Inspection on 16/10/07 for Irene House

This inspection was carried out on 16th October 2007.

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

Irene House 06/03/07

Irene House 18/10/06

Irene House 05/01/06

Irene House 03/08/05

Irene House 23/02/05

Irene House 13/09/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Irene House 1 Parkfield Road Worthing West Sussex BN13 1EN Lead Inspector Mrs S Gawley Unannounced Inspection 16th October 2007 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 Irene House DS0000024160.V344838.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. Irene House DS0000024160.V344838.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Irene House Address 1 Parkfield Road Worthing West Sussex BN13 1EN 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) 01903 529060 01903 529058 srijit.duffadar@guildcare.org www.guildcare.org Guild Care Srijit Duffadar Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Irene House DS0000024160.V344838.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home with nursing - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category - (OP) The maximum number of service users to be accommodated is 40. Date of last inspection 6th March 2007 Brief Description of the Service: Irene House is a care home registered to accommodate forty residents over the age of sixty-five years, some of who may have nursing needs. The home is situated in a residential area of Worthing. It is a detached, two-storey building with a central courtyard area and private parking facilities at the front entrance. Residents are accommodated in single rooms with a wash hand basin. Two bedrooms have en-suite toilet facilities. There is a passenger lift for access from the ground floor to the first floor. There are three lounge areas and two dining rooms. Irene House is owned by Guild Care, an organisation, which has three other care, homes in the area. The current level of fees range from £412 to £560. Items not covered by the fee include hairdresser, chiropodist, aromatherapy, daily papers and toiletries. Irene House DS0000024160.V344838.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit as part of the inspection process took place on the morning and afternoon of 16 10 07. The registered manager facilitated the inspection. The commission was in receipt of an Annual Quality Assurance Assessment (AQAA) and any documents required on the day were made available. We were also in receipt of two surveys from residents and one from a relative. The comments in these surveys were all positive. Four residents were case tracked, their care plans and medicine administration charts were inspected and they were also spoken to. They expressed satisfaction with all aspects of the home saying that staff were very caring and the food was very good. All residents spoken to throughout the day stated great satisfaction in the care they receive, that they are always treated in a respectful manner and that they enjoyed the varied activities. Staff were observed offering care in a respectful and encouraging manner. All of the above was used in the compilation of this report. The atmosphere in the home was very relaxed and sociable. Several of the residents were sitting in the sitting room; many used the well-decorated dining room lunch and some residents were assisted with their meals in their rooms. Residents receive a good level of care from dedicated, caring and enthusiastic staff. What the service does well: The communal areas are well decorated. There is a well-developed activities programme in the home with some activity on four days of the week. Residents enjoy nutritious attractively served meals. There is a trip out in the organisations mini bus on Mondays. Staff appear motivated and enthusiastic. Residents stated that although staff appear very busy they do not have to wait long if they call for help. Irene House DS0000024160.V344838.R01.S.doc Version 5.2 Page 6 These ensure good outcomes for people who use the service. What has improved since the last inspection? 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. Irene House DS0000024160.V344838.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 Irene House DS0000024160.V344838.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): 3. Standard 6 does not apply All Residents have an assessment of need carried out prior to admission. People who use this service experience good outcomes, as there is a clear assessment and admission process. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Evidence of pre admission assessment was seen in the care plans. This ensures that Irene House can meet the needs of that individual. Residents spoken to stated that they had enough information about the home before admission and that they were made welcome on arrival. The assessment covers all areas of need, health, personal and social Irene House DS0000024160.V344838.R01.S.doc Version 5.2 Page 9 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): Residents have a comprehensive plan of care documented. The resident’s health care needs are met. Medication is safely stored and administered in the home. Resident’s privacy and dignity is respected and protected by the staff. People who use this service experience good outcomes because all needs are assessed and met and residents are treated with respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All residents had a plan of care. Four residents were case tracked. The care plans inspected contained comprehensive information on health, personal and social need. The care plans were drawn up following an assessment of their needs. These included nutritional assessments, mobility, hygiene, continence, and pressure areas, lifestyle summary and risk assessments. The care plans were up to date and had evidence of monthly review. Irene House