Inspection on 04/05/05 for Ixworth Court

This inspection was carried out on 4th May 2005.

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 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

Ixworth Court 27/06/07

Ixworth Court 29/06/06

Ixworth Court 19/12/05

Ixworth Court 10/02/05

Ixworth Court 03/08/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Ixworth Court Thetford Road Ixworth Bury St Edmunds Suffolk, IP31 2HD Lead Inspector Jan Davies Announced 4 May 2005 th 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. Ixworth Court I54 - I04 S37046 Ixworth Court V219268 050624 Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Ixworth Court Address Thetford Road, Ixworth, Bury St Edmunds, Suffolk IP31 2HD 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) 01359 230101 01359 232734 not given Suffolk County Council Mrs Susan Jean Hill Care Home 35 Category(ies) of DE(1) OP(35) registration, with number of places Ixworth Court I54 - I04 S37046 Ixworth Court V219268 050624 Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 10.2.05 Brief Description of the Service: Ixworth Court is a purpose built home that provides well furnished accommodation for 22 frail elderly, mixed gender and culture, residents. It is situated in Ixworth which is a village with good community facilities approximately 10 miles from Bury St Edmunds. It is a single storey building separated into 2 units with surrounding safe gardens. Each unit consists of a comforatble lounge, dining room and kitchen area. All bedrooms are single with en-suite facilities. There are also assisted/communal bathrooms and additional toilet facilities.Ixworth court is owned and operated by Suffolk County Council.There is a day care centre within the building where social events are held and a small shop for the purchasing of every-day items. Ixworth Court I54 - I04 S37046 Ixworth Court V219268 050624 Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was an announced one and took place on a normal week-day in May between the hours of 10.30am and 4pm and was the first inspection of the home within this year’s programme. There were several residents in the home at the time who contributed to the inspection and their views and comments have been incorporated into the writing of this report. What the service does well: There was evidence that an assessment of need was undertaken prior to new residents being admitted to the home. Also there was evidence that risk assessments had been developed to support the independence of residents and that these assessments cross-referenced to information in care plans which were developed from the initial assessment. The home continued to provide a varied and interesting social programme for residents and there was evidence that this was done in consultation with the residents. Contact with families was encouraged and supported and relatives spoken with confirmed that they were made welcome and that staff members were most friendly and helpful. Residents were complimentary of the staff in the home and the support they received from them. There was a positive attitude to staff training. Care staff members were accessing NVQ courses as appropriate to individual study levels and the home had achieved the relevant percentage of staff trained to level 2 NVQ. The Registered Manager held the Diploma in Care Management and the Senior Team Leader had NVQ Level 3 in Care. There were clear and effective systems in place to ensure Health and Safety matters were managed. Staff training was provided in relation to fire safety, and moving and handling with evidence of annual updates. All records asked for were available and were up to date. Ixworth Court I54 - I04 S37046 Ixworth Court V219268 050624 Stage4.doc Version 1.30 Page 6 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. Ixworth Court I54 - I04 S37046 Ixworth Court V219268 050624 Stage4.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 Ixworth Court I54 - I04 S37046 Ixworth Court V219268 050624 Stage4.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 The admission procedure was clear and there was a proper assessment in place for all prospective residents prior to people moving into the home. Care needs were being properly assessed and catered for. EVIDENCE: The admission procedure was appropriate to guide staff on the actions to be taken to ensure that new residents needs were properly assessed and planned for. A number of residents were spoken to and were able to provide significant information about their care needs and the inspector was able to check that this was confirmed in their care plans. This also included asking service users if they had had all the information they needed to make an informed choice about this home. All were very positive about why they had chosen this particular home. Staff members on duty were spoken to and knew, in detail, about the care needs described. The inspector looked at individual records of care and, in three cases all records referring to those residents were looked at. These contained full assessment information. Ixworth Court I54 - I04 S37046 Ixworth Court V219268 050624 Stage4.doc Version 1.30 Page 9 Ixworth Court I54 - I04 S37046 Ixworth Court V219268 050624 Stage4.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) 7,8,9 There were arrangements in place to ensure that the health care needs of residents were identified and met. EVIDENCE: Ixworth Court I54 - I04 S37046 Ixworth Court V219268 050624 Stage4.doc Version 1.30 Page 11 The inspector examined the care plans and care records for several service users. These documents contained requisite personal information about service users, life histories, personal care preferences and records, other preferences such as diet and daily routines, detailed night care arrangements, leisure preferences and full care plans based on a commonly adopted care planning format. The care plans were reviewed by key-workers on a monthly basis and full reviews were conducted annually. Minutes of these review meetings were present in the care records. Each service user’s care records contained a manual handling risk assessment, a nutritional assessment, weight monitoring chart and a continence care assessment. These risk assessments were reviewed on a monthly basis. ds of GP visits were recorded and visits from other healthcare professionals were also kept. The home was successfully using a monitored dosage system for the medication. Receipt, disposal, recording and administration practices were scrutinised and were considered to be acceptable and safe on the day of inspection. No shortfalls were identified or unexplained gaps noted on the medication administration records. Clear risk assessments were in place for service users who were able to self-medicate. Ixworth Court I54 - I04 S37046 Ixworth Court V219268 050624 Stage4.