Inspection on 10/05/05 for Saffron House

This inspection was carried out on 10th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Saffron House 22/12/09

Saffron House 02/09/09

Saffron House 17/10/07

Saffron House 10/04/06

Saffron House 22/09/05

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 10 May 2005 at 9.30am 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. Saffron House C51 S36290 Saffron House V226160 100505.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Saffron House Address 2a High Street Barwell Leicestershire LE9 8DQ 01455 842222 01455 841222 Downing (Barwell) Limited 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) No Registered Manager at time of Inspection Care Home 42 Category(ies) of DE(E) Demential over 65 - 20 registration, with number OP Old Age - 42 of places DE Dementia - 20 PD Physical Disability - 10 PE(E) Physical Disability - 10 Saffron House C51 S36290 Saffron House V226160 100505.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: - Date of last inspection 26/1/2005 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 C51 S36290 Saffron House V226160 100505.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced Inspection. The Home’s Acting Manager was on holiday. Planning for the Inspection included reading the Pre-Inspection Questionnaire completed by the Manager and the 14 Comment Cards returned by residents. The notifications of significant events sent to the Commission for Social Care Inspection by the home were also reviewed, as were the findings from a recent Complaints Investigation. The Inspection took place between 9.40 and 14.20 and included a tour of the building, inspection of records and direct and indirect observation of care practices. The Inspector spoke with twelve residents, four members of staff and the Deputy Manager. The Inspector completed the Inspection on 20/05/05, when the Acting Manager had returned from holiday. These discussions took a further two and a half hours. What the service does well: What has improved since the last inspection? Residents who self medicate now have Responsible Individual risk assessments to ensure this is a low risk for them. Saffron House C51 S36290 Saffron House V226160 100505.doc Version 1.30 Page 6 Residents accommodated have detailed assessments so their needs can be met. Care plans are reviewed monthly and there are risk assessments for falls. Regulation 37 incidents, which affect the welfare of residents, appear to be reported to the Commission for Social Care Inspection within 48 hours. 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 C51 S36290 Saffron House V226160 100505.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 Saffron House C51 S36290 Saffron House V226160 100505.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 home assesses the needs of permanent residents before they are admitted to the home. The home does not fully meet the needs of residents, as staff training is needed to fully understand residents’ conditions. EVIDENCE: From looking at a file of a newly admitted resident it was obvious that there was sufficient information to plan for needs. However staff said that they had not received training in all conditions that residents had, e.g. Parkinsons Disease, stroke, epilepsy. Saffron House C51 S36290 Saffron House V226160 100505.doc Version 1.30 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 standard(s) 7,8,9,10 The care planning system in the home is generally good but the way it is used and implemented is not consistent for all residents and could be improved. Resident’s health needs are generally well met but weight charts need to be maintained – this was a deficit noted on the last inspection report. Improvements are required in the administration of medication and some aspects of documentation and training. Staff members generally treat residents with respect and their right to privacy is upheld, though all staff need to fully understand residents rights. EVIDENCE: Residents care plans inspected were generally well set out and identified what staff had to do to meet residents care needs. However a care plan stated that ‘L responds well to a person centred approach’ without defining what this meant. A weekly weight chart was not fully maintained for one resident, as there were a number of gaps of two weeks length. Residents said they had not heard of a care plan or been involved in setting up their own plans, though were generally complimentary regarding the care they received and said that staff were kind and attentive. Saffron House C51 S36290 Saffron House V226160 100505.doc Version 1.30 Page 10 Care plans had been reviewed on a monthly basis. Staff said they had read care plans but were not involved in setting them up or reviewing them – this is recommended. Residents said they were looked after when they were not well. However it was noted on one resident’s records that she had two falls in April/May 2005 but medical assistance had not been sought. The visiting Area Manager said this would be rectified so this procedure would ensure medical contact for residents in the future if they bumped their heads. Medication records were generally well recorded with only a small number of gaps. The person in charge was asked not to record until the medication had been taken by the resident, as per the required practice. Some residents self medicate which is commended. However one resident was found to have medication on top of her bedside table accessible to any resident who walked in. Staff need to monitor this to ensure safety. The Acting Manager stated that this is now being carried out. Residents thought they were treated with respect and dignity though one lady wanted to only have a female carer to assist with dressing etc. The person in charge, the Deputy Manager on the first inspection day, said this had now been