meet their needs.
Faversham House F55 F05 s6710 faverhsam house v227254 180505 stage 4.doc Version 1.30 Page 9 One recently admitted resident spoken to considered that the majority of his care needs were being well met by the staff at the home. Each resident had a plan of care based upon the Care Management assessment and the homes assessment of needs. The Responsible manager reported that two potential residents had recently visited the home and had stayed for lunch. The home did not offer intermediate care services however they provide one bed for respite care. Faversham House F55 F05 s6710 faverhsam house v227254 180505 stage 4.doc Version 1.30 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 standard(s) 7, 8 and 9 Arrangements are in place to ensure the healthcare needs of residents are met however some shortfalls in the individual plans of care could potentially put residents at risk. The storage, administration and recording of medication protected the residents. EVIDENCE: A sample of individual plans of care were inspected. The format for care planning was user friendly and included photographic identification. A requirement has been made to ensure that the care plans include all aspects of health, personal and social care needs for each individual. Some care plans lacked detail in certain areas. For example, one resident had a significant weight loss recorded. There was no evidence of this being linked to the nutritional risk assessment, no associated plan re eating and drinking and there was no record in the plan of advice from the GP or dietician having been sought. Discussion with the staff suggested that the resident’s nutritional needs were being addressed and nutritional supplements were being given to this resident however the documentation did not accurately reflect this. During the inspection a telephone call to the dietician was overheard and included a
Faversham House F55 F05 s6710 faverhsam house v227254 180505 stage 4.doc Version 1.30 Page 11 referral for this resident. Daily evaluations were recorded to show the care delivered over any 24 hour period. Discussions around the social needs of service users were not considered to be well met by one of the residents. Discussion with the Responsible manager and staff highlighted that this resident was regularly offered the opportunity to go out however she regularly refused to go out when the time came. This resident confirmed that she could exercise choice over her daily activities and she received regular visits from her family members. She enjoyed watching the television and videos in the privacy of her bedroom. The care plan did not record any information about the social needs of this resident and a requirement was made accordingly. (see Standard 7). Staff members spoken to were aware of the social needs of the service users however these were not well recorded in the care plan. Some evidence was seen of residents’ signatures to evidence that the care plan is written with their involvement. Each resident was registered with a General Practitioner and care plans included referrals to other specialist services for example, tissue viability nurse, dentists and chiropodists. Staff members were seen to talk and deal with the residents in a kind, respectful and sensitive way. They were clearly aware of the need to promote the dignity of the residents. Medication practice was in line with the policies and procedures available to the registered nurses who were responsible for the administration of medication. Evidence was seen that the medication administration records (MAR) charts were accurately recorded and the deliveries and returns of prescribed medications were recorded and signed for. Controlled drugs were stored and recorded appropriately. Faversham House F55 F05 s6710 faverhsam house v227254 180505 stage 4.doc Version 1.30 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 standard(s) 12, 14 and 15 Social activities are provided within the home on an individual and group basis.however the recording of residents’ social care needs are not satisfactory. Residents could exercise some choice and control over their lives. Residents were provided with a wholesome appealing balanced diet and the mealtime was a relaxing occasion. EVIDENCE: Since the last inspection an activities co-ordinator had been appointed who provided two or three sessions per week. Sessions included reminiscence, gentle exercising, singing and quizzes. Care staff confirmed that they took residents out to the local shopping centre, public house or the park weather permitting. There was no recorded evidence in the individual care plans of social activities that had been carried out. A requirement has been made. Residents did have the opportunity to sit in the communal lounges or in the privacy of their own bedrooms. The conversations and interactions between the residents and the staff were observed to be positive. Staff were seen sitting talking and holding residents hands. A menu was in place which gave residents choice at mealtimes and showed that a varied and wholesome diet was available. This is developed on a 4 week rota and includes the residents’ likes and dislikes. Residents had been consulted on their personal preferences. One resident said he enjoyed a
Faversham House F55 F05 s6710 faverhsam house v227254 180505 stage 4.doc Version 1.30 Page 13 poached egg for breakfast and had chosen potato cakes the day before. Some of the residents spoke favourably about the home made pies and cakes the cook prepared. Refrigerator and freezer temperatures and kitchen cleaning records were available. Faversham House F55 F05 s6710 faverhsam house v227254 180505 stage 4.doc Version 1.30 Page 14 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Residents were aware of how to make a complaint and a policy was available for the protection of vulnerable adults.to ensure the safety of the residents accommodated in the home. EVIDENCE: The Statement of Purpose and the Service User’s guide contained a copy of the complaints procedure Two residents and a relative commented that they would use the complaints procedure if they felt they had to. Positive comments were made about the approachability of the manager and the staff. The Commission for Social Care Inspection had not received any complaints about this service since the last inspection and there were no complaints recorded in the home’s complaints file. The home had a copy of Trafford’s Multi-Agency policy for the Protection of Vulnerable Adults (POVA) from Abuse. Two staff members could explain the action they would take in the event of a report of an allegation of abuse. The Responsible Individual had attended a Study Day on POVA. A POVA awareness study day at Trafford General Hospital was to be arranged for the staff to attend. Faversham House F55 F05 s6710 faverhsam house v227254 180505 stage 4.doc Version 1.30 Page 15 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 23, 24, 25, and 26 The premises provided a safe, well maintained environment and were clean and comfortable. EVIDENCE: The home had a routine maintenance programme. Ramp access to the front of the home and a passenger lift provided access to the bedroom floors. There was evidence that some further redecoration had been undertaken particularly in a number of bedrooms. Privacy curtains were available in all shared bedrooms to assist in the maintenance of the dignity of each service user. Odour was managed within the home and was supported by the use of plug ins. Emergency call systems were provided in each bedroom and staff were seen to respond speedily when called.
