Inspection on 15/11/06 for Foxgrove Residential Home

This inspection was carried out on 15th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Foxgrove Residential Home 04/01/06

Foxgrove Residential Home 26/10/05

Foxgrove Residential Home 09/03/05

Foxgrove Residential Home 13/09/04

Foxgrove Residential Home 27/10/03

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 Foxgrove Residential Home High Road East Felixstowe Suffolk IP11 9PU Lead Inspector Deborah Kerr Unannounced Inspection 15th November 2006 09:30 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 Foxgrove Residential Home DS0000024392.V323440.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. Foxgrove Residential Home DS0000024392.V323440.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Foxgrove Residential Home Address High Road East Felixstowe Suffolk IP11 9PU 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) 01394 274037 01394 274037 Pri-Med Group Ltd. Mrs Jennifer Ann Coulson Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Foxgrove Residential Home DS0000024392.V323440.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th January 2006 Brief Description of the Service: Foxgrove is a large Victorian house that has been extended and provides accommodation for up to twenty-four older people. It is situated in a residential area of Felixstowe, not far from some shops and other local amenities. On the day of inspection there were nineteen residents living at the home. There are sixteen single rooms and four double rooms. The accommodation is over two floors that are linked by a passenger lift. There is a large lounge facing the gardens with level access to the outside and a separate dining room on the ground floor. All the rooms have at least a toilet and wash basin with some having a full en-suite facility. Healthcare Homes Group purchased the home from Pri-med Group Ltd in April 2006. The new company continue to be registered and trade under the Pri-Med Group Ltd. Evidence was seen that the statement of purpose has been updated to reflect the new ownership. Healthcare Homes have produced a new colour photographic brochure to support the service user guide providing detailed information about moving into the home, the services provided and access to local services. Each resident has a contract, which specifies their agreed fees and how much they are expected to pay on a weekly basis. Fees are calculated depending on the needs of the resident; they range from £400 – £600 per week. These do not cover additional services for example, the hairdresser, chiropodist and personal items such as toiletries and receipt of daily newspapers. Foxgrove Residential Home DS0000024392.V323440.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over nine hours during a weekday. Sue Jenkins accompanied Deborah Kerr on this inspection as part of their induction to become a regulation inspector with the Commission for Social Care Inspection (CSCI). This was a key inspection, which focused on the core standards relating to older people. The report has been written using accumulated evidence gathered prior to and during the inspection, including information obtained from 8 residents ‘Have your say about’ comment cards. Inspectors reviewed the progress of the requirements made at the last inspection on the 4th January 2006. Time was spent talking with eight residents, six staff and the registered manager. Additionally a number of records were inspected including those relating to residents, staff, training, medication, quality assurance and a selection of policies and procedures. What the service does well: What has improved since the last inspection? Eight requirements were made following the last inspection in January 2006. The home has complied with seven of these requirements. A requirement was made for a manual handling assessment for a resident who is not weight bearing to be reviewed. Care plans have daily living needs and activity sheets, which were linked to manual handling assessments. Evidence was seen that these clearly identified the level of support required for each resident. A review of the home’s procedure for dealing with soiled linen has taken place. The home now uses the red bags for soiled linen, which are washed, separately at a high temperature, in accordance with infection control procedures. Radiator covers have throughout the home. are due to be fitted. replaced and the front Foxgrove Residential Home been made and fitted to the majority of the radiators Covers have been made for the remaining radiators and Carpets in the lounge and front entrance have been entrance has been redecorated. DS0000024392.V323440.R01.S.doc Version 5.2 Page 6 Staff files reflected that all staff had received updated Protection of Vulnerable Adults (POVA) training. Evidence was seen that an assessment had been completed and instruction had been given to a resident identified at risk, to ensure their safety in the event of the fire door to their bedroom closing when the fire alarm sounded. 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. Foxgrove Residential Home DS0000024392.V323440.R01.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 Foxgrove Residential Home DS0000024392.V323440.