Inspection on 11/05/06 for Finborough Court

This inspection was carried out on 11th May 2006.

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

Finborough Court 17/07/07

Finborough Court 13/02/06

Finborough Court 15/09/05

Finborough Court 17/03/05

Finborough Court 04/10/04

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 Finborough Court Pilgrims Way Great Finborough Stowmarket Suffolk IP14 3AY Lead Inspector Jane Offord Unannounced Inspection 11th May 2006 12:30p 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 Finborough Court DS0000024385.V294425.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. Finborough Court DS0000024385.V294425.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Finborough Court Address Pilgrims Way Great Finborough Stowmarket Suffolk IP14 3AY 01449 676336 01449 672408 finborough@pilgrimhomes.org.uk 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) Pilgrim Homes Mrs Lynne Durrant Care Home 22 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (4), Old age, not falling within any other of places category (22) Finborough Court DS0000024385.V294425.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 The home may care for up to 22 service users, of whom 4 may be Dementia (DE)(E), and 1 named person may be Dementia (DE). 13th February 2006 Date of last inspection Brief Description of the Service: Finborough Court is a purpose built care home for older people, which was first opened in 1994. It is able to accommodate twenty elderly people in individual rooms in the main care home. On the 11th July 2005 a variation to the home’s conditions of registration was granted, stating that The home may care for up to 22 service users, of whom 4 may be Dementia (DE) (E), and 1 named person may be Dementia (DE) (E). In addition to the twenty beds in the main care home, an additional two places are registered in the attached flats, which offer sheltered accommodation. There is an agreement with the regulatory body that these two places can offer emergency respite care when needed, to ensure continuity of care for service users occupying any of the flats, should they become unwell or unable to manage, and require a period of short term / respite care. Whilst the National Care Standards Commission had not required particular flats to be nominated in this respect, this was on the understanding that no more than two persons living in the sheltered flats would be provided with emergency respite care at any given point in time. The Service Users Guide for Finborough Court says that We welcome applications from Protestant Evangelical Christians of any denomination who are entitled to live in the UK, regardless of their ethnic origin, nationality, marital status or gender, but they must be over 65 years of age and need residential care. We are able to take care of elderly people who need to use a wheelchair and those with failing hearing and eyesight. This is reflected in the routines within the home, which includes morning prayers at 11am, and two worship services on Sunday afternoons and Monday mornings. The home is part of a larger complex managed by Pilgrim Homes, which includes sheltered flats and bungalows. It is situated in the village of Great Finborough, approximately three miles from Stowmarket. The village, although small, does have a shop / post office, pub, and two schools. Fees for the home range between £458.00 and £562.00 per week depending on the level of care required by the resident. Finborough Court DS0000024385.V294425.R01.S.doc Version 5.1 Page 5 Finborough Court DS0000024385.V294425.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection focussing on the core standards for Older People. It took place on a weekday between 12.30 and 16.30. The manager was available throughout the visit to assist with the inspection process. During the visit a number of residents and visitors were spoken with and a tour of the home was undertaken. A short medication administration round was observed and a selection of the home’s policies were seen. Maintenance records, menus, duty rotas, three residents’ files and care plans and two staff files were all inspected. On the day of inspection the home was clean, tidy and had a calm and welcoming feel. Residents were moving freely between their own rooms and the communal areas, choosing where to spend their time and who to spend it with. Interactions between staff and residents were friendly and respectful. What the service does well: What has improved since the last inspection? What they could do better: One staff file seen did not contain all the required identification checks or an up to date CRB check. The home did not have a copy of the most recent Protection of Vulnerable Adults (POVA) guidelines for Suffolk. One communal bathroom was unusable due to stored equipment. Finborough Court DS0000024385.V294425.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. Finborough Court DS0000024385.V294425.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 Finborough Court DS0000024385.V294425.