Inspection on 25/07/07 for Scarletts

This inspection was carried out on 25th July 2007.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Scarletts 17/07/08

Scarletts 17/08/06

Scarletts 06/12/05

Scarletts 09/06/05

Scarletts 12/10/04

Scarletts 18/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Scarletts Recreation Road Colchester Essex CO1 2HJ Lead Inspector Neal Cranmer Key Unannounced Inspection 25th July 2007 09:00 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 Scarletts DS0000017928.V347268.R02.S.doc Version 5.2 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. Scarletts DS0000017928.V347268.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Scarletts Address Recreation Road Colchester Essex CO1 2HJ 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) 01206 792429 01206 870694 Southend Care Limited Mrs Mandy Faires Care Home 50 Category(ies) of Dementia - over 65 years of age (16), Old age, registration, with number not falling within any other category (50) of places Scarletts DS0000017928.V347268.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 50 persons) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 16 persons) The total number of service users accommodated in the home must not exceed 50 persons The registered provider must review staffing levels (care and ancillary) in consultation with the Commission, within six months of dementia registration, to ensure that staffing levels are sufficient to meet the needs and number of service users 17th August 2006 Date of last inspection Brief Description of the Service: Scarletts Residential Care Home is a purpose built care home for older people, located close to Colchester town. It accommodates up to 63 people, in 31 single rooms and 16 double rooms: however, at present the home is choosing to use 13 of the double rooms as single rooms, and has therefore reduced the number of beds to 50 at the current time. Accommodation is on two floors, with a passenger lift providing access to the first floor, a variety of communal lounge areas, a large dining room and pleasant grounds. Scarletts is registered to provide care to 63 older people (over the age of 65). The home provides 24-hour personal care and support, and has appropriate aids and equipment (e.g. mobile hoist, assisted bathing facilities, hand rails, etc.) to assist residents with limited mobility. The homes conditions of registration have recently been amended to enable the home to accommodate up to 16 individuals who suffer with dementia. The home does not provide nursing care. The home is owned by Southend Care Ltd, and the manager (Mandy Faires) was present during the inspection. The current scale of charges, as notified to the inspector by the home’s registered manager at the time of the inspection visit is between £367.15 and £450 per week, with additional charges for personal items (toiletries, hairdresser, newspapers, chiropody, etc.). A ‘service users’ guide’ is available to prospective residents to inform them about the home. Scarletts DS0000017928.V347268.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report follows an unannounced key inspection of Scarletts, which took place on the 25th July 2007, with the assistance of the registered manager Mrs Mandy Faires. On the day of the inspection visit the home was providing care and support to 48 residents. The inspection process included discussions with residents, staff and the manager; in addition, feedback was received from a visiting healthcare professional. During the course of the inspection an environmental tour of the premises was undertaken including a sample of individual bedroom areas, communal areas, the laundry and kitchen facilities. In addition to this tour a range of documentary evidence, including policies and procedures were sampled. What the service does well: What has improved since the last inspection? The home’s medication practice has been improved in relation to recording administration of medicines, and the requirement set from the previous inspection has now been met. Scarletts DS0000017928.V347268.R02.S.doc Version 5.2 Page 6 Records relating to complaints have been improved, and are now appropriately maintained. A significant amount of re-decoration has been undertaken since the last inspection, and overall the home is looking good, apart from one or two areas (these were discussed with the registered manager at the time of the inspection). Recruitment records sampled were all in order and contained all of the necessary information required under regulation. 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. The summary of this inspection report can be made available in other formats on request. Scarletts DS0000017928.V347268.R02.S.doc Version 5.2 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 Scarletts DS0000017928.V347268.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and those admitted for intermediate care can expect their needs to be assessed by an individual who is competent to do so and be confident that the home will have the skills and facilities to meet their needs. EVIDENCE: The home employs a placement co-ordinator whose role it is to carry out all the pre-admission assessments for prospective residents. The sample of the assessments seen showed that they were comprehensively detailed. These assessments are used as the basis for formulating the initial plan of care. The home provides three intermediate care beds, which are specifically dedicated to residents admitted for intermediate care. At the time of the inspection two residents who were admitted for intermediate care were in residence. Both these care plans were sampled as part of the inspection Scarletts DS0000017928.V347268.R02.S.doc Version 5.2 Page 9 process. The home was deemed to be appropriately equipped to meet the needs of residents admitted for intermediate care. Scarletts DS0000017928.V347268.