Inspection on 17/07/07 for Finborough Court

This inspection was carried out on 17th July 2007.

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 11/05/06

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 Julie Small Unannounced Inspection 17th July 2007 10:40 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.V346244.R01.S.doc Version 5.2 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.V346244.R01.S.doc Version 5.2 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 www.pilgrimhomes.org.uk Pilgrim Homes 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) 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.V346244.R01.S.doc Version 5.2 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). 11th May 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 (NCSC) 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. This arrangement was made with NCSC the previous regulatory body. The home is now registered and regulated by the Commission for Social Care Inspection (CSCI). 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.V346244.R01.S.doc Version 5.2 Page 5 At the time of the inspection fees for the home range between £490.00 and £591.00 per week depending on the level of care required by the resident. Finborough Court DS0000024385.V346244.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on Tuesday 17th July 2007 from 10.40 to 17.40. The inspection was a key inspection which focused on the core standards relating to older people and was undertaken by regulatory inspector Julie Small. The report has been written using accumulated evidence gained prior to and during the inspection. The home’s manager Mrs Lynne Durrant was present during the inspection and provided the requested information promptly and in an open manner. The manager said that service users were referred to as residents and this term will be used throughout this report. During the inspection a tour of the building and observation of work practice was undertaken. Two residents, a visitor to the home and three staff members were spoken with. Records viewed included three resident, four staff recruitment, training, fire safety and accident records. Further records viewed are detailed in the main body of this report. Prior to the inspection an annual quality assurance assessment (AQAA) questionnaire and staff, visitors and residents surveys were sent to the home. The AQAA was returned to CSCI (Commission for Social Care Inspection) and five staff surveys, six relative/visitor surveys and six resident surveys were returned, however, one did not respond to the questions in the survey. The surveys were mainly complementary about the home and the service they provided. What the service does well: What has improved since the last inspection? The home had obtained a copy of the most recent guidelines issued by the Vulnerable Adult Protection Committee of Suffolk. Staff files viewed included the required information in Schedule 2. All bathrooms were clear of stored equipment. Finborough Court DS0000024385.V346244.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Finborough Court DS0000024385.V346244.R01.S.doc Version 5.2 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.V346244.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, 5, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents can expect that they are provided with the information they need to make decisions about living at the home, that their needs are assessed prior to them moving into the home and that they have the opportunity to visit the home prior to moving in. The home does not provide an intermediate care service. EVIDENCE: The home’s Statement of Purpose was viewed and provided information about the home, which included the numbers of places provided, the criteria for residents, the complaints procedure and information about how the home met the specific needs of residents. Finborough Court DS0000024385.V346244.R01.S.doc Version 5.2 Page 10 The Service User’s Guide was viewed and included information about the home, residents and staff, terms and conditions and fees for the home, which could be accessed from the home’s manager. Two residents spoken with said that they had visited the home before they decided that they wanted to live there. They said that they met the staff and looked around the home. One resident said that they had originally applied to use the very sheltered service, which was provided by the organisation. However, following discussion with the manager about their needs and future they had decided to live at the home. They said that they had made the best decision. The relative/visitor survey asked if they received enough information about the home to help them to make decisions and four answered always and two answered usually. The resident survey asked if they received enough information about the home before they moved in, so they could decide if it was the right place for them and five answered yes. Three resident’s records were viewed and there were detailed needs assessments completed by the manager. The home’s pre-admission needs assessments included details of the name, address, reasons for admission, medical and health needs and wellbeing, abilities and interests. The records held updated needs assessments, which had been undertaken to identify the changing needs and preferences of residents. There were care plans which detailed how the home met the resident’s needs. The manager said that prior to moving into the home, prospective residents were visited where they lived and the assessment was undertaken. She said that some residents moved into the home after they had lived in the very sheltered accommodation if their needs required it. The manager said that prospective residents and their families were provided with the opportunity to visit the home before they made decisions about moving in. The AQAA stated that ‘a trial period of four weeks was agreed to allow the service user to confirm the decision to stay and for the home to ascertain that care needs can be appropriately met’. Finborough Court DS0000024385.V346244.