Inspection on 24/01/07 for Suffolk Court

This inspection was carried out on 24th January 2007.

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 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 10/11/08

Suffolk Court 15/11/07

Suffolk Court 30/11/05

Suffolk Court 31/05/05

Suffolk Court 17/11/04

Suffolk Court 22/06/04

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Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Suffolk Court Silver Lane Yeadon Leeds LS19 7JN Lead Inspector Valerie Francis Unannounced Inspection 24th January 2007 10:30 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 Suffolk Court DS0000033240.V321032.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.V321032.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 N/A 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.V321032.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th November 2005 Brief Description of the Service: Suffolk Court is a forty bedded home for older people, thirty three are for permanent service users the remaining seven are dedicated for respite services. The home is owned by Leeds City Council and managed by Mrs Fiona Wood. Situated at Yeadon a suburb of Leeds the home is close to the local shops and amenities. The home is a two storey building with a passenger lift to the first floor and has gardens to the rear of the home and car parking facilities to the front. Suffolk Court DS0000033240.V321032.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report brings together evidence gathered at this first Key unannounced Inspection visit to Suffolk Court on the 24th January 2007 by one inspector over a period of 7 hours. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk During this visit discussions were held with service users, relatives and staff, records were examined and all areas of the home were seen. Comment cards were sent out to residents and their relatives to give people an opportunity to share their views of the service provided at the home with CSCI. Twenty seven residents and seven relatives responded, their views are included in the body of this report, and what the service does well. A pre inspection questionnaire was sent to the home prior to this key inspection asking for information about the records, residents, staffing and the general running of the home, this was returned six weeks before the inspection. As part of this unannounced inspection the quality of information given to people about the care home was looked at. People who use services were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the service user’s guide, statement of terms and conditions the licences agreement of living at the home, and the complaints procedure. There were a mixture of responses given by the residents seen during this visit some were aware others were unaware of a service user guide or of the licences agreement of living at the home. Visiting relatives said that they had seen these documents. Most residents knew who to talk to if they were unhappy about anything in the home Suffolk Court DS0000033240.V321032.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The manager is now registered with the CSCI as manager of Suffolk Court. Suffolk Court DS0000033240.V321032.R01.S.doc Version 5.2 Page 7 An alternative monitoring form relating to residents money has been devised to ensure residents confidentiality. 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. Suffolk Court DS0000033240.V321032.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.V321032.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 & 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An up to date Statement of Purpose and Service User Guide is not available, therefore, residents do not have written information about the services and facilities provided by the home. Residents’ needs are fully assessed prior to moving in to the home to ensure that their needs can be met. EVIDENCE: The home has produced a Statement of Purpose and Service User Guide, however, the document is out of date and requires revising to reflect the current situation within the home. A copy of which must be given to each of the residents. As part of this inspection residents were specifically asked if they were aware of the service user guide and none of them were able to confirm Suffolk Court DS0000033240.V321032.R01.S.doc Version 5.2 Page 10 that they had received written information about the home. It should be noted that the some of the residents has some short term memory loss. However relatives spoken with said that they had received information about the home so that they were sure that the home was suitable for their relatives to come and live. There was evidence on the care file seen of new residents that assessment are carried out by the Social workers or placement agencies these were in the format of the” Easy Care” document. Some details were better than others. One resident assessment information seen had good information for staff to write a good plan of needs and what action to be taken to meet the assessed needs. None of the residents spoken to could remember anybody visiting them before moving in to the home, however, relatives spoken to said that they had been involved in the assessment process. Intermediate care is not provided in the home. Suffolk Court DS0000033240.V321032.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s health and personal care needs are fully assessed and recorded in their plan of care. Residents are protected by the medication polices and procedure, and staff training. EVIDENCE: Not all residents have a Life Style Plan, people who are on respite care do not have a life style plan, there is a care plan that from the placement agency but not in enough detail of actions to be taken. Life Style Plans identify resident’s personal and health care needs with risk assessments for falls, nutrition and moving and handling. However some identified risk did not have a plan of action that needs to be taken to minimise or manage the risk. Suffolk Court DS0000033240.V321032.R01.S.doc Version 5.2 Page 12 The care plans are reviewed on a monthly basis. A daily record is kept for each resident, which clearly shows how they have spent their time and what care has been given. Daily records for one resident showed that care needs had changed. In discussions with staff they confirmed this and said they knew how to meet his needs, however, the Life Style Plan did not reflect this change. The visiting nurse said staff work closely with them by discussing any issues they may have regarding the health care of residents. Visitors said that from what they see when they visit they felt that people living at the home are treated with dignity and respect with staff knocking on doors before entering and residents being addressed properly. The medication system was in the process of being changed to a blister pack with monthly delivery. The medication is securely and appropriately stored with records kept. All senior staff responsible for administering medication have received appropriate training. Suffolk Court DS0000033240.V321032.