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): 3, 6. People who use this service can expect to have their needs assessed prior to admission and be assured they can be met. This service does not offer Intermediate Care. EVIDENCE: Three recently admitted residents’ files were seen. They all contained a preadmission assessment of need. Areas covered were mobility, personal hygiene, communication, tissue viability, elimination, diet, pain and medication. In addition assessment was made of the prospective resident’s emotional status and mental health needs. Their sexuality, memory and spiritual needs were also recorded. A moving and handling assessment was undertaken prior to admission. One visitor spoken with said they had visited before their relative had been admitted to the home so they could arrange the furniture in the room as their relative liked. Another resident said they had been given a tour of the home before admission. Finborough Court DS0000024385.V294425.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, 11. People who use this service can expect to have a care plan to help meet their needs, be protected by the home’s medication administration policy and practice and be treated with respect. They and their relatives can expect to be supported sensitively at the time of death. EVIDENCE: Each of the three residents’ files seen had contact details of the resident’s GP and other professional support such as community nurse, social worker, optician and dentist. One file had records of visits by the community nurses to do dressings for the resident’s feet and appointments for attendance at the diabetic foot clinic. Another resident said they were being taken that afternoon to pick up their new glasses from the optician. Each resident had a care plan and if the resident was able it was agreed with them and signed by them. In addition to the main care plan there was a care plan summary related to the Activities of Daily Living (ADLs). So, for example, under communication it was recorded ‘xxxx is a little deaf and wears a hearing aid in the right ear’. Each file also contained assessments for nutrition, moving and handling and tissue viability that were signed to show they were reviewed. Finborough Court DS0000024385.V294425.R01.S.doc Version 5.1 Page 11 The format for the care plans gives the opportunity to look at short term and long term goals for each identified need. The interventions seen were simple and relevant. One resident had a care plan for managing chronic pain and included in the interventions was one that said ‘To observe body language and facial expression for signs of discomfort’. Care plans were kept securely in the nurses’ office but accessible to any member of staff. Daily records were informative and gave a picture of the resident and their experience of the day. One recorded ‘xxxx is not so cheerful today’ another said ‘yyyy has been to the lounge to hear zzzz play the piano. They really enjoyed that’. A short medication administration round took place after lunch and was observed. In addition to residents’ identification photographs with the monitored dosage packs there was also a record of how the resident liked to be addressed. Medication administration records (MAR sheets) were inspected and found to be correctly completed with no gaps in signature boxes and ‘as required’ (PRN) medication having the amount of medication recorded each time it was administered or an appropriate code used. The home has a policy about administration of homely remedies and the folder used to record each administration was seen. The member of staff said they would contact the GP if the need for the homely remedy continued. The medication policy was seen and covered most areas relating to medication administration, storage and disposal. There was an assessment for residents who wished to self medicate. In discussion with the manager it was recommended that, to build on good practice, a list should be available of the signatures and initials of all staff who administer medication. Residents spoken with all said they were very happy with the way their care was carried out. Staff were respectful and responded to requests and call bells quickly. It was noted during the day that call bell alarms only rang for a short time. One resident told the inspector about their preference, due to a health issue, of having a bath early each day. They said, ‘the nurse’ was very good about helping them into the bath and then discreetly leaving them to wash in private, returning when they rang the bell. All the files seen had recorded residents’ final wishes, their own spiritual advisor and the executor to be contacted in the event of their death. One file had a note to say ‘does not want a post mortem’. One resident and relative said that when another member of their family had been terminally ill in the home the staff had been so supportive. Relatives had been welcomed to stay twenty-four hours a day and their needs were met by the service. Finborough Court DS0000024385.V294425.