CARE HOMES FOR OLDER PEOPLE
Innisfree Residential Home 15-17 Polsham Park Paignton Devon TQ3 2AD Lead Inspector
Andrea Peryer Unannounced Inspection 1st March 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Innisfree Residential Home DS0000064536.V288036.R01.S.doc Version 5.1 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. Innisfree Residential Home DS0000064536.V288036.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Innisfree Residential Home Address 15-17 Polsham Park Paignton Devon TQ3 2AD 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) 01803 665436 Mrs Jacqueline Glenning Mrs Linda Mary Wilbraham Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Innisfree Residential Home DS0000064536.V288036.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 25th May 2005 Brief Description of the Service: Innisfree is a large detached property situated on the level and within walking distance of local facilities including library, park and shops. Accommodation is provided in single rooms, all with en-suite facilities. The home offers a choice of communal areas; the ground floor has a day room, conservatory and a dining room; and on the first floor there is small quiet lounge. To facilitate access within the home, there is lift to the first floor and a stairlift for a short internal flight of steps between levels Innisfree Residential Home DS0000064536.V288036.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This is the first inspection since the current owner took over the running of the home on …… . The manager and the staff team hade remained working with the new owner so that the staffing arrangements have remained on the whole unchanged. The inspection was carried out with the deputy manager, residents and staff were part of the discussion about the home and four residents care was looked at in detail. A range of documentation was also considered throughout the inspection including care plans, care assessments and staff files. Residents were spoken too in their private rooms or in the homes dining and lounge areas. What the service does well: What has improved since the last inspection?
The service has extended staff application forms and now has a system in place to ensure all staff in the home do not start work until all reference checks, including police checks are completed. This ensures that potential staff who are not suitable to work with vulnerable people are not employed in the home. The home has continued to improve upon the décor and furnishings in the home with residents being part of choosing new furniture in the homes lounge. The home has a new laundry area, which has improved the laundry facilities in
Innisfree Residential Home DS0000064536.V288036.R01.S.doc Version 5.1 Page 6 the home and reduced the potential hazards of moving laundry to and from the basement area. In November 2005 the home was successfully in obtaining the investors in people award, this is an award that demonstrates the homes commitment to providing quality services. What they could do better:
Assessment documents varied in how well they were completed for example one file was well completed with a range of forms in while another file had forms in that had not been fully completed. Initial and ongoing assessment documents should be consistently completed for all residents as this information helps to give staff the information they need to meet residents needs. Similarly, the detailed knowledge of resident’s preferences and interests is not always reflected in the assessment documents. For example some residents participate in the planned or informal activities in the home and what they have enjoyed is not recorded. The assessment documents have been used in the home for a long time and a new format might make it easier to capture the information that members of staff need to provide consistent care to residents. Risk assessments for the premises were not available and so staff could not confirm if water valves had been fitted to sink units to ensure water temperatures did not reach such a point that the water was hot enough to burn or scald residents. It was also noted that throughout the home were door wedges that while not in use on the day of the inspection would indicate that staff wedge open doors. Wedging doors open is a potential fire hazard and if these doors are to be opened they should be fitted with fire safety approved devises. In discussion with staff it became clear that these areas of health and safety may well have already been noted and were being addressed by the manager and owner. The owner and manage must ensure that staff are aware of risk assessments for the premises including fire safety and water temperatures and should ensure that all areas of the home are maintained to ensure the safety of staff and residents. The owner must provide regulation 26 reports that are submitted to the Commission, this helps to inform the Commission of some of the day to day events in the home and demonstrates how the homes owner monitors practices and procedures in the home. Innisfree Residential Home DS0000064536.V288036.R01.S.doc Version 5.1 Page 7 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. Innisfree Residential Home DS0000064536.V288036.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Innisfree Residential Home DS0000064536.V288036.R01.S.doc Version 5.1 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Residents do not move into the home without having his or her needs being assessed and being assured that these will be met. The home does not provide intermediate care. EVIDENCE: Two residents files were examined and discussed with the member of staff in charge for that day. This included discussion about how the home obtains information prior to residents coming into the home and how the home assess and inform potential residents. The files examined show a range of assessment documentation including correspondence with resident’s relatives asking for a social history of residents past and present likes, dislikes, hobbies and interests. Assessment information also included an initial enquiry form, which staff confirmed was completed over the telephone with discussion with the potential resident, the resident’s representative such as a care manager or a relative. Assessment documents detail potential risks including risks from falls and manual handling. The documents examined varied in how well they were completed for example one file was well completed with a range of forms in while another file had forms in that had not been fully completed. This was discussed with the staff on duty who said that this was due to a delay in having the opportunity to talk with the resident and the family of the resident.
