Inspection on 10/11/08 for Suffolk Court

This inspection was carried out on 10th November 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Suffolk Court 15/11/07

Suffolk Court 24/01/07

Suffolk Court 30/11/05

Suffolk Court 31/05/05

Suffolk Court 17/11/04

Suffolk Court 22/06/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 30/01/2009.

CARE HOMES FOR OLDER PEOPLE Suffolk Court Silver Lane Yeadon Leeds LS19 7JN Lead Inspector Hebrew Rawlins Key Unannounced Inspection 10th November 2008 08:40 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 Suffolk Court DS0000033240.V373068.R01.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. Suffolk Court DS0000033240.V373068.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Suffolk Court Address Silver Lane Yeadon Leeds LS19 7JN 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) 0113 2509540 P/F 0113 2509540 fiona.wood@leeds.gov.uk Leeds City Council Department of Social Services Miss Fiona Tracy Wood Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40), Physical disability (1) of places Suffolk Court DS0000033240.V373068.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 2007 Brief Description of the Service: Suffolk Court is a local authority home providing personal care primarily for older people of both sexes. There are 33 permanent places and seven places dedicated to respite services. The home is a two storey building on two floors with stairs and a passenger lift providing access to the first floor. Accommodation is in single rooms, all of which have en-suite facilities and there are well-equipped and large assisted communal bathing facilities. There are plenty of toilets situated throughout the building. Lounge and dining facilities are situated on both floors with the main large dining and lounge area on the ground floor. There is level access to the enclosed gardens with some rooms overlooking this attractive area. The home is situated in Yeadon and is close to many local amenities. Information about the service is available in a Statement of Purpose and Service User Guide. Copies of the inspection reports are available on request. The fees range from £77.15 to £497.30 per week. There are additional charges for hairdressing and newspapers. This information was provided by the service on the 10th November 2008. Suffolk Court DS0000033240.V373068.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means that people that use the service experience adequate quality outcomes. The inspection process included looking at information we have received about the service since the last key inspection, as well as this unannounced visit to the home, which was carried out between 08:40 and 16.30 hrs on the 10th November 2008. The methods we used included looking at records, observing staff at work, talking to people living at the home, talking to staff and looking around the property. Before the visit we had provided some people living at the home, their relatives and other healthcare professionals with survey questionnaires so that they could share their views of the service with us. The information they provided has been used as evidence in the body of the report. The home had also completed and returned their Annual Quality Assurance Assessment form and the information provided has also been used as evidence in the body of the report. The purpose of the visit was to assess what progress the home had made in meeting the requirements made in the last inspection report and the impact of any changes in the quality of life experienced by people living at the home. We have recently improved our practice when making requirements to improve national consistency. Some requirements from previous inspections may have been deleted or carried forward as recommendations, but only when it is considered that people that use the service are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. The registered manager was on leave, so the senior carer was available throughout the day of the visit and proved to have a very positive attitude to the inspection process. Feedback was given to the senior carer at the end of the visit. Suffolk Court DS0000033240.V373068.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The level of detail in some support plans on how personal care and health related task are carried out is not always detailed enough and could lead to important needs being overlooked. Staff involved in the administration of medication need to be updated to make sure that they follow polices and procedures so that people at the home are not placed at potential risk. Suffolk Court DS0000033240.V373068.R01.S.doc Version 5.2 Page 7 It is recommended the manager review the staffing levels regularly. This is so that she can be sure enough staff are on duty at nights to meet the needs of people living in the home. The size and layout of the building should be taken into consideration when doing this. 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. Suffolk Court DS0000033240.V373068.R01.S.doc Version 5.2 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 Suffolk Court DS0000033240.V373068.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 5 People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can make an informed choice about the home through visits and the information they are given. EVIDENCE: Information for people and visitors is available in the reception area, along with a copy of the statement of purpose and service user guide both are continually reviewed. There are other files of useful information about the home and the services it provides. Five people we spoke to said they felt well informed before they moved into the home. One visitor said they chose the home after looking round a few. The family and their relative came to look round a few times and the person’s care Suffolk Court DS0000033240.V373068.R01.S.doc Version 5.2 Page 10 needs were assessed during one of these visits. They said that they had been given all the information they needed to make an informed decision. Information from surveys and talking to people said that: • They had been given enough information about the services provided by the home. • One person said they and their relative had been well supported when they moved into the home. • They were satisfied with the services received. Suffolk Court DS0000033240.V373068.