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): 12, 13, 14, 15. People who use this service can expect to be encouraged to maintain contact with family and friends, to have choice about how they occupy their time and to be offered a wholesome diet. EVIDENCE: Underpinning the philosophy of the home there are a number of Christian services and prayer meetings throughout each week. Residents choose which gatherings they want to attend. A member of staff organises other activities including craft, knitting and scrabble sessions. The manager said outings are arranged and residents can choose to participate or not. A large number of staff and residents recently went to the restaurant in a local garden centre for lunch. This outing was enjoyed by all and photographs of the event were on display in the entrance hall. Two residents spoken with said they were happy with their own company and spent a lot of time reading. One resident said they had brought a large collection of their own books with them ‘all of which bear reading more than once’. The other resident said the home had a selection of books available to be borrowed. Finborough Court DS0000024385.V294425.R01.S.doc Version 5.1 Page 13 A number of people visited during the day and were welcomed. Residents entertained guests in the communal areas or their own rooms, as they preferred. Visitors spoken with said there were no restrictions on visiting. The menus were seen and showed that at lunch time there was always a choice of main meal with the second choice being fish or vegetarian. A third option for a soft diet was also available. The evening meal was a light cooked dish such as beans on toast, omelette or fish fingers with sandwiches or soup and a dessert of fruit or something like strawberry whip. The kitchen assistant spoken with said breakfast offered a choice of fruit, cereal or porridge and toast or bread and butter with jam or marmalade. All the cakes and pastry used in menus was prepared in the kitchens. Residents spoken with all said they enjoyed the food being offered. The kitchens and food stores were inspected and found to be clean and tidy with the stores well stocked. The refrigerators and freezers temperatures were recorded twice daily and were within safe limits for food storage. Food deliveries were also temperature probed on arrival and readings recorded. Prepared food stored in refrigerators was covered and dated. Finborough Court DS0000024385.V294425.R01.S.doc Version 5.1 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 the following standard(s): 16, 18. People who use this service can expect to have any complaint taken seriously and be protected from abuse but they cannot be assured that staff have the most up to date guidelines available for managing potentially abusive situations. EVIDENCE: CSCI have not received a complaint for this service since the last inspection. The complaints log for the home was seen and the last complaint recorded was in February 2005 and showed it was adequately investigated. The complaints policy is concise and displayed on the notice board between the lounge and the accommodation. Residents spoken with said they had not had cause to complain but knew they could and identified who they would talk to in the first instance. The POVA policy was seen. It is a comprehensive document used by all the Pilgrim Homes services. It was not cross referenced to guide staff to local procedures. The folder of the Suffolk POVA guidelines was not the most recent. The manager agreed to obtain a copy of the up to date folder for staff reference. Staff spoken with said they had had training in POVA and were able to explain what they would do if they had any suspicions that a resident was in any way at risk. Finborough Court DS0000024385.V294425.R01.S.doc Version 5.1 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 the following standard(s): 19, 21, 26. People who use this service can expect to live in a clean, well maintained home however they cannot be assured that some bathrooms will not be used for the storage of equipment. EVIDENCE: On the day of inspection the home was clean and tidy with no offensive odours present. The gardens were attractive with the grass recently cut leaving the remains of a display of daffodils standing. There was a decking area, with garden furniture, that had level access from the man lounge. One resident had been sitting outside but come back in as the day was very hot. The home had been purpose built and is on sloping ground so there is one storey at the front and two at the back. The individual rooms all have views over the gardens or the surrounding countryside. The main lounge ad dining room is a spacious circular room with windows most of the way round. The home is maintained to high standard with ongoing refurbishment. A number of the toilets have recently been repainted. Finborough Court DS0000024385.V294425.R01.S.doc Version 5.1 Page 16 The staff team includes a dedicated maintenance person who made their records available for the inspection. The day-to-day repairs log showed that problems were attended to within one or two working days. All the residents’ rooms have en-suite facilities; in addition there are communal assisted bathrooms for residents who are less mobile. The bathrooms were all clean and had a supply of liquid soap and paper towels for hand washing. The bathroom near rooms 1 to 4 was found to be full of equipment, to the point where the bath was inaccessible. The laundry was visited and was clean and tidy. Hand washing facilities were available. The washing machines had a sluicing programme and the infection control policy stated soiled linen should be placed in alginate bags for transport to the laundry. Some of these were in evidence. There was a poster referring to the control of substances hazardous to health (COSHH) regulations on the wall together with information about the symbols used on clothing to designate how they should be cleaned. Finborough Court DS0000024385.V294425.R01.S.doc Version 5.1 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 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. People