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5,6, Quality in this outcome area is good. Prospective residents can expect to be provided with detailed information to help them make a decision to move into the home, however they cannot be assured that the information will be available in an appropriate format suitable for all residents. Residents can expect to have a contract with the home and a needs assessment undertaken prior to admission to ensure the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There was evidence that the statement of purpose has been updated to reflect new ownership of the home. Healthcare Homes have produced a new colour photographic brochure to support the service user guide providing detailed information about moving into the home, the services provided and access to local services. However consideration needs to be given to providing information in a format suitable for all residents including those with a visual impairment. Foxgrove Residential Home DS0000024392.V323440.R01.S.doc Version 5.2 Page 9 The care plans and personal files of three residents were inspected. Evidence was seen that all three residents had a copy of the terms and conditions of residence agreeing their individual fee, which was signed and dated by them or on their behalf by their relative or representative. Staff have received mandatory training to ensure they have the skills and experience to meet the individual needs of the residents. Each resident’s file contained a pre-admission needs assessment, which identified the individual’s needs. Additionally a review of this assessment is undertaken on admission, which forms the basis of the individuals care plan. Residents are given the opportunity to visit the home prior to moving in. It was confirmed in discussion with one resident that they had an introductory visit, followed by a second visit where they decided to stay. The statement of purpose reflects the procedure for emergency admissions and evidence was seen that the home followed this procedure with a resident that recently moved into the home in an emergency as a result of a fall and not being able to look after themselves at home The home does not provide intermediate care. Foxgrove Residential Home DS0000024392.V323440.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11, Quality in this outcome area is adequate. Residents can expect to have care plans in place that reflect their health, personal and social needs and have access to healthcare professionals, however they cannot currently expect to be protected by the home’s procedures for administering medication. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans of three residents were inspected to track their care and the level of support they required. The care plans were easy to follow and contained information relating to individual’s health, personal and social care needs. Each of the care plans had a consent form to obtain the resident’s agreement to take part in the discussions and implementation of their care plan although these had not been signed or completed by the resident. There was evidence that the care plans were being reviewed monthly by staff and updated where necessary. Care plans are currently held in three communal files, which makes it difficult for individual residents to access information about themselves whilst maintaining confidentiality for other Foxgrove Residential Home DS0000024392.V323440.R01.S.doc Version 5.2 Page 11 residents. The inspector was provided with evidence that new care plans are being prepared in individual personal files. Each of the care plans had needs and activity sheets, which identified individual goals of the resident. These related to their daily living needs and had associated risk assessments in place with regards to moving and handling, nutritional screening and self medicating. It was evident that resident’s health needs were being monitored. Care plans had detailed case notes reflecting resident’s medical history and progress notes which identified where there was a concern raised either by the resident themselves or by a member of staff about their general health and well-being. The notes reflected where intervention had been sought from other health professionals, for example, one resident experiencing pain and discomfort in the shoulder was referred to the Rheumatology clinic at Ipswich Hospital. There was evidence that the condition was being managed by medication. One of the inspectors completed an audit of the home’s medication, which reflected all medications entering and leaving the home had been accounted for. The home undertakes their own monthly medication audit. Inspection of these audits confirmed they were accurate with the exception of the July 2006 audit, which had entries, referring to two miscalculations with no evidence or explanation given to substantiate the miscalculation. Each Medication Administration Records (MAR) chart has an information cover sheet with a photograph of the resident for identification purposes. However inspection of these records showed that two of the residents did not have a photograph attached. A requirement was made following the last inspection about the need for the MAR chart to record the number of tablets administered where residents were prescribed one or two tablets. It was noted during this inspection that there were twelve occasions when the number of tablets administered had not been recorded and this remains an area of concern. When only 1 tablet was administered the remaining tablet was left in the blister pack, which was open with a risk of the tablet