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Although people are receiving health and personal care based on their individual needs this could be compromised by the inconsistency of the records and the administration of medication. EVIDENCE: The manager has a system for auditing care plans and making sure they are detailed and individual. She has identified that some of them need to be more ‘person centred’. Staff spoken to had a good awareness of people’s needs and abilities and said that they used the care plans regularly. Case tracking was done for six people living in the home. This involved looking at their care records and medication charts. They showed that: - Suffolk Court DS0000033240.V373068.R01.S.doc Version 5.2 Page 12 • • Not all the documents had been dated and signed by the person writing them. Healthcare assessments are carried out. Some of the plans would benefit from additional information about the individuals needs, abilities and preferences. For example: • The care plans for people with dementia did not say how it affected them and how staff could help them. All areas of personal care and support needed were around problems with poor memory and being disorientated. Nutritional assessments are carried out but the outcomes are not always reflected in the care plans. On examination of two records there was no evidence that people had been weighed. The care records must clearly show the weight of people who use the service and what action has been taken by staff to ensure dietary needs are addressed to prevent serious consequences to their health. The medication administration record (MAR) showed that the sheets were not always signed when medication is given. This could lead to people being given medication twice. The lunchtime medication round was observed and it was of concern that people’s medication was placed on the dining table in a cap for them to take and the person administering the medication then moved on to another person without checking that the medication had been taken. This means that other people on the table could take the medication and the staff could not be 100 sure the person who’s medication it is has taken it. • • Information from people living in the home and returned surveys said that: • • • • People’s privacy and dignity was respected. Healthcare professionals said they saw people in their own rooms. People usually got the care and support they needed. People were treated with respect. Relatives were kept up to date about changes in the person’s condition such as illnesses or accidents Suffolk Court DS0000033240.V373068.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15 People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s choices are respected and contact with family and friends is encouraged. EVIDENCE: Relatives and visitors said that they could come at any time and they were always made to feel welcome. The atmosphere in the home was warm and friendly. It was clear that there were good relationships between people living in the home, their visitors and staff. People said that they could choose how to spend their time, when to get up, when to go to bed and where to eat their meals. They said that the staff were kind and attentive and did what they could to meet their needs. There is a regular programme of activities through the week. It includes reminiscence sessions, sing- a-longs, quizzes and bingo. Everybody is encouraged to join in but people can choose whether or not they want to. Suffolk Court DS0000033240.V373068.R01.S.doc Version 5.2 Page 14 Plans for Christmas activities are well under way including trips out and entertainers coming in to the home. Local clergy visit the home regularly. One person goes to their church every week. Menu plans are in place and these are changed at regular intervals. People can choose what they want to eat and alternatives are always available if they do not want what is on the menu for that day. The cook speaks to people and is aware of individual’s likes and dislikes and will accommodate these and any special diets or preferences. The kitchen was clean, tidy and well organised. Meals were nicely served and people said that they enjoyed their food. Suffolk Court DS0000033240.V373068.R01.S.doc Version 5.2 Page 15 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 People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be confident that their concerns will be listened to, taken seriously and acted on. EVIDENCE: A complaints procedure is in place. It is made available to everybody in the Statement of Purpose and the useful information file. Complaints leaflets are readily available for people to use. People said that they knew what to do and who to speak to if they had any concerns. The home has adult protection policies and information in place and the home has got copies of the local authority adult protection procedures. Most staff have received training around abuse. Staff said that they would report suspected or actual abuse to the person in charge. Suffolk Court DS0000033240.V373068.R01.S.doc Version 5.2 Page 16 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, 20, 23, 24, 25 and 26 People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home enables