Inspection on 15/09/05 for Finborough Court

This inspection was carried out on 15th September 2005.

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 11/05/06

Finborough Court 13/02/06

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 Joe Staines Announced Inspection 15th September 2005 12:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Finborough Court DS0000024385.V253229.R01.S.doc Version 5.0 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.V253229.R01.S.doc Version 5.0 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.V253229.R01.S.doc Version 5.0 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). 17th March 2005 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. Finborough Court DS0000024385.V253229.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report outlines the findings from an announced inspection carried out on 15th September 2005. The inspection was undertaken by Joe Staines (Regulation Inspector), with the assistance of Mrs Lynne Durant (Registered Manager), Maureen Sim (Director of Care Services) and Peter Tervet (Responsible Individual). All of the above mentioned representatives of the home, the staff on duty and service users living in the home were all helpful and contributed fully to the inspection process. This inspection focussed on a number of standards, identified by the Commission for Social Care Inspection as key standards, that must be assessed at least once in a 12 month period, and in particular looked at how the home was managing the change in registration, to allow for the care of more service users with a diagnosis of dementia. A total of 8 comment cards were received by service users and relatives/visitors. No adverse comments were made in any of the comment cards received. Examples of the positive comments made include, “ …I therefore do this retrospectively but with the added benefit of seeing the care given in her last days, it was excellent. The support given to the family was very special indeed.” “I think at Finborough Court there is a wonderful family atmosphere maintained through kind dedicated staff”. Seven service users were either spoken to, or indirectly observed by the inspector as part of the inspection, 4 service users files were examined, and a total of 2 staff interviews took place, in addition to a detailed discussion with the registered manager, responsible individual, and director of care services. What the service does well: What has improved since the last inspection? The home has positively adapted in response to the change in registration to allow more service users with dementia to be cared for, including changes to Finborough Court DS0000024385.V253229.R01.S.doc Version 5.0 Page 6 assessment and care planning procedures, staff training, and information about the services offered by the home. The inspection confirmed that the needs of service users with dementia were being met in a safe environment. The home has also responded positively to the requirements made following the last inspection, in relation to records, staff recruitment, and information provided about the home. 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. Finborough Court DS0000024385.V253229.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Finborough Court DS0000024385.V253229.R01.S.doc Version 5.0 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 the following standard(s): 1&3 Standard 3 was deemed to have been exceeded. Prospective service users can be confident that the home will ensure that a detailed assessment will be undertaken prior to admission, and that information provided by the home provides those considering using the service with an accurate and detailed picture of the way the home operates, and services it provides. EVIDENCE: The inspector examined the files of 4 service users, including those who had been admitted under the new registration categories of dementia (DE). Each of the files examined contained a completed assessment form, and in the case of a service user with dementia, an additional assessment tool for residents with dementia. These assessments were all completed, and included sections on the following: Mobility, Personal hygiene/bathing, washing and dressing, Skin care, Elimination (Urine and Bowels), Eating and Drinking (Diet, Fluids, Oral Hygiene), Pain, Medication, Breathing, Sleep, Communication (Sight, Hearing, Speech), Memory and Orientation, Emotional and Mental Health, Sexuality, Spiritual/Social Activities, and Equipment and Aids. The assessments included the signature of the staff completing the assessment, and the service users, or Finborough Court DS0000024385.V253229.R01.S.doc Version 5.0 Page 9 relative involved. The additional tool for residents with dementia ensured that more detailed assessments were undertaken, covering the areas of Memory, Orientation, Emotional and Mental health needs, and any specific aids required to support the person concerned. The assessments seen by the inspector had been completed in details, with no gaps, and useful pieces of information obtained about service users, leading to the home having the opportunity to provide a package of care designed to meet the individual needs of service users. The inspector examined the statement of purpose. The document contained all the information required by regulations, and had been updated to reflect the change in registration category. Finborough Court DS0000024385.V253229.R01.S.doc Version 5.0 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 Standard 7 was exceeded, with care plans demonstrating that prospective service users and their relatives can be confident that the needs of service users, including health needs, will be thoroughly assessed. Medication was safely administered within a framework of a clear policy and training for staff involved. The evidence obtained at this inspection confirmed that service users and their relatives can