Inspection on 29/12/05 for Saffron Homes

This inspection was carried out on 29th December 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

Saffron Homes 12/11/08

Saffron Homes 06/11/06

Saffron Homes 08/06/05

Saffron Homes 02/12/04

Saffron Homes 08/06/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Saffron Homes Devon Road Whitehall Bristol BS5 9AD Lead Inspector Melanie Edwards Announced Inspection 29th December 2005 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 Saffron Homes DS0000020384.V265632.R01.S.doc Version 5.0 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. Saffron Homes DS0000020384.V265632.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Saffron Homes Address Devon Road Whitehall Bristol BS5 9AD 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) 0117 9396681 0117 9396654 shelyerrunelcare.org.uk Brunelcare Mrs Sheena McNeil Helyer Care Home 62 Category(ies) of Dementia (25), Dementia - over 65 years of age registration, with number (10), Mental disorder, excluding learning of places disability or dementia (10), Old age, not falling within any other category (62), Physical disability (10) Saffron Homes DS0000020384.V265632.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. May accommodate up to 12 persons aged 50 years and over requiring day care. May accommodate up to 25 persons aged 50 years and over with dementia. Manager must be a RN on Parts 1 or 12 of the NMC register Staffing notice dated 06/04/1998 applies. Date of last inspection 8th June 2005 Brief Description of the Service: Saffron Homes is registered with the Commission for Social Care Inspection to provide nursing care to 62 service users over 50 years of age. This includes 25 service users with dementia. Brunelcare is the registered provider. Mrs Sheena Helyer is the registered manager, having been at the home since June 2004. She previously worked at Deerhurst, another of the Brunelcare Care Homes. Saffron Homes has been in existence since 1972 and comprises three separate areas. Irwin House the newest part of the home was built in November 2001 and is a two-storey building with 14 single bedrooms upstairs and 12 downstairs. There is a large lounge-dining room on each floor, having TV, music and a small kitchen area. The upper floor of Irwin House provides Intermediate Care to 14 people, funded by the Avon and Wiltshire Mental Health Partnership (AWP), admitted from hospital for rehabilitation before going back to their own homes. Saffron Court was originally built in 1993 but refurbished in early 2002. It has been specifically designed to care for those with dementia and has been decorated following advice from Dementia Voice. The building surrounds a central courtyard that includes a sensory garden. Saffron House is currently empty and Brunelcare are considering options available for its viable use. For this reason only 51 beds are available at the current time. Saffron Homes DS0000020384.V265632.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Seventeen residents and a number of visitors, including several relatives were consulted to find out their views of the Home and the type of service and care provided. The registered manager, the manager of the fourteen intermediate care beds, one registered nurse, four care assistants, and one of the chefs were also consulted to find out about their individual roles and responsibilities, training needs, and how they assist and support residents. There were a number of pre-inspection feedback forms sent to the Commission for Social Care Inspection area office, from residents, relatives, and from one of the GPs. who is responsible for residents’ medical care. Staff were observed assisting residents with their needs. A selection of records relating to the day-to-day running and management of the Home were inspected. A range of resident’s care records and care plans were also reviewed. The majority of the environment was seen and the only areas that were not inspected were a small number of bedrooms. What the service does well: 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. Saffron Homes DS0000020384.V265632.R01.S.doc Version 5.0 Page 6 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Saffron Homes DS0000020384.V265632.R01.S.doc Version 5.0 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 Saffron Homes DS0000020384.V265632.R01.S.doc Version 5.0 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 the following standard(s): 2,3,4 Residents’ assessed needs are met and residents and their representatives are provided with a contract that details the facilities and services provided. EVIDENCE: Six residents assessment records were inspected to find out how residents care needs are assessed. The records of residents who have a varied range of care needs were selected to monitor how different needs are assessed. The assessment records were informative, and showed the Home had consulted with residents and their representatives to ascertain the range of physical, mental and social needs the person had. An assessment of each residents skin vulnerability, and the risk of developing pressure sores had also been completed. There was also a nutritional needs assessment to monitor the dietary and nutritional needs of each resident. The assessments had been reviewed and updated on a regular basis. One of the senior registered nurses is allocated the responsibility of auditing care plans and ensuring they are being regularly reviewed and updated, and reflect residents changing needs. Saffron Homes DS0000020384.V265632.R01.S.doc Version 5.0 Page 9 A number of completed Commission for Social Care Inspection questionnaire comments cards were returned to the office of the Commission for Social Care Inspection These had been completed by resident’s representatives and by one of the GPs responsible for the medical care of residents. All of the comments cards completed included positive comments about the care and service that the Home provides. Each resident is provided with a detailed copy of a statement of terms and conditions for staying at the Home. Random copies of contracts that were inspected contained a range of information about the service provided, fees that are charged for staying at the Home, and any extra costs. This information is a legal requirement, which also helps inform residents and their representatives about the type of service they will