being dropped and unaccounted for. Where medication is not administered a code was entered on the MAR chart as zero. The audit highlighted there were seven occasions where the code was entered but no explanation provided on the back of the MAR chart of why the resident had not taken their medication. There were two entries on the MAR charts where a dose had been changed by hand; but there was no explanation, signature or date recorded. The controlled drug book was checked against a resident’s MAR chart and was found to be correct. However the MAR chart had not been signed for the entire month, the manager confirmed this was usual practice as staff had signed the controlled drug book instead. The MAR chart must be signed, as this is a record of the administration of the medication whereas the controlled drug Foxgrove Residential Home DS0000024392.V323440.R01.S.doc Version 5.2 Page 12 book is a record of the stock being held. The number of morphine sulphate tablets recorded in the controlled drug book was checked against the number in the box of one of the residents being tracked and was found to be accurate. The home has eight residents that currently self medicate. One risk assessment reviewed was found to be relevant to the resident. Another resident who partially self medicates had a drawer of open medicines and two boxes of medicines on the top of the drawer. Whilst talking to the resident it was clear they were confused about the medication they were supposed to be taking. They had been prescribed several courses of antibiotics, which were being administered by the staff. The drawer was not locked and the resident stated they did not have a key, however discussion with the manager confirmed they had been provided with the key. The resident’s risk assessment reflected that they were being monitored and managing well. However it was agreed with the manager that the residents’ ability to self medicate would be re assessed and discussed with the individual concerned. Evidence was seen throughout the inspection that residents were being called by their preferred name and residents spoken with felt that staff respected their privacy and dignity. Staff were observed knocking and waiting before entering resident’s rooms. The interactions between residents and staff were observed to be friendly and appropriate. The home has four double rooms, evidence was seen that a married couple occupied one of these rooms and another of the double rooms was in the process of being decorated in preparation for another married couple. All other residents have single rooms and evidence was seen that they could have private telephones installed in their rooms. The care plans have a form for discharge and death arrangements, however only two of the three care plans being tracked had any information recorded. This information only covered resident’s wishes with regards to funeral arrangements and religious preferences. The guidelines produced by the Department of Health (DOH) on palliative and end of life care within all care home settings was discussed with the manager. Evidence was shown to the inspector that there is a section to be completed in the new care plans to address the final wishes of the residents. Foxgrove Residential Home DS0000024392.V323440.R01.S.doc Version 5.2 Page 13 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. People living in the home are supported to make decisions and choices about their daily lives and have a lifestyle that matches their expectations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A notice board in the hallway had a range of forthcoming activities, which included a letter from the Mayor announcing a date for a Christmas visit to the home. There were details of outings to places, for example Exploring Deban, Stoneham Barns and productions at the Spa Pavilion. There was also a notice advertising fortnightly visits by the mobile library. During November scheduled activities included an afternoon of poetry and a visit by the Reverend to show videos and slides of “Suffolk under the skies”. Residents informed the inspectors that a musical entertainer had recently been to the home and played the violin and the piano. There was a mixed reaction about their visit, one resident commented, “it was wonderful” while another felt that as it was amplified the music was too loud. A letter had been written to the home inviting residents and staff to take part in an annual quiz at Walton Church Hall, the home had entered two teams the previous year. Foxgrove Residential Home DS0000024392.V323440.R01.S.doc Version 5.2 Page 14 One resident spoken with described what it was like for them living in the home, “Foxgrove achieves what it sets out to do, residing in the home is what you would reasonably expect from living in a care home and they provide a good standard, but there is no place like home”. However they had no complaints and found the “staff entirely helpful” They described spending their day reading and writing letters and three times a week they walked into the town of Felixstowe. Another resident spoken with told the inspectors “I think Foxgrove is a lovely home and I am lucky to be here” and “I receive good care, and on the whole staff are very good, they take time to get to know you”. The resident described spending their day writing letters or doing needlework. They used to attend a church in Walton, however due to deteriorating