Inspection on 13/12/05 for Seven Arches

This inspection was carried out on 13th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Seven Arches 24/07/08

Seven Arches 07/08/07

Seven Arches 06/09/06

Seven Arches 29/03/06

Seven Arches 22/03/05

Seven Arches 12/05/04

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 Seven Arches Lea Rigg Cornsland Brentwood Essex CM14 4JN Lead Inspector Carolyn Delaney Unannounced Inspection 13th December 2005 14:00 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 Seven Arches DS0000015560.V273283.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. Seven Arches DS0000015560.V273283.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Seven Arches Address Lea Rigg Cornsland Brentwood Essex CM14 4JN 01277 263076 01277 216692 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) Brentwood Homes Limited Mr Lochan Kunkun Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30), Terminally ill (4) of places Seven Arches DS0000015560.V273283.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Nursing and personal care to be provided for up to 30 Older People. Nursing care for up to 4 Older People with a Terminal Illness. Maximum number to be cared for shall not exceed 30. Date of last inspection 22nd March 2005 Brief Description of the Service: Seven Arches is a large purpose built two storey property situated in a quiet residential area close to Brentwood town centre and within approximately one mile from Brentwood rail station. The home provides single bedroom accommodation for up to a maximum of thirty older people, including up to a maximum of four people who have a diagnosed terminal illness. Residents have access to extensive well maintained external grounds and the home is decorated and maintained to a high standard. Seven Arches DS0000015560.V273283.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine inspection carried out between 14.00 and 17.00 on 13th December 2005. Records including assessments, care plans, daily care notes and risk assessment documents in respect of three people living at the home were examined. Two residents and four relatives were spoken with during the inspection. Three members of staff including the manager were spoken with and records in respect of the recruitment, training and supervision of staff were sampled. A number of records including policies and procedures in respect of the day-today management of the home were examined. Key standards as identified in the intended outcomes sections of this report are inspected at least once every twelve months. Where key standards have not been inspected on this occasion they will have been inspected at the previous inspection. Reports in respect of previous inspections may be accessed via the Commissions website www.csci.org.uk. What the service does well: Seven Arches provides a safe, comfortable and homely environment for older people who have a variety of nursing needs. Staff are well trained and supported and employed in appropriate numbers so that residents needs are met. Information about residents such as care and treatment, risks to their health and wellbeing is recorded in a detailed way and kept up to date so that all staff are aware of these needs and how to assist residents to carry out daily activities. The home is well managed and residents and their relatives are consulted regularly about the care and services provided. Seven Arches DS0000015560.V273283.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Assessments of each person’s nursing needs must be consistently carried out and recorded before they are offered a place at the home so as to determine that and assure the residents and or their relatives that the home can meet these needs. All nursing staff working at the home must ensure that they record accurately and consistently when they administer medication in accordance with the home policies and procedures and current legislation. Records kept in respect of staff training and supervision should be kept in a more organised manner so as to provide evidence upon request of the practices in the home and all staff, including those who work at night, must have regular training regarding the management of fire risks at the home. There should be provided for residents a place where they may keep monies and items of value for safekeeping and a system in place for recording such items receipt and return. Seven Arches DS0000015560.V273283.R01.S.doc Version 5.0 Page 7 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. Seven Arches DS0000015560.V273283.R01.S.doc Version 5.0 Page 8 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 Seven Arches DS0000015560.V273283.R01.S.doc Version 5.0 Page 9 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&5 Assessments of prospective residents nursing and care needs are not carried out in a consistent manner so as to determine that the home will be able to meet these needs. A visit to the home is offered to the resident and / or their representative so that they can make a decision as to whether they would wish to move in, prior to any assessment is carried out by staff at the home. EVIDENCE: There was no pre- admission assessment for one resident who had been recently admitted to the home. The nurse who visited this person said that she had a detailed social services assessment prior to making the visit to assess the patient. Pre-admission assessments, which were carried out, varied in content and did not always include sufficient information so as to determine that the home could meet the needs. Seven Arches DS0000015560.V273283.R01.S.doc Version 5.0 Page 10 It was positive to note that detailed assessments of each persons nursing and general care needs carried out upon their admission to the home and that at this initial stage the key nursing, general