DS0000024160.V344838.R01.S.doc Version 5.2 Page 10 Access to specialist health support is available as required including general practitioner, chiropodists, dentists and outpatient appointments. The residents are fully involved in the development and maintenance of their care plans. New documentation is being put in place to support this process. Medicines are stored, administered, recorded and disposed of appropriately. One resident self-medicated at present and a locked space is provided in the bedroom. Medicine administration charts inspected were up to date. The four residents case tracked and many others were spoken to during the inspection and they confirmed that they are treated with respect at all times and that their privacy and dignity are protected. Throughout the inspection it was observed that residents are spoken to with respect. Staff knocked on doors and greeted residents prior to entering rooms. Irene House DS0000024160.V344838.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12-15 The lifestyle offered in the home meets resident’s needs and preferences. Visitors are welcome and residents enjoy a varied diet. People who use this service experience good outcomes as activities and events provided satisfy their social, cultural and recreational needs. Nutritional food is offered of a high quality This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a well-developed activities programme in the home with some activity on four days a week. This is to be increased to six days a week. Activities coordinators support these activities. Residents are consulted on choices of activities and in meal planning. Activity records are maintained for residents. Residents spoken to confirmed this and staff stated that most of the residents join in the activities. This includes in house activities, outside entertainers and trips out. The activities include scrabble, arts and crafts, music and movement and aromatherapy. There is a trip out every Monday to local villages and beauty Irene House DS0000024160.V344838.R01.S.doc Version 5.2 Page 12 spots. The organisation has an employee who will take residents shopping on an individual basis. The home had a summer fair and seasonal events are planned such as a Halloween quiz and a pumpkin-carving day. Evidence of these activities was seen in the activities diary. There are also monthly communion and regular residents meetings. The minutes of these meetings were seen. Residents spoken to stated that they had choice in times to go to bed and to get up. There is a four-week menu in place, which appears nutritious and offers variety and choice. There was a choice of three hot meals on offer on the day of the site visit. Residents spoken to expressed satisfaction with the meals. Residents requiring assistance was offered this in a respectful manner. Irene House DS0000024160.V344838.R01.S.doc Version 5.2 Page 13 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 Complaints are appropriately managed. Residents are fully protected from abuse People who use this service experience good outcomes because there is a complaints procedure, and trained staff protect residents from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The ethos of the home is that it welcomes complaints and suggestions about the service, uses these positively and learns from them. There is a clear and accessible complaints procedure in place which residents were aware of, although all stated that they did not have reason to complain. The manager stated that at the residents meetings he encourages the relatives to be partners in the care of residents and to bring any issues to the attention of staff so they could be dealt with and not allowed to escalate. On discussion with staff it was evident that there is an open and encouraging culture in the home, which gives staff and residents the confidence to raise any concerns. Any comments or concerns are used in quality assurance. Irene House DS0000024160.V344838.R01.S.doc Version 5.2 Page 14 There are policies and procedures in place regarding safeguarding adults and whistle blowing. Staff spoken to were very clear about their responsibilities towards the people living in the home. Staff receive safeguarding adults training in their induction and they have updates. An update is to be given once the manager has attended a workshop on revised safeguarding adults policies and procedures. Irene House DS0000024160.V344838.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20,21,24 26 Residents live in a safe and well-maintained environment and have the specialist equipment required to maximise independence. There is some shortfall in infection control procedures. Residents have comfortable personalised bedrooms. The home is clean and hygienic. People who use this service experience good outcomes because the home is safe, clean and well maintained. This judgement has been made using available evidence including a visit to this service EVIDENCE: The home provides a physical environment that is appropriate to the specific needs of the people who live there. The well-maintained environment Irene House DS0000024160.V344838.R01.S.doc Version 5.2 Page 16 provides specialist aids and equipment to meet the needs of the people who use the service. There was however a mop standing in dirty water near the kitchen area and there was also a bowl of prawns unlabeled and undated in the fridge These issues were discussed with the catering manager and the manager as they pose a risk of infection. The home is a very pleasant, safe place to live and bedrooms are personalised. The communal areas are decorated to a high standard and have comfortable good quality furnishings. The Commission had been notified however that the lift had been out of order and there was a delay in having it repaired due to difficulty in getting parts. The repair engineer was present on the day of the site visit and the Registered Manager confirmed by email the following that repairs were complete. There is also a budget in place to replace the lift so as to prevent such breakdowns in future. There is an ongoing maintenance programme with rooms being decorated as they become vacant. Scuffed paint was seen in two bedrooms and this was discussed with the registered manager. There are sufficient toilets close to communal areas and there are sufficient assisted bathing facilities Residents spoken to and surveys confirmed that the home is always fresh and clean. Irene House DS0000024160.V344838.