mobility they were finding it increasingly difficult to access the church, which has prevented them from attending services, but they are still in contact with some of the parishioners who visit them at the home. It was evident whilst meeting and talking with residents that they are supported to exercise choice and control over their lives. The majority of the residents are able bodied and require minimal support from staff. Two of the residents have their own vehicles and choose to go out shopping or visiting friends. Residents look after their own finances or have a relative or power of attorney to manage their finances on their behalf. This was confirmed through discussion with residents. Evidence was seen that residents had brought their own possessions with them to personalise their rooms. One resident showed the inspectors a selection of pictures and described what each one meant to them, remembering loved ones and reliving their past through the pictures. A four-week rolling menu was seen displayed on the board in the dining room. The menus reflected that residents have a choice of three cooked meals a day with coffee and biscuits mid morning and tea and cakes mid afternoon. The midday meal was seen being prepared by the chef. Lunch consisted of roast chicken, roast potatoes accompanied by glazed carrots and parsnips and french beans, followed by fruit crumble and custard. A separate fruit crumble had been made for people who were diabetic and the custard sweetened with a sugar substitute. There was no alternative choice to the main meal being prepared, however the chef confirmed that all residents had pre chosen the roast but if a resident had changed their mind they would offer an alternative. Residents are provided with a menu to make a choice for the following day, menu forms seen confirmed that all residents had chosen the roast dinner. Foxgrove Residential Home DS0000024392.V323440.R01.S.doc Version 5.2 Page 15 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. People who use this service can expect that complaints will be taken seriously and investigated and be protected by the homes procedures for the Protection of Vulnerable Adults (POVA). This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents are issued with a copy of the complaints procedure. However as with the statement of purpose and service users guide consideration needs to be given to how the home provide the information for persons living in the home with a visual impairment. The pre inspection questionnaire reflected that there had been three complaints made between June 2005 and January 2006. The complaints log confirmed that these had been investigated by the home’s manager and had been responded to appropriately and the complainant satisfied with the outcome. Residents and staff spoken with during the inspection were confident that if they needed to make a complaint they would do so to the manager and that they would have their concerns listened and responded to. Staff had signed to say they had read and understood the procedure for managing aggression, which had been issued in June 2006 and providing detailed interventions for supporting the residents with dignity and respect to relieve their agitation or the situation causing their aggression. However the home has 26 staff, and only 11 staff had signed the acknowledgement sheet. Foxgrove Residential Home DS0000024392.V323440.R01.S.doc Version 5.2 Page 16 The home’s adult protection policy and procedure had been reviewed in June 2007. The home also had a copy of the Suffolk Vulnerable Adult Protection Committee (VAPC) and are aware that they need to inform the Commission for Social Care Inspection (CSCI). A member of staff spoken with said they would report any incident that they felt could be potentially abusive to senior management. The staff files seen showed that staff had received training in Protection of Vulnerable Adults (POVA). Foxgrove Residential Home DS0000024392.V323440.R01.S.doc Version 5.2 Page 17 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. People living in the home can expect to live in an environment that is welcoming, clean and comfortable, however they cannot be assured of safe evacuation in the event of fire and risks of scalding and burns. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Foxgrove is a large Victorian house, which has been extended and adapted providing accommodation for up to twenty-four older people, although at the time of this inspection there were nineteen residents living in the home. The sixteen single and four double bedrooms have en-suite washing and toilet facilities. Six rooms also have an en-suite shower or bath. Evidence was seen that individual rooms were personalised with the residents’ own belongings and contained the appropriate furniture. Accommodation is on two floors with access via a passenger lift. Foxgrove Residential Home DS0000024392.V323440.R01.S.doc Version 5.2 Page 18 The home is comfortably furnished and nicely decorated throughout, with good quality furniture, fixtures and fittings. The lounge was nicely laid out providing a comfortable and relaxing room for residents to sit, fresh flowers were on display and bowls of fresh fruit were placed on coffee table and accessible to the residents. Since the last inspection the entrance foyer has been decorated and new carpets have been fitted in the foyer and the lounge. Bedroom number 6 has been