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans are not sufficiently detailed to ensure that residents’ needs will be appropriately met, however personal healthcare needs were satisfactorily met, in a way that respects the privacy and dignity of residents. Medication practice within the home was good and protected residents. EVIDENCE: From observation during the inspection and from feedback from residents, visiting professionals and staff at the home were seen to be providing appropriate support to help meet residents’ personal care needs. There was evidence of regular liaison by staff with general practitioners and District Nurses. Scarletts DS0000017928.V347268.R02.S.doc Version 5.2 Page 11 Feedback received from one visiting professional indicted a view that the home provides a good level of care and communication, and that interaction from staff towards residents was good. Discussion with staff indicated a good level of awareness about how to meet residents needs, however this was not reflected in the care plans. Guidance for staff was often unclear with statements like ‘requires help with personal care’ statements like these need to be clarified further to identify in what way is help required, significant discussion took place with the registered manager about how the care plans could be further developed. It was noted that significant work had already been undertaken to improve the care plans, further work is however required to take them to the next step. The home has in place robust policies and procedures covering the receipt and storage of medicines, controlled drugs, administration and recording. Medicines, which become out of date, are returned to pharmacy via a medication returns book. Staff administering medicines are all team leaders or senior carers, and do so only upon completion of training. A record of all staff administering medicines is maintained with sample signatures. The home does maintain controlled medicines, and these were seen to be appropriately stored, records pertaining to these medicines were scrutinised and were in order. Discussion with the registered manager confirmed that at the time of the inspection their were no residents in residence who were self medicating. During the course of the inspection staff were observed supporting residents in a friendly and respectful manner, staff spoke with were well aware of the importance of privacy and dignity and gave examples of how they maintained these issues in their daily practice. Residents spoke of staff always being polite and respectful and indicated that they felt staff supported them with their personal care needs in a way that preserved their dignity. Scarletts DS0000017928.V347268.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect the home to provide an environment that meets their social and recreational preferences in a flexible way that provides them with choice in regard to their daily lives. Residents can expect to be provided with a diet that is varied and nutritious. EVIDENCE: The activity programme in Scarletts continued to offer a variety that was appropriate to the needs of the residents. The weekly programme included: bingo, cooking, painting, keep fit, news updates, garden updates and quizzes. The home also takes residents to local attractions and activities, which they often visit jointly with a sister home. The home keeps records of activities taken part in by residents, and it was clear from viewing these that residents appreciated the programme of activities on offer. Residents were seen using all areas of the home, and those spoken with said that there were no restrictions on them. The atmosphere observed in the home was one of calm. Scarletts DS0000017928.V347268.R02.S.doc Version 5.2 Page 13 Staff spoken with spoke of encouraging residents to maintain links with their families and friends. The visitor’s book, which was sampled, showed that visitors are free to visit the home at any time, and evidenced a good turnover of visitors to the home. Routines observed in the home were flexible, and staff were seen supporting residents to make choices rather than making them for them. The menus sampled on the day of the inspection reflected a variety of balanced and nutritional meals being provided. Overall the kitchen was seen to be clean and well organised, and the food stocks seen were of a good quality. The meal provided on the day was appealing and residents spoken with spoke of meals being good Scarletts DS0000017928.V347268.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that any concerns and complaints expressed will be listened to and acted upon, and that the home has in place robust policies and procedures for responding to allegations or incidences of abuse. EVIDENCE: Since the previous inspection there have been three complaints received, each of which had been logged by the home. A sample of the logs indicated that the complainants had been informed of the outcome of the investigation undertaken. Discussion with residents indicated that they were aware of who to speak to in the event that they felt the need to raise a complaint. The Adult Protection policy and procedure used by the home is unchanged and remains a good working document and is sufficiently detailed and informative to ensure the protection of residents. Discussion with the registered manager indicated that all staff have now received training in adult protection. All five of the staff files sampled during the course of the inspection confirmed this to be the case. Scarletts DS0000017928.V347268.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24,25 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect to be supported in an environment that is generally homely and safe, and which is well maintained, and in which they will be encouraged and supported to bring their own possessions when moving into the home. Residents can also expect the home to be clean and hygienic. EVIDENCE: Overall on the day of the inspection the home was clean and tidy and from observation was generally well maintained. It was evident that a number of areas of the home had undergone refurbishment and redecoration since the previous inspection including: most of the bedrooms, the lounges and the dining room. Scarletts DS0000017928.V347268.R02.S.doc Version 5.2 Page 16 However there were still some areas where the feel of the home was not one of homeliness (these areas were discussed with the registered manager at the time of the inspection). It was noted during the tour that a significant number of radiators remain unguarded or of the low surface temperature variety, and as such continue to pose a risk to residents. During the environmental tour of the premises a number of resident’s rooms were seen, those seen were pleasantly decorated and evidence was seen of resident’s personal possessions. The laundry area remains suitable for its stated purpose, and was equipped with washing machines that were capable of meeting infection control requirements. Scarletts DS0000017928.V347268.