Inspection on 10/04/06 for Saffron House

This inspection was carried out on 10th April 2006.

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 House 22/12/09

Saffron House 02/09/09

Saffron House 17/10/07

Saffron House 22/09/05

Saffron House 10/05/05

Saffron House 26/01/05

Saffron House 11/06/04

Saffron House 20/03/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Saffron House 2a High Street Barwell Leicestershire LE9 8DQ Lead Inspector Keith Charlton Unannounced Inspection 10th April 2006 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 House DS0000036290.V286950.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. Saffron House DS0000036290.V286950.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Saffron House Address 2a High Street Barwell Leicestershire LE9 8DQ 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) 01455 842222 01455 841222 Downing (Barwell) Limited To be determined Care Home 42 Category(ies) of Dementia (20), Dementia - over 65 years of age registration, with number (20), Old age, not falling within any other of places category (42), Physical disability (10), Physical disability over 65 years of age (10) Saffron House DS0000036290.V286950.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons who fall within either category DE or DE (E) may only be accommodated on the ground floor No person under 55 years of age who falls within categories PD or DE may be accommodated in the home Service User Categories PD & PD (E) No person who falls within categories PD or PD (E) may be admitted to the home when 10 persons of those categories/combined categories are already accommodated within the home Service User Categories DE & DE (E) No person who falls within categories DE or DE (E) may be admitted to the home when 20 persons of those categories/combined categories are already accommodated within the home To be able to admit the named person of category LD 55 named in variation application number 56181 dated 18th September 2003 4. 5. Date of last inspection Brief Description of the Service: Saffron house is a purpose built care home situated in the centre of Barwell, Leicestershire. It is registered for forty-two service users within the categories of old age, Dementia and Physical Disability. The home is not registered to provide nursing care. The home is situated on two floors and these are accessed by a passenger lift. The home has a dining room and lounge on each floor and a further five lounges throughout the home. The home has forty-two single bedrooms, which have ensuite facilities. The home is currently managed by an acting manager and employs care staff. Close to the home are a number of hotels and restaurants and is within close proximity of Mallory Park Race track and Market Bosworth. The home has a grassed area and flowerbeds at the back of the property and a circular walkway. The home has electric gates fitted to the exterior of the home for safety and to prevent intruders. Saffron House DS0000036290.V286950.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on 11/4/06. The inspector arrived at the home at 9.45am and finished the inspection at 16.10pm. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views of the service provided. The primary method of Inspection used was ‘case tracking’ which involves selecting clients and tracking the care they received through looking at their records, talking with them where possible, and looking at their accommodation. On this occasion the inspector ‘case tracked’ three clients. This was an unannounced Inspection. The Home’s Registered Manager was present. Planning for the Inspection included reading the notifications of significant events sent to the Commission for Social Care Inspection and the correspondence with the Company regarding following up Requirements from the last Inspection Report. Because of the level of Requirements from the last inspection another inspection visit took place in November 2005 to follow up these Requirements. There has been one Complaints Investigation in January 2006 though none of the allegations were substantiated and the Registered Manager has also undertaken follow up work to pursue any related issues. The Inspection included looking at communal and private areas of the building, inspection of records and direct and indirect observation of care practices. The Inspector spoke with seven residents, three members of staff and two relatives. What the service does well: Service users commented on their quality of life and said that the food was good; staff were generally friendly, that they liked their bedrooms and they could bring in their own things. Staff were observed to be friendly and respectful towards service users. There is an Activities Programme, which residents generally like, and they thought the Activities Worker was very cheerful, friendly and positive. The premises were found to be in a clean and tidy condition. Saffron House DS0000036290.V286950.R01.S.doc Version 5.1 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. Saffron House DS0000036290.V286950.R01.S.doc Version 5.1 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 House DS0000036290.V286950.R01.S.doc Version 5.1 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): 3,6 Prospective service users have their needs are assessed. The judgement for the performance of the service for this standard is: excellent. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A newly admitted service user said that the Registered Manager had spent a long time with finding out her needs prior to admission and she appreciated this attention to detail. From looking at files of service users it was obvious that there was very detailed assessment information to plan for service users needs. The service does not admit service users solely for intermediate care. Saffron House DS0000036290.V286950.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The system of writing care plans results in staff being able to know service users needs. Service users are generally satisfied with staff treating them with respect. The medication systems are generally good. The judgement for the performance of the service for these standards is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Most service users were generally complimentary regarding the care they received and said that staff were attentive. There was one comment received that ‘younger’ staff do not always listen and sometimes spoke down to service users and that staff sometimes raised their voices to service users. The Registered Manager said this would be brought to the attention of staff and be monitored. Care plans had the required information regarding service users health, medical and physical care needs and they have been reviewed by the Registered Manager on a monthly basis. Saffron House DS0000036290.V286950.R01.S.doc Version 5.1 Page 10 Weight charts are maintained for service users and an Action Plan in place to deal with any needs, e.g. at risk of high or low weight though at the time of the inspection the scales needed repair which had been followed up by the Registered Manager. Staff said they had been asked to read care plans though not all had yet been read. The Registered Manager said this would be followed up. Residents said they were looked after when they were not well and that staff would get a doctor if they asked. The accident records generally showed staff alerting medical authorities if service users were injured. This was not carried out on two occasions but was then picked up by the staff members reminded of the proper procedure. The Registered Manager said there needed to be a discussion with a GP practice so that staff are appropriately referring service users when they are injured or unwell. Staff said that only senior staff issued medication and that the pharmacist had given training. Medication records were generally well recorded with only one gap. A service user said that it was important that she had her medication as soon as she needed it because of her medical condition and she sometimes had to wait up to forty-five minutes for it – the Registered Manager said a system would be put in place to ensure proper practice. Saffron House DS0000036290.V286950.