redecorated and a double room was in the process of being refurbished including expanding the en-suite facilities in preparation for a married couple to share. Some of the paintwork on skirting boards and doorways is chipped and marked in places, particularly around the doorways to the rooms leading off from the lounge, which needs attention. The stair carpet is frayed round the bottom rung and discoloured around the floor level join in the hallway. The carpet on the landing is starting to lift and ripple causing a potential tripping hazard and needs to be repaired or replaced. Communal bathrooms and toilets have adaptations to assist access for residents with reduced mobility. A hoist was being stored in the upstairs shower and was partially blocking the fire escape route. A small shelf used for trays and other objects by staff was seen jutting out into the downstairs corridor. Further along the corridor was a laundry trolley with clean sheets on top left unattended. The corridor had signage indicating this was a fire escape route; both of these objects would cause congestion in an emergency evacuation situation. Bathrooms seen had the appropriate liquid hand wash and paper towels. A requirement was made at the previous inspection that towels were not to be left in bathrooms for communal use as this posed a risk of cross infection. The shower room had a stack of clean towels on a shelf although there was no evidence to suggest that the towels were being used communally. However, the home has one sling and a couple of slide sheets to assist staff to transfer residents where required, concerns were raised with the manager about the risk of cross infection occurring through the communal use of these items. Covers had been fitted to most of the radiators throughout the home, with the exception of a few on the upstairs landing and a couple of bedrooms. The manager confirmed that the remaining covers had been made and they were trying to arrange a date for them to be fitted. The upstairs shower room has a heated towel rail, which has not been covered, as it would prevent the door from opening. The manager was advised that they should complete a risk assessment on the likelihood of residents falling against the rail and obtaining burns. The hot water temperature of the bath in the downstairs bathroom fluctuated between 43 and 45 degrees centigrade on the thermometer, which exceeds the recommended safe water temperature and needs to be monitored. Foxgrove Residential Home DS0000024392.V323440.R01.S.doc Version 5.2 Page 19 The laundry room is situated on the ground floor away from the kitchen and dining area. The procedure for dealing with soiled linen was raised as a requirement at the last inspection in January 2006. Soiled garments were being sluiced in a bucket and rinsed prior to washing, as the washing machine does not have a sluice cycle. Evidence was seen at this inspection that new procedures have been implemented. The home now uses two types of red bags supplied by two different companies and used for specific soiled laundry, which staff have been made aware of. A risk assessment for foul linen had been completed. Staff were expected to read and sign to confirm their understanding of the procedure, however only 11 of the 26 staff had signed the document. A member of domestic staff spoken with was clear of their role to provide a good standard of cleaning to ensure the home was hygienic to prevent the spread of infection. Foxgrove Residential Home DS0000024392.V323440.R01.S.doc Version 5.2 Page 20 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. Residents can expect to be supported by a staff team in sufficient numbers that have received training and support and have the knowledge to care for them. They can also expect to be protected by the home’s recruitment procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staffing roster was seen which reflected there was two staff on duty between 8am and 5pm, two staff between 5-10pm and two staff on the night duty between 10pm to 8am. Additional support staff were the head housekeeper and two domestic staff who cover hours of 8am -1pm Monday to Friday, a chef and one kitchen assistant who worked split shifts between 9am – 11am and 5pm – 9pm. One comment card received prior to the inspection from a relative/visitor referred to staff shortages. Staffing levels were discussed with the manager who confirmed that staffing had been tight recently due to a member of staff on long-term leave and another member of staff who had left. They explained they had been using a lot of agency staff as well as and existing staff who were covering extra shifts A new member of care staff and a kitchen assistant has been recruited which has reduced the amount of agency. Based on the needs of the current occupancy of nineteen residents, it was confirmed two staff per shift is adequate. If however the occupancy increased to their maximum of twenty-four residents they agreed two staff per shift would not be sufficient. Foxgrove Residential Home DS0000024392.V323440.R01.S.doc Version 5.2 Page 21 The inspector’s spent time with care staff on duty including one who was a regular carer from an agency and another who was a new member of staff. They both confirmed that the shift had been very busy, rushed and hard going but described the atmosphere in the home as very calm and both commented that they loved working at Foxgrove and