receive, and how much this will cost. Saffron Homes DS0000020384.V265632.R01.S.doc Version 5.0 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 Residents’ care needs are met; and they are treated with respect and sensitivity. Also the system for handling storage and administration and disposal of medication is safe. EVIDENCE: To find out about the care that residents receive, six residents care plans were inspected. Care plans contained a range of information, and demonstrated how to support the residents to meet their health care needs. The majority of care plans were written in a clear and easy to follow style and contained easy to follow instructions for staff to follow when supporting residents with their needs. The content of several care plans inspected was less clear and informative, although they still demonstrated how to meet residents care needs. A `moving and handling’ assessment had also been completed for each resident, and the assessments showed how to support residents who have reduced or very limited mobility. The care plans and accompanying assessments had been reviewed and updated on a regular basis by registered nurses helping to demonstrate residents care needs are monitored and reviewed. Saffron Homes DS0000020384.V265632.R01.S.doc Version 5.0 Page 11 The Home is well supported by the local GP services and a psychiatrist and team who support residents with identified mental health needs. The medication procedures and practices operating in the Home were also inspected with the assistance of one of the senior registered nurses. They demonstrated the Home operates a safe system of administration, disposal and storage of resident’s medication. Residents and visitors spoke positively about the care and service they received. Examples of comments made by residents about the staff and the Home included, ‘the staff are angels’, `it’s alright here’, and `its nice here’. Staff were observed assisting residents with their needs in a calm and respectful manner, and residents looked relaxed and comfortable with staff. Saffron Homes DS0000020384.V265632.R01.S.doc Version 5.0 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 Resident’s, social and recreational interests are met, and they are supported to maintain contact with their families, friends and community, also a varied and well balanced diet is provided. EVIDENCE: An activities coordinator is employed who works five days a week. Copies of the weekly timetable of social activities are on display throughout the Home, to ensure residents are aware of current activities taking place in and out of the Home. Residents can take part in a range of social activities as well as exercise classes and music therapy sessions. There are also regular one to one therapeutic activities for residents who either prefer not to or are unable to take part in group activities. The Home has its own minibus for trips out into the community. On the first day of the inspection a group of residents went out to a nearby shopping centre for the morning. Residents were observed receiving visitors on both days of the inspection. Visitors said that the Home operate a relaxed and flexible visitors policy, which should help residents to be able to keep in contact with family and friends. Saffron Homes DS0000020384.V265632.R01.S.doc Version 5.0 Page 13 To find out what type of food is offered to residents a portion of both lunchtime meals were tasted. These consisted of dishes of either cottage pie or roast chicken pieces accompanied by cooked vegetables. There was a choice of homemade chocolate sponge or fresh fruit or yoghurts for desert. The main meal dishes were satisfactorily cooked and nutritionally well balanced. Residents specific cultural dietary needs are also catered for. All of the residents who were asked said that they thought the meals served in the Home were good and well cooked. The residents’ menu record was inspected to find out if residents are being offered a well balanced diet. There were choices of dishes for each day and the menu was nutritionally well balanced. Staff were observed assisting residents to eat their lunch. Staff were helping residents in a sensitive manner. Saffron Homes DS0000020384.V265632.R01.S.doc Version 5.0 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 Complaints are responded to promptly and there are systems in place to help protect residents from abuse or harm. EVIDENCE: A copy of the complaints procedure is on display on a wall in a well-frequented part of the Home. The procedure includes the contact details for Brunelcare who run the Home, as well as the area office of the Commission for Social Care Inspection, if someone wishes to contact the Commission for Social Care Inspection directly. The residents who were asked said they felt very able to speak to the manager or any of the staff if they had any concerns or wished to make a complaint. The complaints record book showed there had been one complaint received since before the last inspection, the record included the details of how the complaint was dealt with and demonstrated complaints are responded to promptly and thoroughly. There is a procedure in place relating to the issue of protection of vulnerable adults from abuse. The procedure is up to date and includes current Protection of vulnerable adults from abuse guidance information. This information is needed to help guide staff in the event of an allegation of abuse being made. The Home also ensures all staff attend training sessions to help them in understanding the principle of the protection of vulnerable adults from abuse. Saffron Homes DS0000020384.V265632.R01.S.doc Version 5.0 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 safe, and looks satisfactorily maintained and suitable to meet resident’s range of needs. EVIDENCE: Saffron Homes DS0000020384.V265632.R01.S.doc Version 5.0 Page 16 Irwin House is a purpose built care home for twenty-six people. The fourteenbedded intermediate care unit is on the top floor and there are also four beds on the ground floor. The remaining eight beds on the ground floor are for people who need general nursing care. There is lift access to the top floor and this has a keypad to prevent unsafe usage by residents. The stairs are also secured in this way. The Home was satisfactorily maintained throughout. Saffron Court is a single storey building, built in a square, around