be confident that staff will respect their privacy and dignity, including in circumstances where service users, and those involved, are coping with a terminal illness EVIDENCE: Four care plans were examined. Each care plan was based on the Activities of Daily Living (ADL) model of care. There were 13 elements of care that were assessed for each service user, including mobility, personal hygiene, medication, communication and spiritual and social activities. The plans evidenced that all elements were assessed, objectives set and evaluations completed and signed. The examination of files confirmed that reviews took place at least annually, or when a change in a service users condition had occurred. Finborough Court DS0000024385.V253229.R01.S.doc Version 5.0 Page 11 The care plans included risk assessments, in relation to the service user’s health needs, including pressure area care and moving and handling. The care plans that were examined evidenced that the staff promoted and maintained service users health. An example was the use of a nutritional assessment tool. The care staff completed a record of weights on admission and ongoing, in addition to dietary and fluid intake and output. All medication administration records (MAR) sheets were examined and found to have been signed appropriately. Advice was given around the codes used when medication was not administered, to avoid confusion about the reasons, and the use of ticks for staff giving non prescribed items, such as build up drinks, where signatures would enhance the system. The home operated the Boots Monitored Dosage System. Training records confirmed that staff had been provided with training in health related areas, including medication administration, diabetes care and continence promotion. Feedback was received from relatives of service users who had lived at the home up to the time of their death. The feedback was extremely positive, describing the care given as “excellent” and describing the support given as “very special indeed”. Care plans included information about the preferences of service users in the event of their death. Evidence obtained from discussion with a senior member of staff confirmed that the home has in the past made every effort to continue to support service users and their families and friends in the event of their being diagnosed with terminal illness whose needs can still be met in the home. Staff reported that service users who needed extra turning would have a chart to record the frequency of turning. The home had a guest room that can be used by relatives of service users who are in the last stages of terminal illness. Finborough Court DS0000024385.V253229.R01.S.doc Version 5.0 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 The standard assessed was exceeded, with clear evidence of a wide range of activities, provided in accordance with service users wishes. EVIDENCE: The care plans examined included the element of social activities for each service user. The home provided a printed list of activities provided by the home. These included weekly craft classes, a knitting circle, monthly music and movement, annual Christmas sale and garden parties, “scrabble” evenings, shopping trips, annual outings, and a wide range of church services, prayer meetings and women’s fellowship meetings. The inspector observed a reminiscence tea party, provided for a small group of service users, and including service users with dementia. This was provided in a dedicated “reminiscence lounge” adjacent to the main lounge, and was seen as a positive experience by the inspector, who observed service users (including those with dementia) smiling and discussing items associated with their collective pasts. The inspector discussed the home’s programme of activities with service users during the course of the inspection, with consistent responses that the service users were satisfied with the type and level of activities provided by the home. The service users spoken to stated that they were free to opt in or out of activities according to their choice. Finborough Court DS0000024385.V253229.R01.S.doc Version 5.0 Page 13 Finborough Court DS0000024385.V253229.R01.S.doc Version 5.0 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): None of the above standards were inspected on this occasion, and will form the focus of the unannounced inspection to be undertaken before 31st March 2006. EVIDENCE: Finborough Court DS0000024385.V253229.R01.S.doc Version 5.0 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, 20 & 26 The evidence obtained at this inspection confirmed that prospective service users, and their representatives, can be confident that the environment provided is safe, includes suitable communal spaces, and is maintained to a high standard of cleanliness and hygiene, resulting in the standard being exceeded. EVIDENCE: The inspector toured the interior and exterior of the building. As part of the home’s development of the provision of services to people with dementia, the garden had been enclosed with railings. The home was purpose built, and had been designed with the needs of service users in mind. Ramps provided easy access in and out of the building. The corridors and door openings to bedrooms and en suite facilities were sufficiently wide for wheelchair users to readily access these areas. The home was maintained to a good decorative standard internally, with all areas clean and looking freshly painted. Domestic staff confirmed that staff leave messages in a specific book regarding areas of the home that need cleaning. Training records demonstrated that training is Finborough Court DS0000024385.V253229.R01.S.doc Version 5.0 Page 16 provided to both care and domestic staff in the use of carpet shampooing equipment. In addition to this, domestic staff had been supported in attending specific training in the control of substances hazardous to health. This