Inspection on 12/05/05 for Friars Hall Nursing Home

This inspection was carried out on 12th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Friars Hall Nursing Home 11/07/07

Friars Hall Nursing Home 19/07/06

Friars Hall Nursing Home 27/02/06

Friars Hall Nursing Home 07/01/05

Friars Hall Nursing Home 02/06/04

Friars Hall Nursing Home 16/02/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Friars Hall Nursing Home Friars Road Hadleigh Suffolk IP7 6AF Lead Inspector Claire Hutton Unannounced 12 May 2005 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 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. Friars Hall Nursing Home I54-I04 S24393 Friars Hall V228859 050512 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Friars Hall Nursing Home Address Friars Road Hadleigh Ipswich Suffolk IP7 6AF 01473 822159 01473 822682 None Mrs Lalitha Samual Telephone number Fax number Email 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 Laura Hampson Care Home CRH 42 Category(ies) of OP Old Age (42) registration, with number of places Friars Hall Nursing Home I54-I04 S24393 Friars Hall V228859 050512 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 7th January 2005 Brief Description of the Service: Friar’s Hall is a privately owned care home providing both nursing and personal care to a maximum of 42 older people. The home is located on the outskirts of the small market town of Hadleigh, where amenities such as shops, pubs, church and post office are available. Buses run from the town centre to Ipswich, Colchester and Sudbury towns. The home stands in it’s own grounds at the end of a long gravel drive. It had a car parking area, a garden with some seating for service users and a staff residence where nurses from overseas could be accommodated while they completed adaptation courses to allow them to practice in the United Kingdom. The building is a converted and extended Victorian house, with a shaft lift giving access to both floors. There were 30 single bedrooms, 26 with en suite toilet facilities, and 6 double bedrooms (1 with en suite toilet). The manager is a trained nurse and she has trained nursing personnel on the staff. Care staff are employed to carry out additional caring tasks. The Registered Proprietor has interests in other residential services elsewhere. Friars Hall Nursing Home I54-I04 S24393 Friars Hall V228859 050512 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection carried out over 7 hours on a mid week day in May. Five residents were spoken with in private. Six members of staff were spoken with including the designated nurse in charge. The registered manager was not part of the inspection as she was on annual leave at the time, but feedback was given via the telephone afterwards. The owner of the home was present for the feedback on the day. Two relatives were also spoken with. One social worker was also spoken with after the inspection date. A tour was made of the communal accommodation and private bedrooms were seen with the resident’s permission. Records inspected included the pre admission assessment on residents; five care plans and associated daily statements, the general communication book, and accident records, records of complaints and staff roters. What the service does well: What has improved since the last inspection? What they could do better: One key area that must be addressed and a way forward was agreed, was the concern that some residents at the home had significant signs of mental frailty Friars Hall Nursing Home I54-I04 S24393 Friars Hall V228859 050512 Stage 4.doc Version 1.30 Page 6 that had taken the home outside its registered category. The home is not registered to care for older people with dementia, however four care plans examined stated that those individuals had dementia. Other people at the home suggested more people may be in that category. The matters was discussed with the owner and it was agreed that the home must identify residents who have shown a significant deterioration in their mental capacity since coming to the home and these people must be formally assessed by a person qualified to do so. Once this is established only then can a decision be made as to the best solution to ensure the home does not continue to operate outside of its registration. Other areas for development included activities on offer to residents, a further development in a fall reduction strategy of the residents and ensuring that the home complies with the freedom of information act – especially in relation to records such as the homes communication book. One area raised by residents and staff was the answering of call bells. It was felt that on occasions residents had to wait too long for a response to the bell and that care staff were a little impatient on these rare occasions. The owner agreed to review this matter with the staff group. 