a central courtyard, and Brunelcare sought guidance and advice from ‘Dementia Voice’ charity in its decoration and design. The Home is located close to private houses, a junior school, and a short distance from local shops and nearby bus stops, making the Home very much part of the local community. The building is wheelchair accessible; and there is a passenger lift servicing the upper floor. The Home is a purpose built nursing home, designed around the needs for which it is intended. There are adaptations in place throughout the Home to assist residents as well as visitors who are disabled. The environment looked clean tidy and free from any unpleasant odour. The majority of the building was viewed both inside and out. The only areas that were not seen were a small number of bedrooms. A full time maintenance worker is employed to address general maintenance and this person was observed carrying out their duties during the inspection. Service records were seen for the lift and showed that an external contractor had serviced the lift in the last twelve months. Saffron Homes DS0000020384.V265632.R01.S.doc Version 5.0 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 The staff are competent and well trained to meet residents needs and recruitment procedures that are in place help to protect residents from harm. EVIDENCE: Staff recruitment records are held at the Brunelcare head office. A regulation manager from the Commission for Social Care Inspection inspected a selection of staff recruitment records at the head office in 2004.The regulation managers inspection of the records demonstrated Brunelcare operate a safe and robust staff recruitment system, and the required ‘safety checks’ are carried out when new employees are recruited. The manager is also sent written confirmation by Brunelcare head office when new staff Criminal Records Bureau Checks and ‘Protection of vulnerable adults from abuse first’ checks have been completed. This is to ensure the manager knows when required checks have been carried out, and is Brunelcare policy for all their care services. There are also two professional references obtained for all newly recruited staff, also helping demonstrate the Home ensures the suitably of all new employees to work in the Home. The training records of two registered nurses and two care assistants were reviewed to see if registered nurses were keeping up to date with their clinical knowledge and practice. There was evidence that demonstrated registered Saffron Homes DS0000020384.V265632.R01.S.doc Version 5.0 Page 18 nurses had attended clinical training sessions, and updating over the last six months. The care assistants’ records also demonstrated staff had attended training sessions over the last six months. Brunelcare provide staff with regular training on a range of issues, including dementia care training, team leader development, equal opportunities, management issues, staff supervision, bereavement, and abuse awareness. Brunelcare’s training policy is to ‘train up’ identified staff to then carry out ‘inhouse’, training with other staff; this is for all mandatory training and some specific training courses. In discussion with the inspector, many staff commented positively about the range of training and development opportunities that are provided for them to assist them in their work and practice. Saffron Homes DS0000020384.V265632.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,37,38 The Home is well run, with residents’ views actively taken into account by management in the running of the service, and there are systems and procedures in place to help protect the health and safety of residents, staff and visitors. EVIDENCE: The environment looked satisfactorily maintained throughout. There are health and safety procedures in place for staff and residents to follow to promote health and safety in the Home. Staff are also provided with general health and safety training as well as moving and handling training, and food safety training. This training should assist staff in maintaining best health and safety practice when at work. Saffron Homes DS0000020384.V265632.R01.S.doc Version 5.0 Page 20 The fire logbook record showed the required fire safety checks were being carried out and are up to date helping to ensure the safety of people inside the building is maintained. Records are kept locked away when not in use ensuring residents confidential information is held securely. All the records inspected were well maintained, up to date and in order. Other records have been referred to elsewhere in this report, and demonstrate wellorganised management in the Home. A number of residents were asked if they knew Mrs Helyer, and did they see her regularly. Many residents said she was very kind, and she would gladly make time to see them if they needed to speak to her. A full time administration manager is also employed to oversee the running of non-clinical management areas of the Home. Mrs Helyer said that she and the administration manager work well together and liaise on a day-to-day basis about matters relating to the running of the Home. There is also a manager who overseas the care provided for the fourteen intermediate beds that are registered for residents with identified mental health needs. From discussion with the manager and with Mrs Helyer it is evident that they communicate and liaise effectively with each other. The Home carries out regular quality-monitoring audits of the care and service that is provided to residents. Residents and their relatives have been consulted about their views of the care and service. An action plan is put in place to effectively address any issues raised from the audit. Saffron Homes DS0000020384.V265632.R01.S.doc Version 5.0 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 3 3 3 X X 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 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 3 3 3 3 3 3 3 STAFFING Standard No Score 27 X 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X 3 3 Saffron Homes DS0000020384.V265632.R01.S.doc Version 5.0 Page 22 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. Standard Regulation Requirement Timescale for action 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 Saffron Homes DS0000020384.V265632.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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