purpose built home complied with all the relevant minimum space requirements for communal areas. The home provides communal space in the form of a large dining area and two lounges. Feedback from service users confirmed that they had sufficient space in which to eat communally and socialise. The home employed domestic staff who worked a total of 51 hours per week. In addition to this, laundry staff worked a total of 16 hours per week. The laundry facilities were viewed, two washing machines and two dryers were in operation. There was adequate space for the laundry personnel to work in a safe environment. Examples were there was space available for a table to fold washing, a space for ironing and a basket allocated to each service user to place their clothes in, prior to taking them to the respective wardrobe in each service users room. Finborough Court DS0000024385.V253229.R01.S.doc Version 5.0 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): 29 & 30 Service users and their representatives can be confident that the home’s recruitment practices were robust, and protected service users. The standard relating to training and staff competency was exceeded, with clear evidence that the home ensures staff are well trained and competent to undertake the tasks required by the job descriptions. EVIDENCE: The inspector examined the recruitment files of four members of staff. The files contained all the information required by regulation, including a clear record of the enquiries made in relation to any employment gaps on application forms. The examination of induction records confirmed that the home has in place a thorough induction programme, containing useful tools, such as a quiz in seven sections (introduction, basic 1st aid, fire safety, handling, missing persons, food handling and wheelchair use), a security question sheet, and the main induction programme, covering 5 units (principles of care, the role of the worker, experiences and needs of service users, being safe at work and the effects of the service setting on service users and staff). Each of the units was divided into more detailed sections, expanding on the overall topic. Foundation training was provided in the same style, with a further five units (applying the values of care, communicating effectively, worker development, recognising and responding to abuse and neglect and understanding the experiences and particular needs of the individuals using the service) building on the induction. Records were seen, confirming that staff had completed all the different Finborough Court DS0000024385.V253229.R01.S.doc Version 5.0 Page 18 sections of the induction and foundation training within the timescales identified in the National Minimum Standards. Training records were maintained in respect of individual staff, and showed that regular training was continuing to be provided to staff at levels appropriate to their posts. These records, and the home’s training calendar showed that training was provided and recorded in relation to dementia care, communication, fire safety, continence care, diabetes, cleaning product training, hoist training, and health and safety. Staff working as senior carers, manager or care team leader had all attended 2 or 3 day conferences with colleagues from different homes run by the same organisation. These were described by staff who had attended them as useful in terms of updating practice and networking with their peers. In addition, two training weeks were set aside for person centred care training. These training weeks provided staff with opportunities to choose from a variety of courses in areas that suited their own training needs. The inspector spoke with service users regarding their perceptions of the competency of staff. All of the service users stated that they thought the staff were extremely competent at all the tasks they undertook to support service users. Finborough Court DS0000024385.V253229.R01.S.doc Version 5.0 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): 38 The evidence obtained at this inspection confirmed that service users and their representatives could be confident that the home was run by a person with the required skills and experience. Their was also evidence, confirming that the health and safety of service users and staff was protected, and given a high priority by the home. EVIDENCE: The manager has completed and been awarded the National Vocational Qualification (NVQ) level 4 in care and management through undertaking the registered managers award. Feedback from staff and service users was consistently positive about the approachability and support provided by the manager of the home. The pre inspection material provided by the home, and examination of records kept at the home confirmed that routine safety checks were undertaken in respect of health and safety. These checks included, amongst others, recorded routine tests of fire safety equipment, heating, call Finborough Court DS0000024385.V253229.R01.S.doc Version 5.0 Page 20 system, water temperature checks, servicing of hoist equipment and the home’s shaft lift, and visits from environmental health and the local authority health and safety department, enhanced by the home’s own health and safety audits, which were also recorded. Finborough Court DS0000024385.V253229.R01.S.doc Version 5.0 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 3 X 4 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 4 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 3 X X X X X 4 STAFFING Standard No Score 27 X 28 X 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X 3 Finborough Court DS0000024385.V253229.R01.S.doc Version 5.0 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Finborough Court DS0000024385.V253229.R01.S.doc Version 5.0 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.V253229.R01.S.doc Version 5.0 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!