Inspection on 17/07/07 for Florence House

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 (sorry - unknown). 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

Florence House 01/06/09

Florence House 12/03/07

Florence House 18/10/05

Florence House 17/05/05

Florence House 09/11/04

Florence House 18/05/04

Florence House 24/03/04

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 Florence House 220 Park Road Peterborough Cambridgeshire PE1 2UJ Lead Inspector Andy Green Key Unannounced Inspection 17th July 2007 10:30 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 DS0000015170.V346339.R02.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. DS0000015170.V346339.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Florence House Address 220 Park Road Peterborough Cambridgeshire PE1 2UJ 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) 01733 315900 01733 702272 florence.house@tiscali.co.uk Park Road Baptist Housing Association Ltd Mrs Barbara Franco De Olim Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places DS0000015170.V346339.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th March 2007 Brief Description of the Service: Florence House is a Christian Retirement Home situated in a residential area of Peterborough, close to the Central Park. Accommodation for 21 elderly people is provided on two floors in 17 single rooms and 2 double rooms, all with ensuite facilities. The home has a large lounge and dining room with a lounge area. There are attractive gardens to the front and rear of the property. The home is near to the city centre of Peterborough has a wide range of shopping and leisure facilities. There are good road and rail links from Peterborough to London and other major cities. The fees range from £386 to £400 per week Copies of CSCI reports are made available to residents and relatives upon request. DS0000015170.V346339.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Andy Green, Regulation Inspector, undertook this unannounced inspection on 17th July 2007. The inspector met with the manager, deputy manager, care staff and residents to gather their views regarding the care and support that is provided in the home. A number of records were inspected including care plans, training records, staff files, fire records and medication. A tour of the building and grounds was also undertaken. What the service does well: What has improved since the last inspection? The Statement of Purpose has been amended to include the registered manager’s details. The assessment process has been improved to ensure that all appropriate information has been received prior to the resident being admitted. A new medication trolley has been purchased to improve medication storage and administration. Some improvements have been made to staff supervision and the manager and deputies will ensure that regular recorded sessions are maintained. Improvements have been made to the recruitment processes including CRB and POVA checking. DS0000015170.V346339.R02.S.doc Version 5.2 Page 6 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. DS0000015170.V346339.R02.S.doc Version 5.2 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 DS0000015170.V346339.R02.S.doc Version 5.2 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): 1,3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home produces a variety of information to ensure that prospective residents can decide if they wish to live in the home. DS0000015170.V346339.R02.S.doc Version 5.2 Page 9 EVIDENCE: The Statement of Purpose and The Service Users Guide have been updated since the last inspection to include the registered manager’s details. Prospective residents and their family/relatives continue to be encouraged to visit Florence House as part of the assessment process, prior to admission. This was clearly evidenced during the day by the visit of two relatives who were involved with their mothers’ admission to the home. The manager has reviewed and amended the pre admission assessment form to ensure that mental health needs are identified and assessed. An example was seen in the file of a recently admitted resident. The manager stated that a resident has been re-assessed by a CPN regarding her mental health needs. Following this assessment it is now clear that there is a diagnosis of dementia and action is being taken to refer the resident to a more suitable home to meet her needs. The manager stated that the resident’s family are aware of the situation and involved with identifying a new placement. The manager stated that she would inform CSCI regarding the outcome of this situation. The home does not provide intermediate care. DS0000015170.V346339.R02.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive appropriate health and personal care to meet their assessed needs. DS0000015170.V346339.R02.S.doc Version 5.2 Page 11 EVIDENCE: Three care plans were inspected and a variety of information is in place including specific guidelines for the delivery of personal care and support that is required. Waterlow pressure charts, weight monitoring and nutritional monitoring charts are in place. Evidence of monthly reviews were seen but it was noted, however, that the space for reviews still remains small and it is recommended that the care plan forms be enlarged or a new format put in place so that more information can be recorded. The manager stated that she is reviewing a number of processes in the home including care planning to ensure that all documentation is appropriate. It was noted that the care plans follow a nursing model and need to be presented in a more person centred approach, which reflects the resident’s social care needs. The inclusion of a social profile, key worker notes and activity preferences would promote a more social model of care in the home. Residents continue to receive regular visits from healthcare professionals including district nurses, GPs, chiropodist and a dentist as required. Visits are recorded in resident’s care plans. The care staff in the home assist residents with personal care where necessary. The residents privacy and dignity is maintained at all times and residents spoken to confirmed that they were treated in a dignified and friendly manner at all times. Staff were observed to knock on the resident’s bedroom door before entering. Medication records including controlled medicines were inspected and they were accurate. A new medication trolley has been purchased since the last inspection, which is kept securely. Staffs who administer medication receive training and the manager stated that one of the deputy managers is attending a Medication Foundation course so that she can carry out ongoing training for staff in the home. DS0000015170.V346339.R02.