Innisfree Residential Home DS0000064536.V288036.R01.S.doc Version 5.1 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): 10 Residents feel they are treated with respect and their right to privacy is upheld EVIDENCE: Residents said that staff respected their individual choices and wishes. One resident gave the example of how staff had respected her wishes in relation to the seasoning in foods (the resident had strong feelings about how food should be prepared and served) and another resident explained how the homes staff had respected her wish to attend communion. Residents said that staff usually knocked the door before entering rooms and that they felt able to raise issues with staff and know that staff would not discuss them. Staff said that training and induction included information on privacy, respecting confidentiality and respecting individuals choices and wishes. The homes service users guide includes a statement confirming that residents will be treated with respect and dignity. Innisfree Residential Home DS0000064536.V288036.R01.S.doc Version 5.1 Page 11 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, Residents maintain contact with family and friends in the home and local community and the lifestyle in the home satisfies their social, cultural and recreational needs. EVIDENCE: Resident’s files and ongoing records in the home show that resident’s preferences and choices are part of the homes initial assessment, which is then carried over into the residents care plans and ongoing assessments. The assessment forms are forms that have been in use in the home for some time and while they are adequate do not really demonstrate the level of information that the staff have about resident’s needs and preferences and how they spend their time in the home or community. When speaking to staff it is clear that the staff had a detailed knowledge of resident’s preferences and interests, which is not always reflected in the assessment documents. For example some residents participate in the planned or informal activities in the home and what they have enjoyed is not recorded. The home has a social activity organiser who visits the home twice a week and residents said that they enjoyed the activities that this person offers. Other residents described participation in communion in the home and one resident had until recently been going out of the home to church. Residents consistently said that family and friends were welcomed in the home. Innisfree Residential Home DS0000064536.V288036.R01.S.doc Version 5.1 Page 12 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): x Not fully inspected on this occasion EVIDENCE: The inspector did not fully explore these standards with residents or staff. However the staff and residents spoken did say that they felt able to bring any concerns to the homes manager or the owner and that any concerns were addressed. Innisfree Residential Home DS0000064536.V288036.R01.S.doc Version 5.1 Page 13 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): 20 Residents have access to safe and comfortable indoor and outdoor communal facilities. EVIDENCE: Since the last inspection the providers have purchased new lounge furniture, which have improved the overall appearance of the homes lounge and have removed curtains, which has let more light into the homes lounge/conservatory area. Staff said that the residents had helped to choose the new furniture and had enjoyed in being actively involved in plans for the home. The providers have also moved the laundry area from the basement to an adapted building and this has meant members of staff had more room to complete laundry tasks and are not bringing laundry into a main corridor area. This is much safer for staff and residents as there is less risk of cross infection and makes the laundry area a more pleasant area for staff to work in. On touring the premises the home appeared, clean and homely and personalised with residents personal affects. Please also see standard 38 re Health and Safety and the premises.