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The quality of life for service users is good. The judgement for the performance of the service for these standards is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users said they were satisfied with the current level of activities. The service employs an Activities Organiser who works four days a week. A service user is able to go out to shop and was looking forward to going on Age Concern outings. Service users were seen playing large scale dominoes that they appeared to be enjoying. Service users and visitors said that there were no restrictions on visiting times and visitors were welcome. A visitor said she could help herself to a drink for herself and her mother. Service users, staff and relatives said that there were no rigid rules. This was also indicated in the home’s Statement of Purpose. Saffron House DS0000036290.V286950.R01.S.doc Version 5.1 Page 12 Service users said that the food was good. Records indicated that there was a choice of main meal and dessert. A staff member was seen to assist a service user with feeding. A relative said that staff assist with eating when necessary. Saffron House DS0000036290.V286950.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Service users/their representatives can be confident that complaints will be properly followed up and staff are vigilant regarding protection from abuse. The judgement for the performance of the service for these standards is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users said that they thought that if they had a complaint that this would be properly dealt with by the Registered Manager. They again said they felt safe in the home. The complaints records indicated one complaint they had been appropriately dealt with by the Registered Manager with an apology given by the staff concerned. Staff said that they had received training in abuse and the staff asked as to the adult protection procedure had an understanding of the steps they needed to take in the event of abuse though some struggled as to which Agencies to contact in the event of Management not following up the issues. The Registered Manager said that she would compile a short procedural statement and supply to staff so that they are all clear as to the proper procedure. Saffron House DS0000036290.V286950.R01.S.doc Version 5.1 Page 14 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 Facilities are homely and comfortable. The judgement for the performance of the service for these standards is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users again said that they liked their bedrooms and bedrooms were found to be personalised and homely. Residents said they were able to bring in their own furniture to make their rooms more homely. The handyman was seen to be painting the first floor corridor at the time of the visit so maintenance of the premises is seen as an ongoing priority for management. The Home was found to be in a clean and tidy condition and facilities were found to be free of any offensive odours. Saffron House DS0000036290.V286950.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 Staffing levels need to be reviewed to always meet service users needs. The recruitment process now protects service users. Staff training is encouraged but other issues need to be covered to raise awareness of service users needs. The judgement for the performance of the service for these standards is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were some comments from service users, staff and a relative that at times there were not enough staff, in particular at night from 8.00pm to 8.00am. There are three to four staff care staff on duty on each wing of the Home in the morning, reducing to three staff in the afternoon/evening. The Registered Provider must ensure that this is sufficient to cover service users needs as this was an issue raised this year by the Commission for Social Care Inspection There is now domestic cover seven days a week. From the staff records inspected they all had references and Protection of Vulnerable Adults checks in place. Staff said they had received training, e.g. Moving and Handling and dementia training and staff said they were encouraged to undertake National Vocational Qualification level 2 and 3 training – the Registered Manager said that there Saffron House DS0000036290.V286950.R01.S.doc Version 5.1 Page 16 were a large number of staff with National Vocational Qualification level 2 and others are undertaking this at present. The Registered Manager said that she intended to carry out an audit of training needs to identify all training needed as staff have not received training in all health conditions that residents have, e.g. Parkinsons Disease, stroke, epilepsy etc. and this was being currently organised to increase staff awareness. Saffron House DS0000036290.V286950.R01.S.doc Version 5.1 Page 17 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): 31,33,35,38 Management systems are organised and systematic. Health and Safety systems protect the welfare needs of service users. The judgement for the performance of the service for these standards is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users , staff and relatives thought that the Registered Manager was efficient and organised and protective of service users welfare. A Quality Assurance system has been formulated by the Registered Manager and is due for implementation to actively seek the opinions of all residents, relatives, staff and other stakeholders. Saffron House DS0000036290.V286950.R01.S.doc Version 5.1 Page 18 Service users monies were checked and found to be in order. Proper records – running balances, receipts etc are kept apart from two signatures are needed for all transactions, including the staff member receiving monies. The monthly Regulation 26 Report on the running of the home is now undertaken by the Area Manager and is being sent to the Commission for Social Care Inspection. A service user appeared to be lifted inappropriately. The Registered Manager stated that staff had received training and staff would be furhter appraised of the proper Moving and Handling procedures and given refresher training as necessary. Fire drills and fire bell testing is now carried out on a regular basis. The hot water supply was tested and found to be within the National Standard. The Registered Manager said that there were no outstanding Requirements from the Environmental Health Officers last Report though recommendations are being followed up. Saffron House DS0000036290.V286950.R01.S.doc Version 5.1 Page 19 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 4 X 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Saffron House DS0000036290.V286950.R01.S.doc Version 5.1 Page 20 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. 1. 2. Refer to Standard OP7 OP29 Good Practice Recommendations The Registered Manager could review staffing levels on all shifts All staff should have a clear record of their training and development needs and achievements. Staff would benefits from training for conditions including Strokes, Diabetes, Parkinson’s Disease Saffron House DS0000036290.V286950.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Saffron House DS0000036290.V286950.R01.S.doc Version 5.1 Page 22 - 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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