Faversham House F55 F05 s6710 faverhsam house v227254 180505 stage 4.doc Version 1.30 Page 16 The bedrooms were personalised with photographs and items of furniture from the residents’ own homes The staff monitored the water temperatures to ensure the levels were safe and the radiators were covered. Laundry facilities were sited away from the food preparation areas. The home had 2 washing machines with sluicing facilities and foul laundry could be washed at the appropriate temperature. The homes infection control policy and COSHH information was available for staff to access. The home had a contractor for the disposal of clinical waste. Faversham House F55 F05 s6710 faverhsam house v227254 180505 stage 4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 and 30 The numbers and skill mix of staff were sufficient to meet the needs of the residents accommodated. EVIDENCE: At the time of the inspection the home accommodated 19 residents assessed as requiring nursing care. The numbers and skill mix of the staff at the time of the inspection were sufficient to meet the residents’ needs. A registered nurse provided additional hours offering holistic therapies to the residents accommodated including massage, reiki and aromatherapy. At the time of the inspection the therapist was providing some 1:1 hand massage with a resident who found the treatment “wonderful”. There has been a consistent staff team with no staff leaving the home It is recommended that the duty rotas include the surnames and designation of the staff members. In addition the home provided additional catering, laundry and housekeeping/domestic staff. Staff were encouraged to undertake study days and training to equip them with the skills to meet the needs of the residents accommodated. Staff training was a priority in the home and staff spoken to were enthusiastic about updating their knowledge and skills. Registered nursing staff and senior care staff had undergone training in Palliative care in May 2005. Other recent
Faversham House F55 F05 s6710 faverhsam house v227254 180505 stage 4.doc Version 1.30 Page 18 training/updates had included manual handling, fire safety and infection control. Staff received regular supervision and there was evidence that these sessions are linked to training. A requirement was made that the staff recruitment files must be stored in a secure cabinet which is not readily accessible to other staff in the home. Residents made positive comments about the staff in the home.which led them to indicate their experiences were positive. Faversham House F55 F05 s6710 faverhsam house v227254 180505 stage 4.doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 35 and 36 The manager is able to fully discharge her duties and responsibilities. Residents’ financial interests were safeguarded by the systems in place. A formal staff supervision programme was in place to promote staff development and protect the residents accommodated. EVIDENCE: The Registered Provider is also the Registered manager. She is responsible for one home only and has a number of years experience as Registered Nurse (General). The financial records for some of the residents accommodated were examined. A recommendation was made that the staff sign the balance sheet when spending monies have been received into the home. Staff confirmed that they received informal supervision as required and they received regular formal supervision once every two months. Staff supervision
Faversham House F55 F05 s6710 faverhsam house v227254 180505 stage 4.doc Version 1.30 Page 20 records reflected this. Discussion with staff members and observations of their interactions with the residents highlighted that they were aware of a good standard of care practice. Faversham House F55 F05 s6710 faverhsam house v227254 180505 stage 4.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 3 x x x 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x x x x 3 x x Faversham House F55 F05 s6710 faverhsam house v227254 180505 stage 4.doc Version 1.30 Page 22 yes 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 OP24 Regulation 13(4)(a) Requirement The registered person must fit locks upon the doors of service users private accomodation, suitable to service users capabilities. The locks must be accessible to staff in an emergency. Service users must retain a key unless a risk assessment proves otherwise.(Previous timescale of 30 Dec 2004 not met) The registered person must ensure that care plans are a) detailed individualised and contain associated risk assessments b) record the social needs of service users accomodated. The registered person must ensure the staff records are securely stored in the care home. Timescale for action 30 July 2005 2. OP7 15(1) 15 July 2005 3. OP29 17(1)(a) 15th July 2005 Faversham House F55 F05 s6710 faverhsam house v227254 180505 stage 4.doc Version 1.30 Page 23 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 OP27 Good Practice Recommendations It is recommended that the duty rotas include the surnames and designations of the staff . Faversham House F55 F05 s6710 faverhsam house v227254 180505 stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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