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 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The routines within the home are flexible giving service users choice and control over their lives. Visitors are made welcome when they visit the home. Residents enjoy a varied and nutritious diet. EVIDENCE: The daily routine in the home is flexible, with some activities provided by the staff for the residents to take part in if they choose to do so. Plans are made for day trips and visiting entertainment. On the day of the inspection the television in the main sitting area in the ground was being looked at by some of the people who sit in this area or used, however it would appear that it was used as background entertainment. Some residents in this room were seen having their nails painted or having their hands massaged by a member of staff. The inspector was told that residents who need staff assistance mainly use this room. Suffolk Court DS0000033240.V321032.R01.S.doc Version 5.2 Page 14 The home is close to local shops, a supermarket and public houses, two residents independently use the local supermarket/café for shopping and to have coffee. One the day of the inspection one resident was seen coming home with a bag of groceries for himself and fellow residents. Although there was evidence of photo’s of recent social events in the home, a more structured way of planning social activities needs to be in place to make sure that residents do not get bored. Visitors were seen to be warmly welcomed into the home, and stated that this was always the case. Relatives and visitors are invited to the social events that now take place in the home, which makes them more involved with the running of the home. The menus are planned by the cook and the designated care officer, with input from residents on their likes and dislikes to give residents more choice. Meals are discussed with residents at the house meetings as a group and on an individual basis with the cook. A new system has been introduced Residents said they enjoyed their meals and have plenty of choice. Hot and cold beverages are freely available throughout the day. Suffolk Court DS0000033240.V321032.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 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by the homes policies and procedures. EVIDENCE: The home’s complaints procedure is prominently displayed in the entrance hall giving all the correct contact details. A record is kept of any complaints received. A recent allegation made had been handled appropriately and a thorough investigation undertaken. All the appropriate professionals had been involved and detailed records kept. The allegation was found to be not proven. One relative made reference to a complaint, which they felt had been handled appropriately. As part of this inspection residents were specifically asked if they would know who to speak to if they were unhappy about anything in the home, and wished to make a complaint. From survey information from twenty seven residents, seven people said they usually know who to speak to. All others and those spoken to at the day of the inspection were able to say that they were aware of the procedure to follow an felt they could speak to any member of staff or the manager about any concern they may have. Most staff have received training in the Abuse Awareness, and know the procedure to follow if they suspect abuse of any service user. One member of staff said although she had not received any training she had access to policy procedures. Suffolk Court DS0000033240.V321032.R01.S.doc Version 5.2 Page 16 A new recording system is n place to make sure that all transactions of resident’s money is clearly recorded. When possible they sign to indicate they have received the money. Suffolk Court DS0000033240.V321032.R01.S.doc Version 5.2 Page 17 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 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a clean and generally safe environment. All prospective residents bedrooms have the opportunity to personalise their bedroom. EVIDENCE: The home, a large built detached property, is maintained to an acceptable standard. The majority of the bedrooms have been personalised and the home was seen to clean and fresh smell throughout. Residents have access to a Variety of sitting areas, some rooms had been designated a quite area. Dining rooms, and all other rooms were warm and cosy. Suffolk Court DS0000033240.V321032.R01.S.doc Version 5.2 Page 18 At the last inspection a recommendation was been made for the carpet on the top floor corridor to be replaced. On this inspection the inspector was told that the quality of the carpet would continue to be monitored to make sure it does not become a health and safety hazard. The carpets in the top floor dining room had cigarettes burns and were worn. One of the fridges in this area was rusting; this could create a poor image to visitors. The residents said they were pleased with the facilities provided within their own rooms, and that they are able to personalise them with their own possessions. The home’s laundry assistant does the washing of residents’ personal items. All other laundry i.e. bedding were sent to outside agency to be laundered. Although protective clothing is worn the practice of hand sluicing soiled laundry before putting into the washing machine compromises infection control. The home has a sluice cycle washing machine, but the appropriate bag for sluicing was not been used. In general the home’s environment and atmosphere was homely, warm and cosy. Suffolk Court DS0000033240.V321032.R01.S.doc Version 5.2 Page 19 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 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is adequately staffed by a competent, well trained and motivated staff team. The number of staff on duty in the home at nights is not enough. Residents are protected by the local authority recruitment procedure. EVIDENCE: Some residents and visitors said in the survey information that sometimes there is not enough staff on duty. During discussion with staff they indicated that the dependency level of residents have changed and at times some people were more dependent on staff and needed two to three staff for assistance. There is fifteen minutes handover at the beginning and end of each shift. Rotas seen indicated that there are four care staff, one of which is a senior care assistant, the manager or care officer is also on duty during the hours of 7.30am until 2.30pm when the staffing level decrease to three or four staff until 9.30. In addition to the care staff, domestic and catering staff are also employed. There is an on call care officer for the homes within the local area. Suffolk Court DS0000033240.V321032.R01.S.doc Version 5.2 Page 20 The staffing levels at night consist of two waking night staff from 9.15pm to 7. 