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that their needs are set out in an individual plan of care, that their health needs are met, that they are protected by the home’s medication procedures, that they are treated with respect and that their wishes are met at the time of their death. EVIDENCE: Three resident’s care plans were viewed and they provided good details regarding their needs and actions staff should take to meet their needs. The care plan included details regarding their mobility, personal hygiene, their likes and dislikes, preferences, long and short term goals and their psychological, spiritual, emotional and social well being. The care plans were signed and dated by the staff completing them and by the resident or their representative. There was documentary evidence of regular updates to the care plans to meet the resident’s changing needs and preferences. Finborough Court DS0000024385.V346244.R01.S.doc Version 5.2 Page 12 The AQAA stated that care plans were developed using a person centred approach and that staff were provided with person centred care training. One resident’s record viewed detailed how their condition had deteriorated since living in the home and how there had been changes in the care provision. There were references to the wishes and guidance from the resident’s family members and their doctor. Resident’s records viewed contained risk assessments, which included issues in their daily living which may pose risks such as going out, using a wheelchair and using areas around the home. The risk assessments identified the nature of the risks and methods of minimising them. The records included risk assessments on falls, manual handling and nutrition. The AQAA stated that residents were assessed for risk of falls, that advice was sought from the local falls prevention team and that necessary action was implemented to minimise risks. Records identified that each resident was weighed on a regular basis and there were actions identified if there were issues noted regarding their weight. The records detailed residents’ medical history and there was a reference to their personal history, which was completed by the resident. The resident survey asked if they received the care and support they needed and one answered always, three answered sometimes and one answered usually. One stated that they had purchased back, ankle and knee supports for themselves. A survey said that the home has changed since the people with dementia lived at the home, which adds pressure to the staff. The relative/visitor survey asked if the care home met the needs of their relative or friend and four answered always and two answered usually. Comments made were ‘the staff at the home are always very caring’ and ‘first class, happy, clean at all times. The food is very good, well balanced diet. The Christian ethos is very strong at Finborough Court. The staff survey asked if they were given up to date information about the needs of the people they supported and five answered yes. The resident’s records viewed provided clear information of health care visits and treatments, including dental, medical, chiropody and optical. There were details in the plans of any treatment which had been received and guidance provided by health care professionals. The resident survey asked if they received the medical support they needed and three answered always, one answered usually and one answered sometimes. Finborough Court DS0000024385.V346244.R01.S.doc Version 5.2 Page 13 The home’s medication storage and lunchtime medication administration was observed. Medication was in a secured trolley, which was stored in a lockable treatment room when not in use. The medication records were viewed and clearly identified medication prescribed for each resident and there was a photograph of each resident. There were no gaps identified in the records viewed, and there was clear references made when residents had not taken their medication, for example if they had been in hospital or had refused their medication. A staff member explained the procedure for disposing of medication. There was secure storage available for controlled medication. The controlled medicines records were maintained in a bound book and there was a clear audit system in place. The home had a detailed medication procedure which was viewed. Medication training had been provided to staff who were responsible for the administration of medication. The AQAA stated that in the last twelve months the home had accessed training from a pharmacist on medication administration which was internally assessed and that a certificate was provided. A resident’s records identified that they self medicated, there was a risk assessment in place and the care plan identified support they were to be provided with. The resident was spoken with and explained how they obtained their medication and showed the inspector the lockable drawer where they stored their medication. During a tour of the building, the manager was observed knocking on bedroom doors before entering and they asked for the residents’ permission for the inspector to look at their bedroom. They introduced the inspector to residents and explained why they were in the building. There was lockable storage space provided in each resident’s room. Interaction between residents and staff was observed to be friendly, respectful and professional. Residents spoken with said that the staff treated them with respect and they confirmed that their privacy was respected. The relative/visitor surveys provided complimentary comments regarding how the residents at the home were treated with respect, comments included ‘caring helpful staff, always treat residents with respect’ and ‘the residents are clean, clothes tidy and respected as senior citizens and are spoken to as such’. The manager said that resident’s clothing was labelled to ensure that they were provided with their own clothing when it had been laundered. The labelled clothing was viewed during a visit to the laundry. Finborough Court DS0000024385.V346244.R01.S.doc Version 5.2 Page 14 Each resident’s record viewed included details of their wishes in the event of their death. They detailed the name and contact details of the funeral director and if they had chosen a burial or cremation. The manager explained that the home supported residents if they were nearing the end of their lives and the support they provided to the families. The AQAA stated ‘throughout the period of terminal illness policies and procedures are adhered to, to ensure that privacy and dignity for the service user is maintained’. Finborough Court DS0000024385.V346244.