who use this service can expect to be cared for by adequate numbers of well-trained staff who are correctly recruited but cannot be assured that evidence of the recruitment checks will be available in staff files. EVIDENCE: The files of two members of staff were seen, one of whom had been recruited very recently the other had been working in the home longer. The file of the most recently recruited carer contained evidence of all the checks required under Schedule 4. The date of the CRB was a few days after the date of commencement of employment. The manager said that the carer had always been supervised during those days, had been undergoing induction and was not included in the rostered numbers at that time. The carer confirmed this when spoken with. The file of the longer serving carer did not contain any evidence that identification documents had been seen and showed that the CRB accepted had not been obtained for this post. Both files showed that an induction programme had been followed that covered fire awareness, first aid, health and safety, basic principles of care and moving and handling. Other areas were food hygiene, infection control, dementia care and POVA. This was confirmed in discussions with staff. Finborough Court DS0000024385.V294425.R01.S.doc Version 5.1 Page 18 The manager said that out of 25 care staff, not including registered nurses, 10 have achieved NVQ level 2. Two domestic staff have also achieved it and two further care staff are working towards it. One of the senior care staff and the manager are NVQ assessors. There is a high commitment to training in the organisation. Twice a year a training week is planned with teaching on a variety of topics related to offering person centred care. One method of assessing staff understanding of information is to circulate booklets and questionnaires. The kitchen assistant spoken with showed the inspector two booklets and the questionnaire they had received. The booklets dealt with fire and kitchen safety. They said they would complete them, return them to the manager who would correct them and retain them in their file. As noted earlier in this report the staff team is very stable with some members having been at the home since it opened twelve years ago. The duty rotas were seen and showed the care staff were supported by domestic and laundry staff, a maintenance officer, a cook and two kitchen assistants and clerical support. The rota included the shifts worked by the manager and indicated the on-call rota. Shifts covered by bank staff were recorded. Staff spoken with said there were adequate staff to meet the needs of the residents. Finborough Court DS0000024385.V294425.R01.S.doc Version 5.1 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 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, 38. People who use this service can expect to live in a home managed by a fit person and have their best interests, finances and welfare protected. EVIDENCE: The manager is a trained nurse and has managed the service since it opened twelve years ago. They have achieved an NVQ in management and is an NVQ assessor. In discussion they demonstrated a commitment to building on present good practice and moving towards person centred care. Residents receive a quality questionnaire once a year. Results of the survey are collated and made public. If help to complete the questionnaire is needed the manager said family would assist not staff members. Finborough Court DS0000024385.V294425.R01.S.doc Version 5.1 Page 20 Previous inspections have found residents’ finances were safely handled and the system had an audit trail. The manager said there had been no changes in the methods used. A comprehensive COSHH folder was seen and there was evidence that it was reviewed and updated. There were a number of general risk assessments for the service covering areas such as clinical waste, hot surfaces, fire, electricity, access to the building and water temperatures. There were records showing wheelchairs and small electrical appliances were routinely tested. A water hygiene log book showed all tests had been done in May ’06. Finborough Court DS0000024385.V294425.R01.S.doc Version 5.1 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 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 4 8 3 9 3 10 3 11 3 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 2 4 X 2 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Finborough Court DS0000024385.V294425.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? NO. 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 OP18 Regulation 13 (6) Requirement The home must obtain a copy of the most recent guidelines issued by the Vulnerable Adult Protection Committee of Suffolk for staff information and cross reference the home’s POVA policy to include them. Staff files must retain evidence that all the recruitment checks in Schedule 2 have been undertaken. Timescale for action 30/06/06 2. OP29 19 (b) Sch. 2 11/05/06 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. Refer to Standard OP21 Good Practice Recommendations Bathrooms should be kept clear of stored equipment. Finborough Court DS0000024385.V294425.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Finborough Court DS0000024385.V294425.R01.S.doc Version 5.1 Page 24 - 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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