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. Friars Hall Nursing Home I54-I04 S24393 Friars Hall V228859 050512 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Friars Hall Nursing Home I54-I04 S24393 Friars Hall V228859 050512 Stage 4.doc Version 1.30 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 standard(s) 3, 4 and 6 does not apply People who come to use this service cannot be assured that their individual assessed needs will be known by all staff at the home therefore, they cannot be sure their individual requirements can be met. EVIDENCE: Two of the newest residents to move to Friars Hall were spoken with and information about their assessed needs before moving into the home was examined. Information about individual needs was not sufficient in detail to then draw up a plan of care. Each area of care had one word answers. Basic information such as next of kin and GP was available. In one case most useful information came from the discharge information produced by the hospital. From discussions with the owner and a social worker this lack of information may have been due to the registered manager being on annual leave, but that visits to the residents were done prior to them moving into the home. Friars Hall Nursing Home I54-I04 S24393 Friars Hall V228859 050512 Stage 4.doc Version 1.30 Page 9 In speaking with one resident it was evident that not sufficient information was available on the nutritional requirements, likes and dislikes of food and any proven allergies. This had led to some confusion in catering for this individual. The head cook had tried very hard to accommodate these individual needs. In the general communication book had more detailed information on the care needs of one individual. This had not been transferred to the individual records such as the assessment or developing care plan. This record was not acceptable in terms of the freedom of information act as access to other peoples personal information was within the same document. There was also evidence that those residents requiring nursing care had been determined by an NHS registered nurse. Two of these documents stated that individual residents had dementia. The home is not registered to accommodate people with dementia. A Service Users Guide was requested, but one could not be found, it is expected that information is readily available. Friars Hall Nursing Home I54-I04 S24393 Friars Hall V228859 050512 Stage 4.doc Version 1.30 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 standard(s) 7, 8,and 10 People who use this service have a plan of care in place but cannot be assured of consistent individualised care from care staff. They can expect their privacy to be upheld and know any incidence of pressure care will be documented. EVIDENCE: Five care plans were examined along with daily statements and the general communication book. The quality of the care plans varied in terms of exact care instructions for staff based upon the individual assessment. One care plan had very specific instructions around manually handling needs, whereas another plan did not give any instruction and the assessment had stated there were care needs. Another care plan had very specific instruction on maintaining food and fluid intake and documentation was good. Another care plan had no information on likes/dislikes and dietary needs. Some care plans had good evidence of regular review, but the decline of residents mental abilities was not being monitored and reviewed. Overall care plans lacked consistency. Friars Hall Nursing Home I54-I04 S24393 Friars Hall V228859 050512 Stage 4.doc Version 1.30 Page 11 Care plans did have good information in relation to social history supplied by the families. Staff had access to a document entitled ‘preventing falls’. However in two care plans examined there was a very high incidence of falls recorded. Since January 2005 one resident had 13 falls another 23. There was no falls prevention strategy in either of these care plans. This was an area of concern highlighted at the previous inspection at the home. Three residents spoken with were not fully aware of their care plans, but all felt appropriately cared for. One relative was not so concerned with ‘paperwork’ but felt the home knew how to care for her relative. Documentation relating to all dressings and pressure ulcers was inspected. Documentation was good but did not always conclude when a course of treatment had ended. The nurse in charge confirmed that no one at the home had a pressure ulcers and documentation confirmed this. Dressings on residents were seen to be intact and a resident confirmed they were regularly changed and comfortable. Privacy and dignity was discussed with three residents and all confirmed that staff do their best to ensure privacy is maintained. Individual laundry was said to be returned and rarely went missing. Residents could have either their own phone or could use the home phone in private. Two people spoken to said they would prefer to have curtains hung from the ceiling in shared rooms and not a curtain on a frame, which was difficult to move and use independently. Friars Hall Nursing Home I54-I04 S24393 Friars Hall V228859 050512 Stage 4.doc Version 1.30 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 standard(s) 12, 13 and 15 People who use this service can expect to receive a good quality meal that they will like, have visitors when they wish, but have limited social opportunities presented. EVIDENCE: Three residents spoken with felt there could be more social opportunities and activities available to them. Care plans inspected did not have information on individuals preferred social pass times. One