and safety needs were clearly identified so that appropriate care and treatment can be planned and implemented. Before staff visit prospective residents they request that the person or their representative view the home to see if they would be happy to move in should the home be capable of meeting their assessed needs. Seven Arches does not provide intermediate or rehabilitative care. Seven Arches DS0000015560.V273283.R01.S.doc Version 5.0 Page 11 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, & 11 There is detailed information recorded about residents nursing, care and safety needs so as to ensure that all staff working at the home are aware of and can meet these needs. Staff do not consistently maintain records in respect of the administration of medicines so as to evidence that all residents receive the medicines, which have been prescribed for them and to minimise the risks of mishandling. Residents and their visitors are treated with respect. Residents wishes regarding end of life issues are recorded where they are provided. EVIDENCE: Care plans are written promptly upon each individual’s admission to the home. Care plans, which were sampled, were very detailed in respect of each persons nursing and general care needs. There was evidence of residents or families involvement and agreement in some but not all of the care plans which were Seven Arches DS0000015560.V273283.R01.S.doc Version 5.0 Page 12 sampled. Some residents are not capable of agreeing to or being involved in the development and reviewing of planned care. There were detailed assessments carried out in respect of each person’s nutritional needs, risks of developing pressure sores and risk of falls. These assessments were kept under regular review. At the time of this inspection two people living at the home had pressure sores. It was recorded that these people had been admitted into the home with these and there were detailed plans in respect of the care and management of pressure sores. It was also positive to note that the advice of the resident’s general practitioners had been sought regarding what type of dressings to use to use, as there was no Tissue Viability Nurse specialist support available in the community at the time of this inspection. There was no formal assessment tool in use for assessing the risks to residents of sustaining injury through the use of bedrails, however where bedrails were in use there was a plan of care in place to manage these risks. There were up to date records maintained regarding visits made to residents by other medical and healthcare professionals. At the time of this inspection none of the people living at the home were capable of retaining control of and administering their own medication. Medication Administration Records (MAR) were examined and there were a number of omissions of signatures in respect of the administration of medication. The homes manager undertook to address this. Records maintained in respect of medicines received into the home, and disposed of after the discharge or death of residents were up to date and accurate. Staff were observed to treat residents and their visitors with respect and dignity. There was recorded information regarding resident’s wishes in respect of end of life issues and preferred arrangements following death for those residents who chose to provide this information. Seven Arches DS0000015560.V273283.R01.S.doc Version 5.0 Page 13 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): 13 & 15 People living at Seven Arches may receive visitors at any reasonable time according to their wishes. Staff working at the home ensure that each persons individual nutritional needs are met and that they receive a varied and balanced diet. EVIDENCE: Seven Arches operates an open visiting policy where residents may receive visitors at any time they choose. Visitors who were spoken with during this inspection confirmed this and said that they were always made to feel welcomed when they visited the home. Residents said that the food provided by the home was very good and that there were choices and a daily menu. Residents are weighed on a regular basis and are provided with nutritional supplements if required. It was positive to note that where residents required their meals to be blended or pureed that the reason for this was recorded and that they or their families were involved in this decision. Seven Arches DS0000015560.V273283.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Staff act and are supported and trained so as to ensure the protection of the people who live at the home from harm and abuse. EVIDENCE: There had been no complaints made in respect of the services provided by the home since the last inspection. There is information available to residents and their relatives and friends regarding how to make complaints, including referring complaints to the Commission for Social Care Inspection. Staff receive regular in house training and supervision regarding how to protect the people who live at the home from harm and abuse. Seven Arches DS0000015560.V273283.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 15, & 26 Seven Arches provided comfortable, clean, bright and well-maintained communal and personal spaces for the people who live there. EVIDENCE: Each resident is provided with his or her own bedroom. Twenty-two rooms have ensuite facilities and there are sufficient bathrooms and toilet facilities to meet the assessed needs of residents. The home is maintained to a high standard in terms of general décor and cleanliness. There were no unpleasant odours detected during this or previous inspections. Residents have access to two lounge areas, one of which is used to hold birthday parties and to provide privacy for visitors as required, a dining room, a room for hairdressing and well-maintained attractive garden. Seven Arches DS0000015560.V273283.R01.S.doc Version 5.0 Page 16 The home has equipment such as lifting hoists, wheelchairs and pressure relieving mattresses and cushions to meet the assessed needs of the people who live at the home. Seven Arches DS0000015560.V273283.