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) 12.15 Social activities were well-managed, creative and provided daily variation and interest for people living in the home. Relatives and friends were made welcome. Menus provided variety and nutrition. EVIDENCE: An activities log was kept at the home. This was completed and kept up to date by staff. Entries included a buffet tea, videos, classic concert tapes, a group crossword, singing hymns, playing bingo, doing jigsaws and playing other games. Service users confirmed that entertainments and activities took place within the home and some stated that they would like more card- playing sessions and access to an appropriate room for this. A number of people living in the home were spoken to and everyone who commented on the food said how appetising it was and that they welcomed the daily choices offered. However on the day of the inspection chicken planned for casseroles had been wrongly defrosted and chicken breast for the chicken salad was unavailable. Chicken salad was presented to residents with portions containing several small bones and this was inappropriate, posed some risk of residents chocking and was not what had been planned on the menu. (An alternative meal should have been offered instead of chicken salad in addition to the cauliflower cheese) Ixworth Court I54 - I04 S37046 Ixworth Court V219268 050624 Stage4.doc Version 1.30 Page 13 Feedback from service users and their relatives received both prior to and during the inspection confirmed that visitors were welcome at the home at all times. The bedrooms of service users observed were nicely personalised. Service users had the opportunity to choose the colour and general décor of their rooms. Full hairdressing facilities were available for service users who wished to have their hair done on site. Some residents commented that the reorganisation of premises and new buildings had meant that some minor disruption had occurred. All in the proximity of the current building work were asked their views and all said that they were directly unaffected by the noise/disruption as they could always sit elsewhere and the noise was ‘short-lived.’ However representation was received about the loss of one room, previously used for activities, especially card-playing, and known as the games room as this had been ‘lost’ due to the re-planning arrangements for the home. The responsible authority is encouraged to consider how this deficit can be met and an alternative ‘games’ room be identified. Ixworth Court I54 - I04 S37046 Ixworth Court V219268 050624 Stage4.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) 16,18 There was an appropriate policy for the protection of vulnerable adults. The complaint’s policy and procedure in the home needed to make the necessary link with the role of the CSCI. EVIDENCE: A copy of the local Suffolk adult protection protocols was present at the home. The accompanying Suffolk County Council whistle blowing policy was detailed and informative, explaining the responsibilities incumbent upon staff to refer genuine concerns about issues of poor practice or abuse to management, as well as the legal protection afforded to them under the Public Interest Disclosure Act 1998 in these cases. Care staff and management had a clear awareness of adult protection matters and potentially abusive situations. The homes complaints log did not have scope to indicate if the complaints were substantiated, it was recommended that the outcome of stage 1 of the complaints procedure, i.e. substantiated, not substantiated, partially substantiated or referred to stage 2, be recorded in the complaints log. Also this should include the date at which this stage of resolution was reached. Some information for service users did not include the role of the CSCI (and when the home must notify CSCI of complaints and that complainants can involve the CSCI.) Ixworth Court I54 - I04 S37046 Ixworth Court V219268 050624 Stage4.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) 19,26 Service users were living in a safe, well-maintained and clean environment. EVIDENCE: The home was well designed in line with National Minimum Standards and was properly maintained. Several well- tended and pleasant secure gardens were available for the use of service users. All bedrooms were single bedrooms and were acceptable in size in line with National Minimum Standards. The information above is stated on the basis of information previously submitted to the CSCI by the home and was not verified through measurement at this inspection. Ixworth Court I54 - I04 S37046 Ixworth Court V219268 050624 Stage4.doc Version 1.30 Page 16 Communal space consisted of at least one lounge and one dining room on each house/unit as well as a choice of other general communal areas. There would be no difficulty finding an attractive spot for service users to entertain guests in private at any given time. A good level of storage space was available at the home to store heavy equipment such as wheelchairs, hoists and cleaning machines. The environment was well designed with several adaptations that were suitable for the care of the service users. All hot water outlets within the home were fitted with thermostatic mixing valves to ensure the water was delivered at close to 43°C. Spot checks of hot water temperatures were not undertaken during this inspection. The home was clean on day of inspection and no unpleasant odours were in evidence. Service users confirmed that the home was always very clean. Records were available in each bedroom indicating that the carpets were shampooed approximately once per week. Appropriate sluice and laundry facilities were in place, complying with all relevant legislation. Clear instructions on how to use facilities were available for staff. Ixworth Court I54 - I04 S37046 Ixworth Court V219268 050624 Stage4.