people to live in a safe, and comfortable environment, which encourages independence. EVIDENCE: The home was clean and tidy. People were happy with their rooms and said that they were kept clean and free from smells. The rooms seen were nicely decorated and furnished. It was clear that people can bring their own belongings, and furniture where possible, to personalise their rooms. There is adequate provision of communal toilets and assisted bathrooms. Suffolk Court DS0000033240.V373068.R01.S.doc Version 5.2 Page 17 Communal space for people in the home is to be increased with provision of a conservatory. At the time of visiting the home, work had started on the building of the conservatory. People spoken with were really excited about how it would look when finished. Disposable gloves and aprons are available and there is adequate provision of soap and disposable towels for staff use. This helps to make sure staff follow good infection control practice. People said they were satisfied with the laundry services. Clothes and linens seen were clean, well laundered and ironed. Whilst speaking with staff it was pointed out that there are a number of people’s bedroom windows that are letting in draft making some people’s room feel very cold. The senior carer on duty said this is on the home’s agenda for improvement. Suffolk Court DS0000033240.V373068.R01.S.doc Version 5.2 Page 18 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 People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are not always enough staff to meet people’s needs in timely way. EVIDENCE: In discussion with people they generally confirmed that the staff are good. Comments from them were; ‘good and helpful’, ‘they do what they can for you’. It is recommended the manager review the staffing levels regularly. This is so that she could be sure enough staff are on duty at nights to meet the needs of people living in the home. The size and layout of the building should be taken into consideration when doing this because staff can be busy in different wings and not available to respond to people. At the time of this inspection there were thirty-three people living in the home with two night staff. People said staff were available, sometimes, when they needed them. Some people said sometimes they waited a long time for calls to be answered. The staff were always helpful and cheerful, even when they were very busy. Suffolk Court DS0000033240.V373068.R01.S.doc Version 5.2 Page 19 One person said ‘the demands of some people means staff cannot always be there for others.’ From looking at the Annual Quality Assurance Assessment (AQAA) returned and care plans it was clear that some people living in the home need a lot of physical and psychological support, for safety reasons and to monitor their whereabouts because they walk around a lot and are at risk of falling. This is in addition to people who need two staff to help them with personal care. Information provided by the manager said 98 percent of staff have their National Vocational Qualification (NVQ) at level two or above in care. A sample of three staff employment records was examined and all had complete records with criminal record bureau checks having been carried out. Suffolk Court DS0000033240.V373068.R01.S.doc Version 5.2 Page 20 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, 33, 35, 37 and 38 People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is managed in a manner that promotes good service delivery in the best interest of people using the service. EVIDENCE: The manager has several years experience of caring for older people. Both the registered provider and manager have a positive attitude to the inspection process and have shown a willingness to work with us to maintain and improve standards at the home. There are clear lines of accountability, Suffolk Court DS0000033240.V373068.R01.S.doc Version 5.2 Page 21 which makes sure the home is managed effectively and in the best interest of the people living there. Records of financial matters are maintained within Social Services departmental procedures and audit requirements. People are encouraged to manage their own monies, where achievable. The manager ensures staff are supervised and supported to enable them to care for the people in the home. Information from the Annual Quality Assurance Assessment (AQAA) said that all maintenance and safety checks were carried out and kept up to date. This is to ensure people living in the home are safe. Suffolk Court DS0000033240.V373068.R01.S.doc Version 5.2 Page 22 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 3 x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 3 X X 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 3 3 Suffolk Court DS0000033240.V373068.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13 Requirement The registered manager should make sure that all staff are aware of the medication policies and procedures and follow them. This is so that people are not put at potential risk by unsafe practice relating to the administration of medication. Timescale for action 10/01/09 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 OP7 Good Practice Recommendations The care plans should be more detailed, providing staff with clear guidance about how an individual’s personal, physical, health and social care needs are to be met. Suffolk Court DS0000033240.V373068.R01.S.doc Version 5.2 Page 24 2. OP27 It is recommended the manager review the staffing levels within the home so that potential risks can be minimized. Suffolk Court DS0000033240.V373068.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Suffolk Court DS0000033240.V373068.R01.S.doc Version 5.2 Page 26 - 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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