45am one care assistant and one senior care assistant to forty residents with various care needs. The lay out of the building and the number and the dependency level of residents could compromise resident’s safety when the two members of staff are assisting a resident in one area or home. The staff team were observed meeting resident’s needs in a sensitive manner with appropriate use of informality and humour. Residents’ expressed satisfaction with the staff team as a whole, and made the following comments: “she can’t do enough for you”, and “she’s a real carer”. The training records seen was out of date and did not show any training that had been undertaken by staff in the last three years in most cases despite staff saying that they had attended courses over the years and recently. The information on staff files showed that people recently employed had received induction training programme based on Skills for Care Standards, and there was some personal development plans in place for some members of staff whose file were seen. All new staff undertake induction training and “Welcome to the Department” day. There is a commitment to NVQ training within the home and almost 50 of staff have the award. Four staff recruitment files were seen and there was evidence that all staff are subject to Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) disclosures prior to an offer of employment being made. Two written references are required and the completion of an application form as part of the recruitment procedure. Suffolk Court DS0000033240.V321032.R01.S.doc Version 5.2 Page 21 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 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run and managed. Residents’ health, safety and wellbeing is protected by the homes policies and procedures. EVIDENCE: Since the last inspection the manager of the home has been registered with the CSCI. She is experienced and competent to run the home, she at the time of this inspection completing MCI course, with plans in place to undertake a “Fast track” NVQ in care, she has attended various courses to support her in her management role. Suffolk Court DS0000033240.V321032.R01.S.doc Version 5.2 Page 22 There is now a commitment to health and safety and safe working practices within the home, with all staff receiving health and safety training. Certificates indicating compliance with gas and electricity regulations with records of all safety checks for moving and handling equipments and fire safety were available for inspection. The outcome for formal quality monitoring system is in place and service users and other interested parties are consulted as to their views on the services and facilities provided. However, there was no evidence that this information had been evaluated and an action plan produced to improve the service. Since the last inspection the recording system for monies received for personal allowance has changed and residents now sign a record that relates to them only, in order not to breach resident’s confidentiality. A record is kept for all health and safety risk assessments carried out in the home. The record showed that they are reviewed annually, the care officer sai theses can be reviewed early if needed. Suffolk Court DS0000033240.V321032.R01.S.doc Version 5.2 Page 23 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 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 2 X 2 X 3 X X 2 Suffolk Court DS0000033240.V321032.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 Requirement The home has produced a Statement of Purpose and Service User Guide, however, the document is out of date and requires revising to reflect the current situation within the home. The home must use the assessment information for the respite residents and put together a care plan which outline the care to be provided this plan must be reviewed on every admission to the home. (Identified in the previous report). A record should be kept of all activities carried out and planned for. Identified risk for residents must be assessed and supported by a plan of action to minimise the risk. Care plans must reflect the resident’s needs. (Identified in the previous report) 30/12/05 The providers must introduce an effective system to audit the quality of services offered by the DS0000033240.V321032.R01.S.doc Timescale for action 09/03/07 2. OP7 15 28/02/07 3. 4. OP12 OP7 16(2)(m) 15 09/03/07 09/03/07 5. OP33 24 30/03/07 Suffolk Court Version 5.2 Page 25 home. 6. OP28 18 50 of care staff must achieve NVQ level 2 The provider must give some consideration to increase the staffing level at night in the home. (A response is required to show how this would be done.) The hand sluicing of soiled laundry before putting into the washing machine must cease and the use of appropriate bag for sluicing solid linen must be used. 28/02/07 7. OP27 18 09/02/07 8. OP38 23(2)(k) 28/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP2 OP19 OP9 Good Practice Recommendations Respite residents should be offered a contract identifying the terms and conditions during their stay. The providers should continue to monitor the carpet on the upstairs corridor. Some consideration should be given to include the catering staff in the safe handling of medication course, to make them aware of any possible side effects of food and any medication prescribed. Suffolk Court DS0000033240.V321032.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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.V321032.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!