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29, & 30 Staff are employed in sufficient numbers and skill mix to meet the needs of the people who live at the home. Staff are recruited robustly so as to best protect the interests and welfare of the people who live at the home. Staff receive regular and ongoing training and support, however records maintained in respect of this could be better organised. EVIDENCE: The staff duty rota provided evidence that staff are employed in sufficient numbers to meet the needs of the people who live at the home. Staff do not work excessive hours without appropriate off duty time. Care staff are supported by experienced nursing staff some of whom provide regular in house training, supervision and support which covers how to manage illnesses and conditions associated with the aging process, terminal illness etc. Documents and records in respect of the recruitment of staff were available and up to date. Checks including the receipt of satisfactory references, Seven Arches DS0000015560.V273283.R01.S.doc Version 5.0 Page 18 Criminal Records Bureau (CRB) disclosures, and previous employment history were made and information recorded. Records maintained regarding the interviewing of staff were not consistently maintained. Records and certificates in respect of recruitment, training and supervision are not stored consistently so as to easily evidence training provided. The manager undertook to address this Seven Arches DS0000015560.V273283.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 35, 36 & 38 Seven Arches is well managed with clear lines of accountability and residents and / or their relatives meet regularly with the manager and are consulted and kept up to date with changes to the day to day running of the home. The home does not hold monies or valuables for safekeeping on behalf of the residents who live there and residents are discouraged from keeping monies in their rooms. Staff are supported and supervised in a consistent manner so as to best meet the needs of the people who live at the home. The home is managed and maintained so as to protect the safety and welfare of the people who live in, work at and visit the home. Seven Arches DS0000015560.V273283.R01.S.doc Version 5.0 Page 20 EVIDENCE: The manager works at the home most days in a supernumerary capacity and oversees the day-to-day running and provision of care and treatment. Residents and their relatives can discuss care and any issues with the manager informally or formally when they visit. Relatives are invited to meet with management and staff twice yearly and these meetings generally coincide with planned parties such as the Christmas party so as to maximise attendance. The manager said that residents are discouraged from keeping monies with them, however one resident does and staff do not hold monies on behalf of residents. The manager said that this arrangement suits residents and relatives. Records in respect of the maintenance, upkeep and repair of gas, electrical, mechanical and fire safety equipment were up to date and accurate. There were assessments recorded regarding the risk of outbreak of fire in key areas such as kitchen and laundry and assessments for other areas were being developed in accordance with guidance from Essex Fire & Rescue. It was noted that the last fire safety drill for staff was carried out in August 2005. This did not include all night staff working at the home. Seven Arches DS0000015560.V273283.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 3 3 3 3 3 3 4 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X 3 2 4 X 2 Seven Arches DS0000015560.V273283.R01.S.doc Version 5.0 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 OP3 Regulation 14 Requirement Timescale for action 30/12/05 2 OP9 13(2) 3 OP33 24 The registered persons must ensure that a detailed assessment of each prospective residents nursing and care needs is carried out and recorded prior to their admission to the home so as to determine that the home can meet these needs. The registered persons must 30/12/05 ensure that all staff adhere to the homes policies and procedures in respect of the administration of medicines in the home. An effective system for 28/02/06 monitoring and improving the quality of services, which meets current regulatory requirements must be implemented and a report made available to relevant parties including the Commission for Social Care Inspection. This standard was not fully assessed at this inspection 4 OP35 16(2) (l) The registered persons must ensure that a suitable place is provided for the storage of DS0000015560.V273283.R01.S.doc 30/01/06 Seven Arches Version 5.0 Page 23 5 OP38 23(4) (d) (e) monies and valuables for the residents living at the home, should they choose to do so. The registered persons must ensure that all practicable measures are taken so as to ensure that all staff are prepared to deal with the risks of fire outbreak at the home. 30/01/06 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 Refer to Standard OP30OP29 Good Practice Recommendations The records maintained in respect of staff recruitment, training and supervison of staff would benefit from reorganisation so as to better evidence good pratcices at the home. Seven Arches DS0000015560.V273283.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Seven Arches DS0000015560.V273283.R01.S.doc Version 5.0 Page 25 - 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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