that the manager was extremely supportive. The home has good recruitment procedures. Three staff files looked at showed that all the necessary paperwork and recruitment checks were in place, however it was noted that one member of staff had commenced employment two days prior to their Protection of Vulnerable Adult (POVA) check. The manager explained that this was an oversight and once identified, the employee was sent home on holiday pay until receipt of the POVA first check. Evidence on staff files confirmed that there is a commitment to training. Healthcare Homes have their own training manager who is responsible for ensuring that all staff are trained to do their jobs. The training was described, as “hands on” learning approach, which compliments formal training as part their induction and ongoing training and links in with the Skills for Care Common Induction Standards (CIS). The service encourages all care and ancillary staff to take part in their own learning and development. This was confirmed in discussions with staff. Foxgrove Residential Home DS0000024392.V323440.R01.S.doc Version 5.2 Page 22 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): 31,32,33,35,37,38, Quality in this outcome area is good. Residents can expect to live in a home that is managed by an appropriately qualified and experienced manager however residents cannot currently expect to have their health, safety and welfare protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager joined the previous company Pri-med in 1978. They had a short break-in service and completed a return to practice in healthcare course at Ipswich hospital before returning to Foxgrove as the registered manager. They are a qualified nurse and have a wealth of experience in managing nursing and residential homes. They completed a Diploma in Management run by the Chartered Management Institute. Foxgrove Residential Home DS0000024392.V323440.R01.S.doc Version 5.2 Page 23 Staff and residents spoken with were very complimentary about the manager; who was felt to be approachable and very supportive. Feedback received in one comment card referred to the manager and staff “as friendly”, and commented, “the manager is missed when not there, they are very efficient and professional”. The minutes of a recent staff meeting confirmed that the manager demonstrates a clear sense of leadership and direction. They discussed openly issues about the day-to-day running of the home, including staffing, recruitment of a new kitchen assistant, payroll system, entertainment ideas for residents and the revised system for dealing with soiled laundry. The manager also welcomes the views and opinions from the residents, relatives and external agencies about the services provided via an effective quality assurance monitoring system. The most recent quality assurance report for the 2005 was copied to the Commission for Social Care Inspection (CSCI). The results of the survey provided positive feedback about the service and is used to form the basis of a business plan for the home. The home does not manage the financial affairs of any of the people living in the home, however the managed confirmed that they do hold small amounts of monies for six residents. Records are kept in a register, which showed that transactions were witnessed and had two signatures against them. The balance for one of the residents tracked during the inspection was checked and found to be accurate. A number of the home’s policies and procedures looked at included managing aggression, meeting nutritional needs of residents and provision of residents care equipment and procedures for falls and health and safety. These were detailed and reflected the actions staff should take in each circumstance. Staff had been requested to sign to indicate they had read and understood these procedures, however only eleven staff had signed out of a possible twenty-six. During a tour of the home a number of electrical appliances were checked and had not had a portable appliance test (PAT) carried out to ensure their safety. Plugs to portable appliances in the lounge had not been checked since 2001 and 2002. Evidence of a memo from the office manager was seen in the portable appliance test folder advising the manager that a company will be checking all appliances in all of Healthcare Homes, residential homes starting in November 2006. The Stannah stair lift into the lounge was installed in February 2005. The service agreement referred to four scheduled service visits a year, however according to the maintenance records Stannah had not been to service the lift until June 2006, with a gap of sixteen months, which does not reflect the service agreement or comply with the Lifting Operations and lifting Equipment Regulations (LOLER). Evidence was seen that other moving and handling equipment such as bath hoists and mobile hoist had been serviced and tested in November 2005. Foxgrove Residential Home DS0000024392.V323440.R01.S.doc Version 5.2 Page 24 As already described in the section on the environment to protect the health, safety and welfare of residents the manager must risk assess the uncovered heated towel rail and closely monitor water temperatures for baths and showers to ensure the water does not exceed the safe recommended temperature. The manager wrote to the Commission for Social Care Inspection (CSCI) following the inspection confirming the blender valve on the