CARE HOMES FOR OLDER PEOPLE
Phoenix House 54 Andrews Lane Formby Liverpool Merseyside L37 2EW Lead Inspector
Mrs Trish Thomas Unannounced Inspection 3rd February 2006 13:30 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 Phoenix House DS0000064015.V283631.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. Phoenix House DS0000064015.V283631.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Phoenix House Address 54 Andrews Lane Formby Liverpool Merseyside L37 2EW 01704 831866 01704 831866 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) Total Care Homes Ltd Mr Ralph Edisbury Care Home 18 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (16), of places Sensory impairment (1) Phoenix House DS0000064015.V283631.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Service users to include 18 OP The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection 27/09/05 Date of last inspection Brief Description of the Service: Phoenix House is a care home for 18 older people situated in a quiet residential street in Formby, close to a bus route and train station. The home is a converted Victorian villa with a car park at the front of the building and secluded gardens at the back. There is a large communal lounge, a separate dining room, and bedrooms are situated on ground and upper floors. The home has an assisted bath, but does not have a hoist. Phoenix House is staffed throughout the day and night, providing personal care, home cooked meals and a laundry service. All residents are registered with a G.P. of their choice and are supported in accessing district nursing and paramedical services, in accordance with need. Phoenix House has recently changed ownership, and Mr. Chris Farrar, Total Care Homes Limited, has appointed a manager, Mrs. Sandra Farrell, who has applied for registration with CSCI. Phoenix House DS0000064015.V283631.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection concentrated on spending time with residents in the lounge and seeking their views on the service provided and lifestyle in the home. Discussions took place with the manager and a senior member of staff, the chef and with the responsible person, Mr. Farrar. The dining room, laundry, kitchen, food storage areas and lounge were visited. Health & safety records, care files and medication records were read. What the service does well: What has improved since the last inspection?
Specialist health and care needs are now recorded on residents’ care plans and staff have received instruction in stoma care Kitchen overalls, which have been laundered, are no longer stored in the laundry. The laundry and sluice have been recently re-plastered. The kitchen has been fitted with stainless steel units. Mrs. Sandra Farrell, a senior who has worked in the home for several years, has been appointed as manager and applied for registration with CSCI. A recent fire officers visit found arrangements for fire safety to be satisfactory. Phoenix House DS0000064015.V283631.R01.S.doc Version 5.1 Page 6 A range of activities has been established, and residents were satisfied with their lifestyle in the home. Laminated menus are placed in the hall every day, to ensure that the planned meals are made known to residents and they can request an alternative if necessary. What they could do better:
To ensure that residents are protected by the home’s medication procedures, the manager must instruct staff that all medication is signed for as administered and refusal is indicated by the appropriate code. In this way, administered and refused medication may be checked against monthly returns to the pharmacy. In order to avoid contamination in the food storage areas, the manager must arrange for the freezers and shed (where the freezers are situated), to be thoroughly cleaned and maintained to the highest standards of hygiene. For further guidance, advice may be obtained from the environmental health officer (Sefton Council). To protect residents, visitors and staff from the risks of fire and smoke inhalation, the manager must ensure that fire doors are not wedged open/or for the fitting of automatic closers. To ensure that the building and equipment are safe and do not pose a risk to residents, the manager must provide CSCI with an up to date gas certificate for the home. The home must employ a suitably qualified manager who is registered with CSCI. Mr. Farrar has taken the required action by appointing Mrs. Farrell as manager and she applied for registration with CSCI shortly after her appointment. The registration process was at the stage of awaiting clearances for Mrs. Farrell at the time of inspection, and will be completed when all requested satisfactory clearances have been obtained. To ensure that the home is managed in the best interest of residents, the manager should establish effective quality assurance and quality monitoring systems. These should be based on seeking views of residents to measure success in meeting the aims and objectives of the home. Phoenix House DS0000064015.V283631.