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff provide support to ensure that residents have access to appropriate activities to meet their needs. DS0000015170.V346339.R02.S.doc Version 5.2 Page 13 EVIDENCE: A range of activities including arts and crafts sessions, musical entertainments, outings and access to community events continue to be provided for residents. The registered manager stated that regular paid entertainers provide musical events throughout the year. Programmes of light exercise for residents who wish to participate are regularly provided. Residents often enjoy spending time in the garden with their visitors during the summer months and a recent garden fete had been held in June. A ‘Clothes Show’ is being held in the home later in the month. The manager stated that she wanted to develop more suitable activities and that one of the staff will be focussing on developing this area. The inspector informed the manager about NAPA which is a national organisation involved in promoting activities for the elderly. The inspector agreed to send contact details to the home. A short informal daily act of worship is provided for those who wish to attend and ministers continue make regular visits from local churches. Relatives and friends of residents are encouraged to maintain contact and this was confirmed by residents during the inspection. There is a varied range of meals provided and dietary needs are catered for. Residents, spoken to on the day of inspection, were complimentary about the meals they received. DS0000015170.V346339.R02.S.doc Version 5.2 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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has a complaints process to make sure that residents have their complaints or concerns listened to and acted upon properly. EVIDENCE: The home has a full complaints procedure in place, which are included in the Statement of Purpose and Resident Guide. The CSCI contact details are also included. The complaints process is explained to residents and their relatives Staff receive training in the protection of vulnerable adults to ensure that residents are protected from abuse. Staff met during the inspection confirmed this. There have been no complaints received regarding the home and its care and services since the last inspection. DS0000015170.V346339.R02.S.doc Version 5.2 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): 19,20,23,24,25,26. Quality in this area is good. This judgement has been made using available evidence including a visit to this service. The environment of the home meets the residents needs. DS0000015170.V346339.R02.S.doc Version 5.2 Page 16 EVIDENCE: The home is kept in a clean and tidy way and is free from odours. All bedrooms are en-suite and there are three bathrooms with WCs, two with shower facilities and one separate WC, which are all located close to the residents rooms and near to the lounges and dining area. Four bedrooms were seen on the day of inspection and they were presented in a homely and comfortable manner and personalised to meet the resident’s wishes and preferences. Two of the bedrooms have been re-carpeted. Maintenance issues are discussed and actioned via the regular management committee meetings. The manager stated that bedrooms are redecorated prior to a new resident being admitted to the home. It is recommended that the flooring in one of the upstairs bathrooms is professionally cleaned or replaced as it has become discoloured. A number of stained carpets in bedrooms and communal areas also need to be cleaned or replaced where required. The manager stated that she would discuss these issues with the management committee for further action. The manager also stated that an audit of furniture that needs to be replaced in bedrooms has been undertaken. This is following grant monies that the home has received. The attractive gardens are accessible and continue to be well maintained. DS0000015170.V346339.R02.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Training is provided for care staff so that they are competent to deliver care to the residents they support. EVIDENCE: The home maintains a staff rota and on the day of inspection the registered manager stated that the home is fully staffed at present. The home was well staffed on the day of inspection to meet the needs of residents. There were 4 carers in the morning, 3 carers in the afternoon/evening and 2 waking night staff. The manager was also on duty during the day. Staff spoken to stated that they had received a variety of training including first aid, moving & handling, fire safety, record keeping and care of hearing aids. Health & safety training and POVA training is also received. Refreshers/updates to ensure safe practice are provided throughout the year. Four staff files were inspected and they contained the required documents and recruitment checks. CRB/POVA checking has improved since the last inspection. The manager is aware that a new CRB must be applied for regarding all new staff. The manager stated that a POVA First check is carried out and the staff member is supervised until a satisfactory CRB has been received before their employment is confirmed. DS0000015170.V346339.R02.S.doc Version 5.2 Page 18 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): 31,33,36,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and the manager provides supportive leadership and guidance to staff to ensure that service users receive high quality care. EVIDENCE: The manager is working towards completing an RMA and she is finding that is helping her to identify processes and procedures that need to be reviewed. She receives ongoing support from members of the Management Committee who provide regular input. A management committee meeting was taking place in the home during the day. Some improvements have been made to staff supervision since the last inspection. The majority of staff have received their annual review in May and DS0000015170.V346339.R02.S.doc Version 5.2 Page 19 the manager and her two deputies will be developing a new supervision system The manager stated that all members of staff would receive regular recorded sessions to monitor their practice and development needs throughout the year. Fire records are kept and are recorded regularly. Recent service contracts for fire equipment in the home were seen. PAT testing has improved since the last inspection and records were inspected. Daily fridge and freezer temperatures are kept and records were accurate. The manager stated that thermostatic valves have not yet been fitted to all hand basins and that this issue would be forwarded to the management committee for urgent action. DS0000015170.V346339.R02.S.doc Version 5.2 Page 20 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X 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 X 3 X 2 DS0000015170.V346339.R02.S.doc Version 5.2 Page 21 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. 2. Refer to Standard OP7 OP19 Good Practice Recommendations It is recommended that the care planning process be reviewed to ensure that all information and reviews are adequately. It is recommended that stained or discoloured areas of carpeting / flooring in the home are professionally cleaned or replaced where required. DS0000015170.V346339.R02.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 - 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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