arranged. The Acting Manager said that residents choices in this matter would be respected and this written on the care plan. A comment was heard from a staff member that residents sometimes unnecessarily use their call bells for ‘silly things’ like wanting to go to the toilet or to ask for a drink. These are not ‘silly’ requests and the Manager needs to ensure that all staff thoroughly understand residents rights in these regards. The Acting Manager stated that there would be in house training on this matter. However this comment was made in the context of staff on the first floor being very busy and only having 2/3 care staff able to respond to residents needs. Saffron House C51 S36290 Saffron House V226160 100505.doc Version 1.30 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 standard(s) 12,15 The home offers a generally wide range of social and recreational activities. These meet the needs of residents well. The home helps residents to maintain links with relatives. Residents are offered generally satisfactory food and a choice of menu though the Home needs to ascertain residents preferences. EVIDENCE: Residents said that they were satisfied with the activities organised by the Home. The Home employs an activities worker who was enthusiastic about her work, had set up an activities programme which she showed the Inspector, and described how she talked with residents as to what they wanted to do – this is commended. It is recommended that Activity hours are increased to cover five days a week instead of the current four days a week. Generally the residents said they were satisfied with the food though six out of 14 comment cards received stating that the food was not satisfactory or only satisfactory sometimes. One resident said that vegetables were often overcooked. Another said he did not like gravy poured over his food. The food was therefore sampled – there were three vegetables, which were well cooked though there were large pieces of swede, which needed cutting down to smaller pieces, plus mashed potato (this was a little lumpy, though Saffron House C51 S36290 Saffron House V226160 100505.doc Version 1.30 Page 12 the lamb was tender and well cooked, and the chicken nugget was satisfactorily cooked if an uninspiring menu option. The gravy was tasty. There was also a choice of dessert – home made rice pudding and apple crumble with custard, which looked appetising. Residents are asked what they would like on a daily basis by way of food preference sheets – this is commended. It was recommended that the Manager conduct a food survey and that the cook record residents likes/dislikes to always have this information available in the kitchen, and the cook speak to residents on a frequent one to one basis and attend Residents Meetings. Saffron House C51 S36290 Saffron House V226160 100505.doc Version 1.30 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 standard(s) 18 The home’s Complaints Procedure is accessible to residents and relatives and issues raised are acted upon. Policies and procedures in place to protect residents from abuse are in place. However staff need to be aware of the full whistle blowing procedure in order to be able to protect residents from abuse. EVIDENCE: The Complaints Book was viewed. A visitor had complained about the attitude of staff when she brought to their attention the assault on her by a resident. The Acting Manager is investigating this at present and is to review the risk assessment to determine supervision needs for this resident and is to write to the visitor regarding this. Staff said that they had received training in abuse. However the staff asked were not fully aware of the full procedure to alert outside Agencies if management ignored concerns they brought to them, e.g. they were not aware they should contact the Police or Social Services. Saffron House C51 S36290 Saffron House V226160 100505.doc Version 1.30 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 standard(s) 19,23 The home is well maintained, warm and comfortable. Individual and communal rooms are well decorated and furnished. The home is clean and smells fresh throughout. The kitchen needs to be redecorated, as there are cracks in the plaster. There needs to be an assessment of residents needs in respect of aids and adaptations to fully assist with their needs. EVIDENCE: The Home was found to be in a clean and tidy condition – this is commended. One resident said she wanted to have a cage over her leg in bed, a bar to help her move in bed and a toilet frame. The Home needs to survey residents needs for this type of equipment. Residents 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 hot water from a bath was tested and found to be 42.5c, within the National Standard of 43c. Saffron House C51 S36290 Saffron House V226160 100505.doc Version 1.30 Page 15 Cracks were found in the kitchen, which are an outstanding requirement from the Environmental Health Officer’s Report. Saffron House C51 S36290 Saffron House V226160 100505.doc Version 1.30 Page 16 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) 27,29,30 There are sufficient staff on duty to meet resident’s needs on the ground floor but not on the first floor. Some staff are qualified and competent to do their job however some staff need additional training. The home’s current recruitment practices do protect residents. The practice of employing staff is done with obtaining a Criminal Records Bureau check first so as not to place residents at risk. EVIDENCE: There are 3 care staff on duty on each wing of the Home. From speaking to residents and staff this is sufficient on the ground floor but not on the first floor as there are more demands on staff time, especially when the Deputy Manager is on duty as one of the three staff as she has managerial duties to attend to as well. From the staff records inspected