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. Phoenix House DS0000064015.V283631.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 Phoenix House DS0000064015.V283631.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): Not assessed EVIDENCE: Phoenix House DS0000064015.V283631.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): 7 8 9 10 Care plans were in place for all residents and these had been recently reviewed and updated. Residents’ specialist health needs were recorded on their care plans. All residents are registered with a local GP of their choice or retain their usual GP on admission to the home if possible. There is a system in place for managing residents’ prescribed medication, which was generally satisfactory. A shortfall was noted in record keeping. Residents’ privacy is upheld in personal care giving, storage of personal records and accommodation. EVIDENCE: A sample of three care plans was read and a discussion took place with the manager, Mrs. Sandra Farrell. Senior staff have worked hard since the last inspection to review and update care plans. Information is easily accessed as a summary of dependency and need is completed following each review. Care files contained pre-admission assessments (carried out by home’s staff), social work assessments where appropriate, personal details, action plans and
Phoenix House DS0000064015.V283631.R01.S.doc Version 5.1 Page 11 reviews. The manager said that care plans are to be re-organised into a new format. Specialist needs (in relation to diet and continence) are now recorded on individual care plans. There were records on individual care files of G.P. and district nurse visits and attendance at hospital appointments and clinics. Medication is stored in a locked cupboard and the systems in place for managing prescribed medication, were generally satisfactory. A shortfall was noted in that staff were leaving gaps in Medication Administration Sheets. If a resident is absent or in hospital, the code must be entered, to confirm that the medication has not been administered. In this way an accurate audit of medication administered/refused will be reconciled with returns to the pharmacy and all medication brought into the home will be accounted for. Residents’ privacy and dignity are respected in the home. The home provides single accommodation, and doors to bedrooms, bathrooms and toilets remained closed during the inspection. Residents who commented said that their mail is given to them unopened, and that there is no undue intrusion into their personal affairs. Care records are secured when not in use and the home has a policy on confidentiality. Phoenix House DS0000064015.V283631.R01.S.doc Version 5.1 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 the following standard(s): 12,13,15 Improvements were noted in the variety of in-house activities in the home. Visitors are made welcome and residents are encouraged to maintain contact with family and friends. The standard of meals was to residents’ satisfaction and laminated menus are placed in the hallway each day for residents’ convenience. EVIDENCE: A resident said that there is a quiz every week, which she enjoys. One resident said that she goes out regularly with her family, another goes out to local shops. Senior staff said that the residents recently enjoyed arranging fresh flowers for the dining room tables. The arrangements were seen and looked very attractive. Staff said that the flower arranging afternoon (which was organized by one of the seniors), stimulated conversation between residents, and a finished arrangement was taken to a resident who was poorly in bed. A resident said she had a great time and the flowers were beautiful and are enjoyed every day, in the dining room. The home has links with a local church where residents attend bingo sessions and entertainment. There are regular film shows and sing songs are arranged with a visiting choir group. Resident’s religion/beliefs are recorded on their care plan and religious ministers attend the home, in accordance with the needs of those in residence.