member of staff said there was an exercise class every other Wednesday and one other staff member thought more could be dome around activities, but as care staff they had infrequent chances to do more. One relative spoken to said the only improvement she could see for the home would be more stimulation for the residents. On the afternoon of the inspection there was a religious gathering of prayers and singing that was well attended. The home had two friendly cats that the residents appeared to like. Visitors/relatives were seen to be made welcome on the day of inspection. Two relatives spoken to said they could visit any time and were made to feel welcome. Two residents said their families were in touch with them and were able to maintain good contacts. Friars Hall Nursing Home I54-I04 S24393 Friars Hall V228859 050512 Stage 4.doc Version 1.30 Page 13 A chalk board had the days menu displayed for everyone to see. It read ‘Lasagne or Salmon and Broccoli Bake, Apple Pie and Custard’. Four of the five residents spoken with really enjoyed the food at Friars Hall. They all said the variety, portion size and quality of food was very good. The cook was very approachable and explained how she had a four weekly changing menu and she would ask the resident what they fancied. She had no restriction placed upon her budget and was able to buy good quality food that the residents liked. The cook explained how she pureed food in separate portions for three people and presented it nicely on a plate. For 10 other people she minced only the meat so they could eat it. Friars Hall Nursing Home I54-I04 S24393 Friars Hall V228859 050512 Stage 4.doc Version 1.30 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 standard(s) 16 People who use this service can expect their complaints to be listened to and acted upon. EVIDENCE: The procedure on how and to whom an individual can complain was displayed on the wall in the main corridor. The log of complaints was examined and no complaint had been made since the last inspection. There was evidence that previous complaints had been recorded and resolved. Residents spoken with were confident that they could speak to the registered manager and that she would deal with their problems and concerns. Friars Hall Nursing Home I54-I04 S24393 Friars Hall V228859 050512 Stage 4.doc Version 1.30 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 standard(s) 19, 20, 23, 24, 25 and 26 Friars Hall is generally well maintained and residents can expect to live in a comfortable surroundings that meets their needs. Hygiene practices cannot be assured and therefore residents and staff may be at potential risk of cross infection. EVIDENCE: Friars Hall appeared reasonable well maintained internally. The grounds are quite extensive with good parking facilities. Some areas of the grounds need maintaining, especially those close to the front of the home as weeds were appearing. The communal areas of the dining room, lounge and conservatory were quite pleasant and allowed people to mill around and socialise. The conservatory was said to get rather hot in the summer. The dining room was set for 27 people, but the home had 36 residents accommodated. When asked how the home would accommodate all 36 for dining a staff member said they would put Friars Hall Nursing Home I54-I04 S24393 Friars Hall V228859 050512 Stage 4.doc Version 1.30 Page 16 tables in the lounge area. In practice, some residents had their meals in their rooms and others on tables in their armchairs. The home was clean through out, only one room was identified with an odour of urine, and that was room 49. The laundry room was well equipped, with a good flooring. Each resident had a small box with his or her own clean laundry ready for return. One member of staff brought in soiled laundry and place it in front of the sluice washing machine. The staff were not wearing any protective equipment such as a pair of gloves and apron and the soiled laundry was not in a sealed bag/container. This is a serious concern relating to spread/cross of infection. The shaft lift is modern and well maintained. Bedrooms contained all the appropriate furniture. Those rooms in the new extension had lovely views from the window. More than one resident said they were happy with their individual accommodation and that it met their needs, save for the privacy curtains already mentioned. Equipment such as wheelchairs were appropriately stored. Specialist equipment such as hoists and assisted bath and hand rails were in place around the home. Friars Hall Nursing Home I54-I04 S24393 Friars Hall V228859 050512 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 30 People who use this service will find that there are sufficient staff on duty, but at extremely busy times there may be a delay in response to the call bell. EVIDENCE: Six staff were spoken with in private. Five were pleasant, approachable and cooperative. Each of them spoke about the training they had. Four had NVQ 2 in care and some were studying for NVQ 3 in care. More than one stated they had training in manual handling, fire training and infection control. Four weeks worth of roters were examined. Staffing levels were maintained at eight staff on a morning shift, six staff on an afternoon shift and four on