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that they are provided with appropriate activities, that they are supported to maintain their chosen contacts, that their choices are respected and that they are provided with a balanced diet. EVIDENCE: The resident’s care plans viewed identified their interests, hobbies and religious worship, which they participated in and enjoyed. There were clear records of activities which they had participated in at the home. There were artwork, greeting cards and painted plant pots, which had been made by residents displayed in the home and some items were for sale. The manager said that the proceeds for the sold items was used for paying for social activities for residents, such as day trips. A resident spoken with said that they enjoyed looking at the birds and plants out of their bedroom window and read books. Finborough Court DS0000024385.V346244.R01.S.doc Version 5.2 Page 16 On the morning of the inspection there was a daily devotional, which included a sermon. The manager said that they were held each morning and were conducted by the manager, residents or visitors. The devotional was held in the lounge/dining area and was available for residents to listen to, who wished to remain in their bedrooms, through audio speakers. There was a Sunday worship provided at the home, however, some residents chose to visit their usual place of worship. Residents spoken with said that there were plenty of activities available in the home. They said that their relatives could visit them at any time and were made welcome. The resident survey asked if there were activities arranged by the home which they could take part in. Four answered usually and one answered never. A survey stated that they did not participate in the homes activities but they had lots to keep them busy, such as maintaining contacts with friends and reading their Bible. The AQAA stated that the home had made changes following listening to people who use the services, which included a more varied activities programme which are displayed around the home, that outings were arranged for smaller groups of people to encourage one to one interaction and Bible study had been arranged for Saturday mornings. It stated that the home had developed relationships with local pastors who provided transport to events in mini buses with disabled access. A resident was observed enjoying a visit with a family member. They were introduced to the inspector and said ‘you will find nothing wrong here’. They said that they were happy with the care that their relative received at the home. The manager explained that the home had a group of ‘home visitors’ who worked on a voluntary basis and visited residents at the home. During the inspection there was a ‘home visitors’ meeting and the manager said that they met on a regular basis and planned activities such as a tea which was planned and hymn and praise activities. The manager said that the home visitors had a CRB (Criminal Records Bureau) check and were provided with training sessions such as basic food hygiene, dementia and POVA. A home visitor confirmed that they had a CRB check. The inspector did not view evidence of the checks. However, there were no records available which evidenced the training sessions provided. The home visitors were available to visit residents at the home if the residents wished to have the visits. A home visitor was spoken with and said that they been interviewed by representatives of Pilgrim Homes and they had CRB checks prior to visiting the home. They confirmed that they had received training sessions and explained Finborough Court DS0000024385.V346244.R01.S.doc Version 5.2 Page 17 actions they would take if they had any concerns about the home or safety of the residents. The home visitor said that their role was visiting and befriending the residents if they wished it and that they organised activities. The relative/visitor survey asked if the home helped their relative/friend to keep in touch with them. Two did not answer, three answered always and one answered usually. Comments included ‘the home arranges transport for (the resident) to attend services and meetings what (the resident) wants to do and enjoys’ and ‘they ring me with messages and information’. The survey asked if they were kept up to date with important issues and four answered always and two answered usually. One survey provided the comment ‘recently (the resident) had to be taken to hospital, the home phoned and I reached hospital before (the resident)’. Residents spoken with said that they could bring their personal possessions into the home if they wanted to, the Statement of Purpose confirmed this. Residents said that they chose what they wanted to do in their daily lives. Resident’s records viewed evidenced that residents made choices about their daily living including what they wanted to eat and what activities they wished to participate in. The manager said that resident’s attended a resident’s meeting two times each year, where they discussed issues of the home. They said that they had offered more regular meetings, however, residents were not keen to attend them. A newsletter was viewed which was written and printed by residents of the home, it detailed