Phoenix House DS0000064015.V283631.R01.S.doc Version 5.1 Page 13 Residents said the meals and food portions were very good. There were adequate food stocks in store and the kitchen has recently been re-fitted with stainless steel units. Menus were on display, where residents could read the meals of the day and choose alternatives if necessary. Phoenix House DS0000064015.V283631.R01.S.doc Version 5.1 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 the following standard(s): 16,18 There are systems in the home for responding to complaints and detecting and investigating suspected abuse in accordance with Sefton Council’s Adult Protection Procedures. EVIDENCE: The home has a complaints procedure, which is accessible to residents. There is also an adult protection procedure and “whistle blowing” policy and staff have received training in protection of vulnerable adults. A resident said “If I had a problem I would certainly let them know and I am sure they would put things right. So far, I have had no complaints.” Phoenix House DS0000064015.V283631.R01.S.doc Version 5.1 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 the following standard(s): 19,26 The home is generally well maintained, recent improvements to the building were seen and further maintenance work to exterior brickwork has been scheduled. The home in general, is maintained to a good standard of hygiene. Shortfalls in hygiene were observed in the food storage area. EVIDENCE: The home is an attractive and comfortable period property. The dining room has been decorated and is very well presented. Since the home changed to new ownership, the kitchen has been re-fitted with stainless steel units and the laundry and sluice have been plastered. The grounds are in good condition providing suitable and secluded exterior space for residents in fine weather. There has been considerable financial investment in making improvements to the kitchen and laundry. These areas are less prone the risks of cross infection, the surfaces now being easily cleaned and less likely to harbour
Phoenix House DS0000064015.V283631.R01.S.doc Version 5.1 Page 16 germs. The shed where chilled and frozen foods are stored was less cluttered than at the last visit, but there is the risk of dust, spiders and webs falling from the ceiling into the freezers when they are opened. There was a dead spider on the lid of one freezer. On inspection, the inside of the stand up freezer was seen to be soiled with grit, which could be transferred to food. Phoenix House DS0000064015.V283631.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28,29,30 Staff are competent and experienced in residential care practice. The home has a satisfactory recruitment procedure based on the protection of residents. Staff have received mandatory and NVQ training. EVIDENCE: Mr. Farrar has increased day staff numbers by one since taking over the home. Staff spoken with have worked in Phoenix House for many years and have received mandatory and NVQ training. The appointed manager is due to commence NVQ4 Management. The percentage of NVQ trained staff working in the home was not calculated during this inspection. The home has a recruitment procedure which includes staff vetting and CRB clearance. Phoenix House DS0000064015.V283631.R01.S.doc Version 5.1 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 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): 33,35,38 Mr. Farrar is currently reviewing documents and procedures in the home in the light of changing legislation and best practice. There are systems in the home to ensure that residents’ financial interests are safeguarded. Fire safety procedures were being adhered to other than where a shortfall was noted. There was no up to date Landlord’s Gas Certificate at the time of inspection . EVIDENCE: Quality assurance systems are currently under review. Mr. Farrar is in the process of auditing procedures and records in the home, which were inherited from the previous owner.
Phoenix House DS0000064015.V283631.R01.S.doc Version 5.1 Page 19 The home does not become involved in residents’ personal finances and residents who have no representation, have access to independent advocates. Residents who commented expressed no concerns as to this standard. According to fire records, fire safety procedures were being followed in the home. Fire risk assessments were in place and there had been a recent visit from the Fire Safety Officer, with satisfactory outcomes. A shortfall was observed during this inspection in that the kitchen door was wedged open. This is a fire door and must not be wedged open. If necessary, an automatic closer could be fitted but in the short term, the wedge must be removed as the kitchen is a high fire risk area, especially when cooking is in progress. There was no up to date Landlord’s Gas Certificate. Mr. Farrar said he had trouble contacting the engineer until recently. A visit to the home by the engineer to carry out maintenance on the gas system, had been arranged for the following Monday, 6/2/06. Phoenix House DS0000064015.V283631.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 2 Phoenix House DS0000064015.V283631.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 (2) Requirement The manager must instruct staff who administer medication that instances of refusals/non administration are filled in on the medication record with the appropriate code. Timescale for action 10/02/06 2. OP26 13 (3) The manager must arrange for 10/03/06 the food storage shed and freezers to be regularly and thoroughly cleaned. Outstanding from the last inspection, extended time limit given. The manager must provide CSCI with an up to date gas certificate for the home. The manager must ensure that fire doors are not wedged open/or for the fitting of automatic closers. The home must employ a suitably qualified manager who is registered with CSCI. Outstanding from last inspection. Mrs. Farrell has applied for registration. Clearances were outstanding at the time of
DS0000064015.V283631.R01.S.doc 3. 4. OP38 OP38 23 (2) 23 (4) 30/03/06 28/04/06 5. OP31 8 28/04/06 Phoenix House Version 5.1 Page 22 inspection. Extended time limit given. 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 OP33 Good Practice Recommendations The manager should establish effective quality assurance and quality monitoring systems, based on seeking view of residents to measure success in meeting the aims and objectives of the home. Phoenix House DS0000064015.V283631.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Phoenix House DS0000064015.V283631.R01.S.doc Version 5.1 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!