at night. This numbers included the nurse on duty. The home also employed sufficient cleaning and catering staff. The hours of an overseas nurse were looked at and these showed that although she chose to work long shifts of 13 hours she also look days off. The nurse explained that she chose to cover the vacancies created by other planned absences. Residents spoken with felt that in general there was sufficient staff to meet their needs. However more than one resident and staff member was aware that at busy periods of time residents who rang the call bell may have to wait a time before this was answered. After lunch, there was a flurry of call bell activity. It was explained that two care staff are delegated to each of three areas and one person floats through the three areas helping wherever they are Friars Hall Nursing Home I54-I04 S24393 Friars Hall V228859 050512 Stage 4.doc Version 1.30 Page 18 needed. Also, that the call bell had two settings – one for a normal call for assistance and one for an emergency. This matter was discussed with the owner and she agreed to review the situation to discover if any further improvements could be made. Relatives spoken with felt there were enough staff on duty. Friars Hall Nursing Home I54-I04 S24393 Friars Hall V228859 050512 Stage 4.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,36 and 38 People who use this service can expect to find an approachable manager and owner who are keen to resolve any concerns. EVIDENCE: As stated in the summary the registered manager was not available during this inspection as they were on annual leave, but feedback was given over the telephone. Staff spoken with stated they found the manager approachable and had monthly supervision that lasted about 15 minutes. In addition they had a monthly staff meeting. Residents spoken with stated that they liked the manager and had confidence in their ability. Two relatives said the manager was nice. Friars Hall Nursing Home I54-I04 S24393 Friars Hall V228859 050512 Stage 4.doc Version 1.30 Page 20 In relation to health and safety matters within the home, staff spoken with said they had appropriate health and safety training. Hot water temperatures were tested and were within agreed limits, accidents were well recorded and reported appropriately. Two areas of health and safety for action that were identified was the infection control measures already mentioned and the high number of fire doors propped open throughout the home. This matter was discussed with the owner and they agreed to take advice from the local fire service on this matter. Friars Hall Nursing Home I54-I04 S24393 Friars Hall V228859 050512 Stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 1 1 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 x x 3 3 3 2 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x 3 x x x 3 x 2 Friars Hall Nursing Home I54-I04 S24393 Friars Hall V228859 050512 Stage 4.doc Version 1.30 Page 22 No Are there any outstanding requirements from the last inspection? 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 3 Regulation 14 Requirement Accommodation must not be provided to residents unless their needs have been assessed. The assessment must be in sufficient detail to enable staff to meet the residents needs. Residents who have shown a significant deterioration in their mental capacity since coming to the home must be identified and these residents must be formally assessed by a person qualified to do so. Residents care plans must be in sufficient detail to provide clear guidance to staff on the actions to be taken to meet their welfar and care needs. Particulary in relation to risk assesmsnts and fall prevention. (This aspect is a repeat requirement from 07/01/05). The interests of the residents liesure and recreational activites must be ascertained, recorded and then provided for. The home must remain clean and hygienic, therofre Room 49 must have the odour of urine eliminated by either cleaning or Timescale for action immediate 2. 4 14 start actioning immediatly 3. 7 15 immediate 4. 12 12 (3) 16 (2) 9M) 23 1st July 2005 immediate 5. 26 and 38 Friars Hall Nursing Home I54-I04 S24393 Friars Hall V228859 050512 Stage 4.doc Version 1.30 Page 23 replacement of the carpet. Staff must follow universal precautions when handling soiled laundry, such as plastic apron, gloves and transporting solied linnen in a closed bag/container. 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. 4. Refer to Standard 8 10 27 38 Good Practice Recommendations All documentation relating to nursing care intervention should have a written conclusion. In order to preserve the privacy and the independance of the residents, full length curtians on a track should be suspended from the ceiling. The response to call bells at busy periods should be monitored and the process of deployment of staff reviewed to ascertain if any improvements can be made. Advice should be sought from Suffolk Fire Service on the propping open of fire doors. Friars Hall Nursing Home I54-I04 S24393 Friars Hall V228859 050512 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection St Vincents House Cutler Street Ipswich IP1 1UQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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