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27-29 Residents are protected by the homes recruitment policies and procedures and by an induction and training programme. People who use this service experience good outcomes because a suitably recruited and trained staff meets their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff rota showed sufficient staff on duty at all time and residents spoken to stated that staff always attend when they are called. They also confirmed that they feel their needs are met by competent staff and in a respectful manner. Two of the three surveys received responded that staff always attend, the third responded usually. The home does have to use agency staff to ensure the rota are covered. Staff spoken to were very enthusiastic about their work and were knowledgeable on the needs of the residents. A key worker system is in place which staff confirmed works well. Staff meetings are in place to discuss issues and promote safe practices to ensure good outcomes for the residents. Irene House DS0000024160.V344838.R01.S.doc Version 5.2 Page 18 Personnel files inspected showed that the home follows a recruitment policy and all documents required were in place. Staff do not commence work without having Criminal Records Bureau Clearance and a POVA check. The service ensures that all staff receive relevant training that is focussed on delivering improved outcomes for people using the service. The service puts a high level of importance on training and staff report that they are supported through training to meet the individual needs of people using the service. Induction and training records show that staff are trained to do their jobs. This improves outcomes for residents. A relative commented on a survey that “ The staff are very caring towards my mother and she is happy with the care she receives. The staff are very dedicated”. 51 of the carers have undertaken or are undertaking National Vocational Qualification 2. Evidence of supervision was seen in the staff files. Staff receive mandatory training as well as training on issues relating to the need of the residents such as medication, wound care, dementia, communication and team work. Irene House DS0000024160.V344838.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Residents and staff benefit from experienced management. The home is run in their best interests. Quality assurance procedures are in place and are being further developed. People who use this service experience good outcomes as the home is well managed and is run in their best interests. This judgement has been made using available evidence including a visit to this service EVIDENCE: The Registered Manager has been in post since May of this year and has the qualifications necessary to be registered with the Commission and to maintain registration with the Nursing and Midwifery Council. He is able to describe a Irene House DS0000024160.V344838.R01.S.doc Version 5.2 Page 20 clear vision of the home based on the organisations values and communicates a clear sense of direction He is able to evidence a sound understanding and application of ‘best practice’ which is evident in the staff. The registered manager has put in place teams; Registered Nurses, nursing and care assistants, housekeeping, catering and activities teams so the home is able to consider all aspects of the daily life of our residents- from their clinical needs to their immediate environment i.e. their rooms and the public areas in the home. This ensures the home is run in the best interests of the residents. Effective quality assurance monitoring systems have been developed to elicit opinion from residents, relatives and staff. These include surveys, relatives, residents and staff meetings. Computer systems aid the collation of information and the implementation of intervention if needed. This ensures the home is run n the best interests of the residents. The homes systems for handling residents’ money have been agreed with the Commission and protect residents’ interests. The health safety and welfare of residents and staff are protected by the homes induction and training programme and the provision of health and safety policies and procedures. There was however a shortfall in infection control procedures. All accidents, injuries and incidents are recorded, collated and responded to. Irene House DS0000024160.V344838.R01.S.doc Version 5.2 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 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 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 3 3 3 X X 3 X 2 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 4 X 3 X 3 X X 2 Irene House DS0000024160.V344838.R01.S.doc Version 5.2 Page 22 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 OP19 Regulation 13 (3) Requirement The registered person to make suitable arrangements for the prevention of spread of infection in the home. Timescale for action 01/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Irene House DS0000024160.V344838.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Irene House DS0000024160.V344838.R01.S.doc Version 5.2 Page 24 - 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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