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be assured that the staff team supporting them will be equipped and trained with the necessary skills to meet their needs, and that each member of staff will have gone through a robust recruitment process. EVIDENCE: On the day of the inspection there were forty-eight residents in residence, with nine care staff on duty, in addition to which there were a number of ancillary staff including: a housekeeper, kitchen assistant, cook, laundry person and administrator. Discussion with the manager and five members of the staff team indicated that they felt that the current staffing level were satisfactory to meet the needs of the residents. It was good to see during the course of the inspection that staff were finding time to spend with residents in a variety of activities, indeed the inspector was at one point able to join in a trivial pursuit quiz with a group of residents. The recruitment files for five members of the staff team were sampled. Each file contained a completed application form, which included the individual’s employment history, a criminal declaration, and evidence of two referees. All five of the files sampled had evidence that an induction had been completed, and of training having been undertaken in the following areas: Scarletts DS0000017928.V347268.R02.S.doc Version 5.2 Page 18 manual handling, adult protection, medication administration, fire awareness. Discussion with staff during the course of the inspection indicated that access to staff training was good; and staff were able to relate the theoretical knowledge gained to their practice. Information submitted on the day of the inspection by the registered manager showed that three staff have the N.V.Q level 2, three have level 3, one has level 4 in management and care, 3 are N.V.Q assessors, in addition to those qualified there are a further 9 in the process of doing one of the two awards, with a further 8 waiting to commence the award. Scarletts DS0000017928.V347268.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can be expect to be supported in a home that is well run and managed in their best interests, where their financial interests are generally well safeguarded. However they cannot be assured that all areas of the home are sufficiently well protected to ensure their safety and welfare. EVIDENCE: Discussion with the registered manager confirmed that she has a significant number of years experience of working in the care sector, and is qualified at N.V.Q level four in management and care. Scarletts DS0000017928.V347268.R02.S.doc Version 5.2 Page 20 All of the residents spoken with during the course of the inspection spoke of the manager being very good and caring, stating that she was always approachable. These comments were reiterated during discussions with members of the care team, who further commented on the manager being open and transparent and providing the team with a clear sense of leadership and direction. Quality assurance within the home is addressed through a number of processes including: residents meeting which are held every three monthly, a monthly managers report covering a range of areas relating to the home e.g. Staffing, training, activities. In addition to these processes a monthly visit by a representative of the organisation is carried out under Regulation 26 of the Care Homes Regulations, the last of which was seen to have been carried out in April 2007. The home continues to provide facilities for the safekeeping of resident’s money. Three residents’ accounts were examined, two of which were found to have minor errors. Both the registered manager and her administrator were quick to explore where these errors had originated. The records sampled were generally well kept and detailed and provided a clear financial audit. During the course of the inspection an environmental tour of the premises was undertaken including viewing of residents rooms, bathing and toileting facilities as well as communal areas. As noted (from the environment section) a significant number of radiators remain unguarded both in residents own rooms as well as in communal areas, this continues to pose a risk to residents’ health and well being and remedial action needs to be taken as a matter of urgency. Scarletts DS0000017928.V347268.R02.S.doc Version 5.2 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 X 3 X X 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 x X X X 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 2 Scarletts DS0000017928.V347268.R02.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Care plans must be developed further, to cover all of a person’s needs (personal/health care, mental health and social), and to include clear details of the action required by staff to meet each need. Care plans must be updated when a resident’s needs change. This is a repeat requirement for the second time (last timescale 31/1/06). 2. OP25 OP38 13 The home must progress action to reduce the risk to residents from unprotected hot radiators. This is a repeat requirement. 31/10/07 Timescale for action 31/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Scarletts DS0000017928.V347268.R02.S.doc Version 5.2 Page 23 No. 1. Refer to Standard OP28 Good Practice Recommendations If staff have alternative qualifications that are equivalent to NVQ level to in care or above, evidence to demonstrate this should be maintained in the home. Scarletts DS0000017928.V347268.R02.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Scarletts DS0000017928.V347268.R02.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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