Inspection on 22/09/05 for Saffron House

This inspection was carried out on 22nd September 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 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 22nd September 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 House DS0000036290.V250797.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 House DS0000036290.V250797.R01.S.doc Version 5.0 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.V250797.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. No person under 55 years of age who falls within categories PD or DE may be accommodated in the home Persons who fall within either category DE or DE(E) may only be accommodated on the ground floor 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 10/5/05 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.V250797.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on Thursday 22nd September 2005. The inspector arrived at the home at 9.45am and finished the inspection at 14.20pm. 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 Acting Manager was undertaking training work and therefore not 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 high level of Requirements from the last inspection another inspection visit took place in August 2005 to follow up these Requirements. There have been no recent Complaints Investigations since the current Acting Manager took over. The Inspection included a tour of the building, inspection of records and direct and indirect observation of care practices. The Inspector spoke with ten residents, four members of staff and a relative. The relative was completely satisfied with the running of the service and the Acting Manager for the improvements in the delivery of care to service users. The Inspector completed the Inspection on 28/9/05 with the Acting Manager. What the service does well: Service users said that the food was good, staff were 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. Saffron House DS0000036290.V250797.R01.S.doc Version 5.0 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.V250797.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 House DS0000036290.V250797.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): 3,4 Prospective service users have their needs are assessed though staff training is needed to ensure proper awareness of all service users needs. EVIDENCE: From looking at a file of a service user it was obvious that there was sufficient assessment information to plan for needs. However staff said that they had not received training in all health conditions that residents have, e.g. Parkinsons Disease, stroke, epilepsy etc. The Registered Manager said this was being currently organised to increase staff awareness. Saffron House DS0000036290.V250797.R01.S.doc Version 5.0 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 knowing service users needs though greater consultation with service users /representatives is needed. Medication recording was generally good. EVIDENCE: Service users were generally complimentary regarding the care they received and said that staff were kind and attentive. Care plans generally had the required information regarding service users health, medical and physical care needs though they are currently being reviewed and improved on by the Acting Manager. Care plans had been reviewed on a monthly basis. One service user said that he could not move in the morning but staff tried to get him to mobilise too quickly. He said he had not been consulted about his Care Plan and would like to be. Residents said they had not heard of a care plan or been involved in setting up their own plans, 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. Saffron House DS0000036290.V250797.R01.S.doc Version 5.0 Page 10 Staff said they had read care plans. Residents said they were looked after when they were not well. The accident records showed an improvement in staff alerting medical authorities if service users were injured. This was not carried out on one occasion but was then picked up by the Acting Manager and the staff member reminded of the proper procedure. Medication records were generally well recorded with only a small number of gaps. Saffron House DS0000036290.V250797.R01.S.doc Version 5.0 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): N/A – see last Inspection Report for information on these standards. EVIDENCE: - Saffron House DS0000036290.V250797.R01.S.doc Version 5.0 Page 12 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): 18 Service users/their representatives can be confident that staff are vigilant regarding protection from abuse. EVIDENCE: Service users said that they felt safe in the home. Staff said that they had received training in abuse. Staff were asked as to the adult protection procedure and had a good understanding of the steps they needed to take in the event of abuse. Saffron House DS0000036290.V250797.R01.S.doc Version 5.0 Page 13 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 and protective of residents privacy. EVIDENCE: Service users 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 Home was found to be in a clean and tidy condition though there was an unacceptable odour in the ground floor lounge, which was not tackled until lunchtime. The Acting Manager said that this carpet was a problem because of ingrained odour and it was being replaced in the near future. The rest of the facilities were found to be odour free. Cracks and decor in the kitchen have now been attended to with this area being redecorated. Saffron House DS0000036290.V250797.R01.S.doc Version 5.0 Page 14 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): 27,29,30 Staffing levels do not meet service users needs and the recruitment process does not fully protect service users. EVIDENCE: There were some comments from service users that at times there were not enough staff though this was better since the last inspection. There are three to four staff care staff on duty on each wing of the Home in the morning, reducing to two to three staff in the afternoon/evening. This is sufficient on the first floor but not on the ground floor in the evening where there are only two care staff on duty with one staff ‘floating’ and available from the first floor. The Acting Manager said she would arrange additional cover on the ground floor from 6-9pm. At weekends care staff reduce to six overall. The Registered Provider must ensure that this is sufficient to cover service users needs. From the staff records inspected one had a references, Criminal Records Bureau and a Protection of Vulnerable Adults check missing. Staff said they had undergone Moving and Handling, Food Hygiene training and basic first aid training. An audit of training needs is to be completed by the Acting Manager to identify all training needed who stated that all staff were encouraged to complete National Vocational Qualification level 2 and 3 training. Saffron House DS0000036290.V250797.R01.S.doc Version 5.0 Page 15 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 Health and Safety systems do not fully protect the welfare needs of service users. 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 monthly Regulation 26 Report on the running of the home was not available since May 2005 and had not been sent to the Commission for Social Care Inspection. A service user was observed to be lifted inappropriately. The Acting Manager stated that staff would be appraised of the proper Moving and Handling procedures and given refresher training as necessary. Saffron House DS0000036290.V250797.R01.S.doc Version 5.0 Page 16 A fire drill had not been carried out since 13/5/05, a gap of over four months. Fire drills must be carried out every three months and staff trained on fire procedure. One staff member was not aware of the full procedure. There was a three week gap in the required weekly fire bells testing. Staff said they had not read all the Home’s policies and procedures – the Manager is to ensure that this occurs. Saffron House DS0000036290.V250797.R01.S.doc Version 5.0 Page 17 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 3 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X X 2 2 Saffron House DS0000036290.V250797.R01.S.doc Version 5.0 Page 18 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 2 Standard 4 7 Regulation 18 15 Requirement The Registered Provider needs to ensure staff are trained as to service users health conditions. The Registered Provider needs to ensure that all service users/representatives are consulted as to the Care Plan Flooring in a lounge needs to be replaced. Facilities must be odour free Staffing levels must be sufficient to meet the needs of service users. Staff recruitment procedures must include receiving all documents in schedule 1 of the Care Homes Regulations 2001. A system of Quality Assurance needs to be in place. Regulation 26 Reports on the running of the service need to be carried out on a regular basis. The Registered Provider must ensure that the Health and safety needs of residents and staff are fully protected – proper Moving and Handling techniques and ensuring the proper testing of fire alarms and regular fire DS0000036290.V250797.R01.S.doc Timescale for action 28/12/05 28/11/05 3 4 5 6 19 26 27 29 23 23 18 19 28/11/05 22/09/05 22/10/05 22/10/05 7 8 9 33 37 38 24 26 13 28/12/05 28/10/05 23/09/05 Saffron House Version 5.0 Page 19 drills. 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 House DS0000036290.V250797.R01.S.doc Version 5.0 Page 20 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.V250797.R01.S.doc Version 5.0 Page 21 - 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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