downstairs bath had been adjusted to the correct temperature. At the inspection in January 2006, a requirement was made for the home’s fire risk assessment to be updated to include the risks to one resident that was allowed to smoke in their own room. The manager confirmed that the resident was no longer residing at the home and therefore this was no longer a risk. However two residents were observed smoking outside on the veranda, the manager explained that the residents were happy smoking outside as were staff in line with the home’s ‘No Smoking’ policy inside the house. The fire logbook reflected that regular fire instructions and fire drills were taking place. All staff had received fire safety training from an external trainer in June 2006. The fire alarm system and emergency lighting had been serviced in February 2006 and the fire fighting equipment had been serviced in October 2006, certificates were seen to substantiate these dates. A fire officer visited and inspected the home in May 2006 and did not raise any concerns. Concerns were raised at the last inspection that one resident’s bedroom situated at the end of a corridor had a Dorgard closing device holding it open. However the closing device was not linked to show up on the fire alarm system, but did close when the fire alarm sounded. A risk assessment had been completed and instruction had been given to the resident to ensure their safety in the event of fire door closing. From inspection of records it was evident that records required by the food standards agency were being kept and monitored including the temperature of food being served and, fridge and freezer temperatures. The fridge in the kitchen was reading high on several occasions up to 8 degrees centigrade, the reading for the day of the inspection was 6 degrees centigrade; this needs to be addressed to ensure the safe storage of food. The home does not have a designated staff room and it was noticed that staff tended to congregate in the kitchen. Notices were posted in the kitchen for staff’s attention confirming this arrangement. This arrangement does not meet the work place regulations to provide a separate room for the use of employees. An alternative meeting area should be identified. The home’s certificate of registration was seen displayed and the home’s certificate for employers liability insurance was displayed and which expires in September 2007. Foxgrove Residential Home DS0000024392.V323440.R01.S.doc Version 5.2 Page 25 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 2 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 2 3 3 2 X 3 2 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 3 3 3 3 X 3 2 Foxgrove Residential Home DS0000024392.V323440.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement The MAR sheets must record the number of tablets administered when a prescription allows a range of doses, and if none are given this must be recorded with an explanation. This is a repeat requirement from 04/01/06 The registered manager must make arrangements for the recording and safe administration of medicines in the care home. The registered manager must ensure that residents who are risk assessed to self administer medication, are regularly reviewed to ensure their on going ability to self-administer medicines. A record of residents’ wishes and feelings must be made in their care plan and take into account their final wishes. To ensure the health, safety and welfare of the residents all parts of the home must be free from obstructions to allow for safe evacuation in the event of a fire. DS0000024392.V323440.R01.S.doc Timescale for action 15/12/06 2. OP9 13(2) 15/12/06 3. OP9 13(2) 15/12/06 4. OP11 12(3) 22/12/06 5. OP19 23(4)(iii) 22/12/06 Foxgrove Residential Home Version 5.2 Page 27 6. 7. OP22 OP25 13 (4) (a) 13 (4) 8. OP38 13 (4) (c) Suitable provision must be made for storage of equipment when not in use. A risk assessment must be undertaken to ensure that residents are not at risk of obtaining burns or scolds from the unguarded heated towel rail in the downstairs bathroom. The fridge temperature in the kitchen needs to be addressed to ensure the safe storage of food. 22/12/06 22/12/06 22/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP1 OP19 OP22 Good Practice Recommendations The service users guide and other information about the home should be available in a format suitable for the people with a visual impairment. The paintwork on skirting boards and doorways needs attention. The carpet on the stairs and the landing should be replaced or repaired to a good standard. Consideration should be given to purchasing more moving and handling equipment, such as slings and slide sheets to minimise risk of cross infection occurring through the communal use of these items. Where policies and procedures are reviewed and updated a system should be in place to ensure that all staff read the information and are aware of the changes. To meet the work place (health, safety and welfare) regulations 1992 the registered provider should provide a separate meeting room for the use of employees. 4 5 OP37 OP38 Foxgrove Residential Home DS0000024392.V323440.R01.S.doc Version 5.2 Page 28 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 Foxgrove Residential Home DS0000024392.V323440.R01.S.doc Version 5.2 Page 29 - 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. 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