changes in the home, activities and articles written by residents. Residents were observed being provided with choices of hot and cold drinks throughout the day of the inspection. Lunchtime was observed during the inspection and residents were observed enjoying a lunch of smoked haddock, potatoes and vegetables, there was an alternative choice of an omelette. The meal looked appetising. Residents who required support with eating their meal, were supported by a staff member who remained with them until they had finished eating. The dining area was large and was attractively furnished. The menu was viewed and provided a balanced diet and there was a choice of meals available. A staff member said that the food was good at the home and if residents did not want what was on the menu for the day then they would be provided with further alternatives. Residents spoken with confirmed that they had a choice of meals, that the food was good and that they were provided with sufficient food. Finborough Court DS0000024385.V346244.R01.S.doc Version 5.2 Page 18 Resident’s specific dietary requirements were identified in their care plans. The AQAA stated that a soft or liquidised diet was provided if required. The resident survey asked if they liked the meals at the home. Three answered always, one answered usually and one answered sometimes. Comments included ‘not enough choice’ and ‘we are offered a choice of items’. One survey stated that the home used to provide roast lamb on Sundays but have been told that it is too expensive. Finborough Court DS0000024385.V346244.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that their complaints are acted upon and that they are protected from abuse. EVIDENCE: The home had a complaints procedure, which included CSCI (Commission for Social Care Inspection) contact details. The complaints procedure was provided to prospective residents in the Statement of Purpose. Residents spoken with said that they knew how to make a complaint if they were unhappy about anything in the home. Staff spoken with were aware of how they could support resident or visitors to the home if they wished to make a complaint. The homes complaints records were viewed and clearly identified any complaints received, actions taken and how they had remedied the situations. There had been no complaints made since 2005. The manager was spoken with about informal concerns and requests and how they were recorded and managed. The manager said that they were discussed with the individual and actions were taken as soon as possible, however, there Finborough Court DS0000024385.V346244.R01.S.doc Version 5.2 Page 20 was no formal method of recording them. It is recommended that the home maintain central records of concerns and requests made by residents and visitors to the home and actions taken. The relative/visitor survey asked if they were aware of how to make a complaint, five answered yes and one answered no and stated ‘I am sure I would not need to’. The survey asked if the home had responded appropriately if they raised concerns about the care. Four answered always, one answered usually and two answered N/A. Five staff surveys said that they knew what to do if a resident or relative or friend wished to make a complaint. The resident survey asked if they knew who to talk to if they were not happy. Two answered always, one answered usually, one answered sometimes and one answered never. Four said that they knew how to make a complaint and one said that they did not. One survey stated that they thought that ‘they stick together and never take our part’. Staff spoken with confirmed that they had received POVA (Protection of Vulnerable Adults) training and were aware of the procedure for reporting and recording any concerns or allegations of abuse. The home had clear POVA procedures. Since the last inspection the home had obtained a copy of the guidelines issued by the Vulnerable Adult Protection Committee of Suffolk. The training records viewed evidenced that staff were provided with POVA training. A home visitor and the manager said that the home visitors group had been provided with training sessions, including information of actions to take if they were concerned about the safety of residents or if they informed them of any issues they were not happy with. However, there was no documentary evidence available. The homes procedures were viewed and included aggression toward staff, bullying, concerns and complaints, dealing with violence and aggression, whistle blowing, gifts to staff, management of service users money, valuables and financial affairs, missing service users, physical intervention and restraint and POVA. The staff survey asked if they were aware of the procedure for safeguarding adults, sometimes called POVA and four answered yes and one answered no. Finborough Court DS0000024385.V346244.R01.S.doc Version 5.2 Page 21 Finborough Court DS0000024385.V346244.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that they live in a safe, clean and well maintained environment. EVIDENCE: The home was very clean and well maintained. A domestic staff member was spoken with and explained how they maintained the cleanliness of the home. They confirmed that they had achieved an NVQ qualification related to their work role and they had a clear understanding of infection control and the importance of maintaining a clean environment. All carpets were clean and there were no offensive smells during the inspection. Residents, staff and a visitor spoken with were complimentary about the cleanliness of the home. Finborough Court DS0000024385.V346244.R01.S.doc Version 5.2 Page 23 There were areas in the garden where residents could sit on attractive garden furniture. Areas in the garden were secured and the manager explained that this was to ensure the safety of residents, particularly with dementia. There was a gate which could be opened with a top and bottom latch. There was an area in the grounds which a resident had decorated with plants