Innisfree Residential Home DS0000064536.V288036.R01.S.doc Version 5.1 Page 14 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): 27,2829,30 Resident’s needs are met by the numbers of staff on duty and the skill mix of the staff and residents are supported and protected by the homes recruitment policies and practices. EVIDENCE: The new owner of Innisfree has past experience of running and managing care homes and has management qualifications in care including the NVQ4 Advanced care Management Award The manager has continued with her formal education successfully completing qualifications in care up to and above NVQ level 5 and additional training also includes the Registered Managers Award and NVQ Assessors award. This ensures that the manager and senior staff in the home has the knowledge and skills to inform staff and promote the health and safety of residents. Staff said that they had continued to be trained in key areas such as first aid, manual handling and attending any courses that are relevant to the care of older people such as healthy eating and infection control. Certificates showing the training staff had completed were included in staff files or displayed in the home. Three staff files were examined and they included details of the training, supervision and induction of staff. Further plans for training was also displayed on the homes notice boards. The home has a core team of staff who have been employed at the home for some time (some years). When talking to staff it is clear that they continue to
Innisfree Residential Home DS0000064536.V288036.R01.S.doc Version 5.1 Page 15 have a detailed knowledge of the residents care needs and of residents likes and dislikes. Staff also said that the changes in ownership had not affected the normal running of the home and that they felt supported by the new owner and the manager. Staff files examined also included application forms and police checks and references. Since the last inspection the homes staff application form has been up – dated and now makes clear the convictions are not ‘spent’ under the Rehabilitation of offenders Act for those working in care. The application forms have been extended to include questions about any past history of not being suitable to work with older people under the protection of vulnerable adults guidance. In addition the manager has introduced the development of set written interview questions with expected answers. The manager also implemented changes to ensure that no member of staff is employed in the home until a current criminal records and protection of vulnerable adults checks has been received. In November 2005 the home was successfully in obtaining the investors in people award, this is an award that demonstrates the homes commitment to providing quality services. The owner must provide regulation 26 reports that are submitted to the Commission, this helps to inform the Commission of some of the day to day events in the home and demonstrates how the homes owner monitors practices and procedures in the home. Innisfree Residential Home DS0000064536.V288036.R01.S.doc Version 5.1 Page 16 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38 On the whole the health, safety and welfare of service users are promoted and protected. There are some areas of improvement in health and safety that need to be addressed. EVIDENCE: There is a range of evidence in that home that demonstrates that the welfare and health and safety of residents is taken seriously by the staff and the management team in the home for example good care planning, a range of policies and procedures, residents and staff said that they felt safe and cared for and a well maintained premises. However there were areas that need attention, as the staff on duty could not answer basic questions on some areas of health and safety in the home. The person in charge was not aware of the homes risk assessments for the premises and so could not confirm if water valves had been fitted to sink units to ensure water temperatures did not reach such a point that the water was hot enough to burn or scald residents. This was raised with the member of
Innisfree Residential Home DS0000064536.V288036.R01.S.doc Version 5.1 Page 17 staff as the inspector had noticed that the water at one sink seemed to be very hot. It was also noted that throughout the home were door wedges that while not in use on the day of the inspection would indicate that staff wedge open doors. Wedging doors open is a potential fire hazard and if these doors are to be opened they should be fitted with fire safety approved devises. In discussion with staff it became clear that these areas of health and safety may well have already been noted and were being addressed by the manager and owner. However this was difficult to verify as risk assessments for the premises were not available. The member of staff reassured the inspector that the manager would have this information available on her return from her day off. Innisfree Residential Home DS0000064536.V288036.R01.S.doc Version 5.1 Page 18 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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x x 2 x x x x x x STAFFING Standard No Score 27 x 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 x x x x 2 Innisfree Residential Home DS0000064536.V288036.R01.S.doc Version 5.1 Page 19 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. 1 Standard OP38 Regulation 12,13 Requirement Timescale for action 26/05/06 2 OP38 12,13 Ensure that water temperatures do not become so hot that they burn or scald residents and that this is recorded in the homes risk assessment. Ensure that doors are not 26/05/06 wedged open – fit approved devises to those doors that need to be opened as per the homes fire risk assessment. 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 OP3 OP7 OP38 OP38 Good Practice Recommendations Consistently complete initial and ongoing assessment information Explore alternative assessment formats Spend time in ensuring that staff are aware of the homes risk assessments and potential health and safety risks. The provider should submit monthly regulation 26 reports for the Commissions information Innisfree Residential Home DS0000064536.V288036.R01.S.doc Version 5.1 Page 20 Innisfree Residential Home DS0000064536.V288036.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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