these were in order with CRB and Pova checks in place. The Company have ‘sent’ staff to the Home to work without the Manager interviewing them for suitability. It is strongly recommended that this practice cease as the Manager is qualified to undertake this and in the best position to assess the needs of the Home. Staff appear to be generally well trained as individual training records are available and are due to have health and safety training and basic first aid training. However an audit of training needs is to be completed to identify all training needed. Saffron House C51 S36290 Saffron House V226160 100505.doc Version 1.30 Page 17 Eight staff have received NVQ 2 training and 9 staff are commencing this training. Staff have to pay for CRB checks. It is strongly recommended that the Company pay for these on the basis of fairness and encouraging staff recruitment. Saffron House C51 S36290 Saffron House V226160 100505.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) 33,38 The Home needs to have a quality assurance system in place. There are systems and practices in place to promote the health, safety and welfare of residents and staff but not having regular fire drills threatens the welfare of all in the Home if staff do not appropriately follow the fire drill if such a situation arises. Risk assessments are to be reviewed and added to where necessary. EVIDENCE: A system of Quality Assurance has not yet been implemented in the home. This needs to actively seek the opinions of all residents, relatives, staff and other stakeholders. The Responsible Individual and acting Manager need to oversee all consultation and ensure that suggestions and feedback are responded to and/or acted upon, e.g food preferences. Staff are to receive health and safety training in the near future, as this has been booked for June – August this year. Saffron House C51 S36290 Saffron House V226160 100505.doc Version 1.30 Page 19 A staff member stated that pumping systems are to be removed from the kitchen and laundry so that staff will have to lift heavy bottles instead. Management are to risk assess this. A fire drill had not been carried out since 2/2/04, a gap of over 15 months – this is a serious matter and must not be repeated. Fire drills must be carried out every 3 months and staff trained on fire procedure. The Acting Manager has now carried out two fire drills since the first inspection day. Risk assessments on safe working practices are in place and are to be extended, e.g. for residents access to aerosols and for the GP to be called if medication is wrongly administered. The Fire Officer has approved the Fire Risk Assessment. Staff said they had not read all the Home’s policies and procedures – the Manager is to ensure that this occurs. Saffron House C51 S36290 Saffron House V226160 100505.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 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 2 COMPLAINTS AND PROTECTION 2 x x x 2 x x x STAFFING Standard No Score 27 2 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 2 x x 1 x x x x 2 Saffron House C51 S36290 Saffron House V226160 100505.doc Version 1.30 Page 21 Yes 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. 2. Standard 3 7 Regulation 19 15 Requirement Staff training is needed for all residents conditions- stroke, diabeties, Parkinsons Disease etc All residents care plans and risk assessments to be reviewed to ensure needs are clearly stated. All residents (or their representative) should be part of the review process. Service users identified as being of concern of weight loss must have regular checks as per the Care Plan risk assessment. Staff who administer medication must sign the medication record after medication has been administered and not before. Staff need training to ensure they fully understand residents rights, e.g to drinks, toiletting needs etc. All staff must know the homes policies and procedures on safeguarding residents from abuse. The kitchen requires redecoration and the wall cracks to be repaired. Residents aids and adaptations need to be assessed to ensure they are relevant to assessed C51 S36290 Saffron House V226160 100505.doc Timescale for action 20/8/05 20/8/05 3. 8 13 20/5/05 4. 9 13 10/5/05 5. 10 19 20/605 6. 18 13 20/7/05 7. 8. 19 23 16 12 20/8/05 20/705 Saffron House Version 1.30 Page 22 needs. 9. 10. 27 29 16 18 4 Staff are needed on the first floor to cover residents needs. All staff must have a clear record of their training and development needs and acheivements. A more formal system of Quality Assurance must be implemented in the home. This must actively seek the opinions of all residents, relatives, staff and other stakeholders. The Responsible Individual and acting Manager must oversee all consultation and ensure that suggestions and feedback are responded to and/or acted upon, e.g food preferences. There must be a minimum of three monthly fire drills and all staff to receive fire training. Thee needs to be the full range of risk assessments in place to include all safe working practice issues. 20/6/05 20/8/05 11. 33 24 20/9/05 12. 13. 38 38 23 23 20/6/05 0/7/05 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. 2. 3. 4. 5. Refer to Standard 7 12 33 33 Good Practice Recommendations That staff read all residents Care Plans That an Activities Organiser is employed for 5 days a week instead of the present 4 days a week. That the Manager determine staff appointments. That the Company pay for staff CRB checks. Saffron House C51 S36290 Saffron House V226160 100505.doc Version 1.30 Page 23 Commission for Social Care Inspection The Pavilions, 5 Smith Way Grove Park Enderby Leicestershire 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 C51 S36290 Saffron House V226160 100505.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. 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