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) 27,30 The procedures for the recruitment of staff were robust and provided the safeguards to offer protection to people living in the home. The deployment and number of staff available at all times of day was sufficient to meet the assessed needs of residents. EVIDENCE: Scrutiny of staffing rosters and discussion with staff and service users indicated that the staffing levels at the home were appropriate. Sufficient care staff were on duty at all times during the day, with a care staff member specifically designated to each unit/house. In the mornings additional care staff were on duty. The inspector looked at a number of personnel files for staff recently recruited to the home. These files contained all of the documentation required by Regulation, including two written references, Criminal Records Bureau (CRB) Disclosure checks and proof of identification. It was clear that, in addition to all staff employed at the home, the hairdresser, chiropodist and volunteers had undertaken a CRB Disclosure check upon the request of the manager. Residents spoken to said that the staff at the home were kind and caring and were never too busy to spend individual time with them to support, encourage and reassure at times when this was needed. Ixworth Court I54 - I04 S37046 Ixworth Court V219268 050624 Stage4.doc Version 1.30 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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) 31,32,33,36,37,38 There is appropriate and strong leadership providing staff with guidance and direction to ensure that residents receive consistent quality care. Health, safety and welfare of people using this service was being promoted. EVIDENCE: The combination of the manager’s experience, qualifications, positive and open attitude in evidence during the inspection process and the high level of care in evidence at the home indicated that the manager was suitably qualified and competent to manage the home. There was a pleasant atmosphere at the home on the day of the inspection. The manager and the staff were open, helpful and positive and service users were complimentary about the care they received. Staff stated that morale was fine amongst the staff group. Service users stated that they would have no difficulty in raising concerns with the manager, who was “very nice”. Ixworth Court I54 - I04 S37046 Ixworth Court V219268 050624 Stage4.doc Version 1.30 Page 19 Evidence recorded from more than one source indicated that there were suitable financial procedures in place and that the home was financially viable including a current, up to date certificate demonstrating appropriate Employers Liability Insurance for the business on display outside the main office. Other forms of insurance, such as buildings and contents were not assessed on this occasion. Several care staff confirmed that they received regular formal supervision sessions to support them in their work. Written records of these meetings were kept and stored securely in individual staff members’ personnel files. Staff recruitment and general care records were stored securely in the manager’s office. The working care plan for each service user was kept in their private bedroom. The missing persons policy was examined and was appropriately directional and informative in the event of a service user going missing. The policy contained a prompt for senior staff to alert the CSCI to such situations under Regulation 37. CSCI records confirmed that notifiable incidents were routinely communicated to the CSCI as necessary. All care staff were suitably trained in safe manual handling techniques. This training was updated in the form of refresher courses every two years. Accidents and incidents were being recorded by staff. Cupboards containing hazardous substances were fitted with safety catches and suitable risk assessments were in place. Appropriate systems were in operation for the safe disposal of clinical waste. Ixworth Court I54 - I04 S37046 Ixworth Court V219268 050624 Stage4.doc Version 1.30 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 2 COMPLAINTS AND PROTECTION 3 x x x x x x 3 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 2 x 3 3 3 3 x x 3 3 3 Ixworth Court I54 - I04 S37046 Ixworth Court V219268 050624 Stage4.doc Version 1.30 Page 21 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 15 Regulation 16 Requirement The registered persons must ensure that all food is presented in a manner that is attractive and appealing in terms of texture and appearance and that it is suited to individual assessed requirements . The registered persons must ensure that the homes information correctly refers to a complaints procedure that specifies how complaints may be made and who will deal with them and that they will be responded to within 28 days.This must also include the role of CSCI. Timescale for action 30/6/05 2. 16 22 30/6/05 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. Refer to Standard 12 Good Practice Recommendations the registered persons should identify an appropriate venue for residents for card playing and other social activities in the absence of the day/quiet room previously used for this. I54 - I04 S37046 Ixworth Court V219268 050624 Stage4.doc Version 1.30 Page 22 Ixworth Court 2. Ixworth Court I54 - I04 S37046 Ixworth Court V219268 050624 Stage4.doc Version 1.30 Page 23 Commission for Social Care Inspection 5th Floor St Vincent 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. Extracts may not be used or reproduced without the express permission of CSCI Ixworth Court I54 - I04 S37046 Ixworth Court V219268 050624 Stage4.doc Version 1.30 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!