and garden ornaments and could be viewed from their bedroom window. There was a large open plan dining and lounge area, where residents were observed to be enjoying their lunch and participating in the daily devotional during the inspection. During a tour of the building it was noted that the home was accessible to wheel chair users. Grab rails were provided throughout the home. Bedrooms were provided with wide doors, which could be extended by an additional door panel. There was one room on each wing which did not have the extending facility. Bedrooms were provided with seating, large wardrobe, drawers, bed and ensuite consisting of a wash basin and toilet. There was adequate lighting in each bedroom. The bedrooms were provided with a speaker and residents could listen to the daily devotional from the comfort of their bedrooms. The volume and sound could be controlled by residents in each bedroom. Each bedroom had a call bell, which could be used in all areas of their room. Staff were observed answering call bells throughout the day. Bedrooms viewed were clean and well maintained. Each bedroom had the resident’s personal memorabilia in them and reflected their choice and personality. There was a lockable cupboard in each room where residents could store items in if they wished to. Residents spoken with said that they were happy with their bedroom and that they had bought items when they moved in. Bathrooms were provided with a shower and bath. There was a large parker bath and two baths with an automatic seat. One had been out of order since June 2007. The manager explained that there had been attempts by a contractor to repair it, however, this had not been possible and a new system was ordered. Documentary evidence was viewed to support that the home had acted in a timely manner to ensure that the bath was available for use. Records of regular water temperature checks were viewed. The laundry was viewed and it was clean and tidy. There was hand washing facilities provided in the laundry. Washing machines provided adequate programmes to ensure that soiled laundry was laundered appropriately and had automatic detergent facilities. Finborough Court DS0000024385.V346244.R01.S.doc Version 5.2 Page 24 The training records viewed evidenced that staff were provided with infection control training. The resident survey asked if the home was fresh and clean. Four answered always and one answered usually. One stated ‘a visitor who worked in care said that the home smelled new even though it is 12 – 13 years old’. The relative/visitor surveys provided complimentary comments on the cleanliness of the home, which included ‘clean accommodation’, and standards of hygiene excellent never any smells’. Finborough Court DS0000024385.V346244.R01.S.doc Version 5.2 Page 25 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that they are supported by numbers and skill mix of staff who are trained to do their jobs and that they are protected by the home’s recruitment procedures. EVIDENCE: The staffing rota was viewed and showed that there were care staff on duty twenty four hours each day, with domestic and catering staff providing support. There was one senior and three care staff on the early day shift, one senior and two care staff each afternoon and evening shift and two night wake staff. Staff spoken with said that there was sufficient staff on duty at all times. The staff survey asked if the staffing levels on each shift provided enough time to meet the assessed needs of residents. Three answered yes and two answered sometimes. The AQAA stated that the home maintained a low staff turnover, that the staff rota ensured that staffing levels were maintained at all times and that they had recruited and retained more bank staff. Finborough Court DS0000024385.V346244.R01.S.doc Version 5.2 Page 26 The resident survey asked if staff were available when they needed them. Two answered usually and three answered sometimes. One stated that staff did their best but were overworked and ‘outside’ carers were slower. One survey stated ‘I feel that there is favouritism among the staff, some residents are seen to immediately, they ask others to wait’. Training records viewed showed that staff were provided with training courses such as POVA, manual handling, infection control and dementia. The records were maintained for training courses provided each year, with lists of staff who had attended the training. It is recommended that staff be provided with individual training profiles which identify the training they have been provided with since they started work at the home. The AQAA stated that staff were provided with equality and diversity training. The staff survey asked if they were given training which is a) relevant to their role. b) Helps them to understand and meet the individual needs of residents. c) Keeps them up to date with new ways of working. Five answered yes to all three questions. The relative/visitor survey asked if the staff had the right skills and experience to look after people properly. Six answered always and comments included ‘the staff are very well trained’ and ‘very knowledgeable about individual patients.’ The manager stated that there were various conferences arranged in London for groups of staff, such as senior staff and maintenance staff. New staff were provided with Skills for Care (formerly TOPSS) induction. One newly appointed staff member was spoken with and confirmed that they were working on their induction. They were provided with a workbook and said that they had a final section to work on. The staff member said that they were provided with sufficient training to undertake their role, had regular one to one supervision meetings and received good support. The staff survey asked if the induction covered everything they needed to know when they started. Four answered yes and one did not respond. Four staff recruitment records were viewed and included the required information, including two written references, evidence of CRB (Criminal Records Bureau) checks, application form, identification and a photograph. One record of a kitchen/domestic assistant did not have a CRB check. A copy of the application form was in place. The manager said that they were never alone with residents and they were awaiting the return of the check. The home maintained a record of all CRB checks for staff members which included the date they were received and the CRB number, they destroyed the CRB notification after it was viewed by an inspector. Finborough Court DS0000024385.V346244.R01.S.doc Version 5.2 Page 27 The manager and a staff member said that there were twenty six care staff working at the home and twelve had achieved an minimum of NVQ level 2 and one staff member was in the process of working on their award. When they had completed their award the home would have met the target of 50 of staff to have achieved a minimum of NVQ level 2 by 2007. There were three staff, including the manager, who had achieved an NVQ assessor award and they could support staff who were working toward their award. A staff member spoken with said that they could access the NVQ award as soon as they completed their induction workbook. Finborough Court DS0000024385.V346244.R01.S.doc Version 5.2 Page 28 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that the home is managed by a person who is fit to be in charge, that the home is run in their best interests, that their financial interests are safeguarded and that their health, safety and welfare is protected. EVIDENCE: The manager had been successful in the registered manager application process. The manager had achieved NVQ level 4 registered manager award, which was a combination of care and management. The manager had achieved Finborough Court DS0000024385.V346244.R01.S.doc Version 5.2 Page 29 an NVQ assessor award. The manager attended regular managers conferences, which were organised by the providers of the service. The AQAA stated that the manager developed their skills by attending courses such as intermediate certificate in occupational health and safety and was undertaking a course in healthy eating. There were regular quality assurance satisfaction questionnaires undertaken by staff, residents and visitors. The manager said that the results of the questionnaires were used in the monitoring of quality of the home’s care provision. The results of the surveys were analysed and areas for improvement were identified and methods to improve were actioned. There were resident’s meeting, which took place twice a year. The minutes for the last meeting were viewed and residents were provided with the opportunity to discuss and offer their suggestions for the home. Issues discussed included the menu and activities. The Regulation 26 visit visits were regularly undertaken and the reports were forwarded to CSCI. Residents, who wished for their personal allowances to be kept in a secure place in the home, were provided with the facility. There were clear records maintained which showed all transactions and receipts for spending. During a tour of the building it was noted that residents had a lockable cupboard in their bedroom, in which they could store items if they wished to. The records for water, fridge and freezer temperature checks undertaken in the kitchen were viewed. There were records of water temperature checks in the bathrooms with a notice, which advised staff that they must be undertaken regularly. Accident records were viewed and they were appropriately recorded and reported. The home had a fire risk assessment and fire procedure. There was evidence viewed of regular fire safety checks and evacuation. Health and safety related records were viewed and there was documentary evidence which included maintenance undertaken, electrical appliance testing and water temperature checks. There were records that evidenced that the hoists were regularly serviced. Records of the reporting of required repairs and when they had been completed were viewed. The staff member responsible for making the checks was spoken with and explained their work role with regards to maintenance and health and safety checks. Finborough Court DS0000024385.V346244.R01.S.doc Version 5.2 Page 30 The homes environmental risk assessments were viewed and included legionella, security of the building and clinical waste. There were risk assessments provided for all aspects of possible risks in the environment and methods of minimising them. Staff training records evidenced that staff were provided with health and safety related training such as manual handling, COSHH (control of substances hazardous to health), food hygiene, fire safety and infection control. There were detailed policies and procedures which identified how the health and safety of the home and resident’s was promoted and protected and included emergencies and crises, moving and handling and infection control. Finborough Court DS0000024385.V346244.R01.S.doc Version 5.2 Page 31 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 3 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 3 4 3 3 X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Finborough Court DS0000024385.V346244.R01.S.doc Version 5.2 Page 32 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. 1. Refer to Standard OP18 OP13 Good Practice Recommendations It is recommended that the training sessions provided to home visitors be clearly recorded, including the contents of the sessions and who attended It is recommended that an individual training profile be maintained for each staff member, which evidences which training they have attended since they commenced work at the home. It is recommended that a central record of concerns and requests made, which were not formal complaints, and the action taken be maintained. 2. OP30 3. OP16 Finborough Court DS0000024385.V346244.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V346244.R01.S.doc Version 5.2 Page 34 - 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!