CARE HOMES FOR OLDER PEOPLE
Suffolk Court Silver Lane Yeadon Leeds LS19 7JN Lead Inspector
Chris Levi Unannounced Inspection 30th November 2005 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.V261776.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. Suffolk Court DS0000033240.V261776.R01.S.doc Version 5.0 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 0113 2509540 Leeds City Council Department of Social Services 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.V261776.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 31st May 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.V261776.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced. It started at 10.30am finishing at 3.45 pm. The person in charge at the time of the inspection was the manager, Mrs Fiona Wood, who has yet to be registered with the Commission for Social Care Inspection. Most of the day was spent talking to residents, visitors and staff about living and working at Suffolk Court. Their views are included in the report. People living at the home liked to be referred to as residents in the inspection report. Documents inspected included residents care plans, a staff recruitment file, medication records, , management of residents monies and a review of the homes quality monitoring system. The inspector looked around part of the building. The atmosphere within the home was open, friendly and welcoming. There were numerous visitors to the home during the inspection. All gave positive feedback about the staff working at Suffolk Court. The person in charge was given feedback about the inspection findings at the end of the inspection. What the service does well:
Despite senior staff shortages, the manager Fiona Wilson and her staff team continue to provide a safe, comfortable and friendly environment for residents. Comments from resident’s included. “The staff here are superb.” “My father’s admission to the home was supportive, informative and the staff have made him welcome.” Suffolk Court DS0000033240.V261776.R01.S.doc Version 5.0 Page 6 Residents are consulted regarding proposed changes to the services at the home through a resident’s committee. The manager was able to demonstrate a very thorough procedure for the management of resident’s money, that allowed for it to be kept secure but accessible when required. What has improved since the last inspection? What they could do better:
As identified in the previous inspection report the manager is not yet registered with the Commission for Social Care Inspection. She has been in post for one year and this requirement remains outstanding. A care plan for a recently admitted resident was so basic it failed to provide relevant information about the residents needs. There was no evidence of what action had been taken to minimise falls, and nutritional needs due to low weight. Suffolk Court DS0000033240.V261776.R01.S.doc Version 5.0 Page 7 The inspector did observe, and it was confirmed by the resident and his family that he was receiving very good care. However, the written evidence to support this was missing, and could result in unnecessary risk to the resident. There was no evidence that relatives, staff and visitor questionnaires completed in January 2005 had been evaluated and an action plan for improvement introduced. The upstairs corridor carpet is worn and stained and would benefit from replacement. This was recommended in the previous report. Respite residents should be issued with a contract of the terms and conditions of their stay in the home. The current recording sheet relating to monies received for personal allowances for named residents should be revised as it breaches resident’s confidentiality. 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. Suffolk Court DS0000033240.V261776.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 Suffolk Court DS0000033240.V261776.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): 1,2,3. People who use the service are able to access clear and accurate information to help them decide whether or not they wish to live in the home. Only permanent residents are given written copies of terms and conditions and fees payable. EVIDENCE: Two documents provide prospective residents and their families with information about services provided at Suffolk Court. They are on display in the hallway. Some additional information has been included since the last inspection. The information in these documents should enable prospective residents to decide if they wish to live at Suffolk Court. The Easycare pre admission assessment form looked at provided staff with relevant information about the care needs of a recently admitted resident. All permanent residents or their relatives are given a licence agreement providing information about their rights and responsibilities whilst living at
Suffolk Court DS0000033240.V261776.R01.S.doc Version 5.0 Page 10 Suffolk Court. It is recommended respite residents are also issued with a contract. It was noted at the last inspection that a number of residents had very high dependency care needs. A review of residents care needs has resulted in a number of residents moving to nursing care. The current level of staffing appears appropriate to meet the resident’s care and social needs. Suffolk Court DS0000033240.V261776.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. Staff at Suffolk Court with the assistance of external healthcare professionals meet the health and personal care needs of residents. However some of the written supportive documentation relating to personal care is ineffective. Staff safely administer medication to respite residents. Residents are treated with dignity and respect by staff at Suffolk Court. EVIDENCE: The inspector tracked the care plan of a newly admitted resident and subsequently talked to the resident and his relative in the privacy of his room. The resident has complex personal and health care needs. During discussion with him it was clear that staff are provide very effective personal care and the external health professionals visit as required. The resident said, “ I am happy to live here and staff are very kind and give me the help I need.”
Suffolk Court DS0000033240.V261776.R01.S.doc Version 5.0 Page 12 His relative said he is made welcome and kept informed of his father’s condition. This included recent visits to the accident and emergency department of the local hospital following a number of falls. He was very satisfied with the service and said, “The staff are superb”. However, the written information in the residents care plan was poor. There was little information advising staff how to minimise the resident’s risk of falls. No action taken on a risk assessment for nutrition that indicated a high risk. The pen picture was blank, a number of forms were include with the residents name but were blank or not necessary to his care. It is acknowledged that due to senior staff shortages within home for a number of months, the manager has prioritised her work- load to meeting resident’s needs. However, a review of care plans, by senior staff, must be undertaken, to ensure they provide accurate and relevant information. The providers have recently introduced a malnutrition assessment form. This requires staff to calculate complex information. The inspector has some concerns that it has been introduced with little or no training for staff who have to use it. The administration of medication to respite residents has improved since the last inspection. Staff are now able to read what medication they are administering when residents bring medication from home. A number of residents said the staff are lovely, helpful, kind and respectful when providing personal care. Suffolk Court DS0000033240.V261776.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): 12,13,14. Residents are given opportunities to choose how they spend their day. Activities are available for residents who wish to participate. Visitors are welcomed to the home at any time. EVIDENCE: Residents confirmed that they spend their days in ways that meet their individual needs. One resident said she enjoyed going into the village and visiting the local supermarket. Another said,” I like to spend my day in this little lounge its more peaceful in here.” A number of activities are available for residents. The choice is displayed in the main entrance. A game of dominoes was in progress during the visit. A number of newspapers and magazines are accessible in the foyer. A number of visitors were asked for their views about the service offered to them as visitors, and to their relatives as residents. Without exception, they were very positive in their responses. Visitors were observed interacting very well with both the manager and staff and made welcome during the visit. The
Suffolk Court DS0000033240.V261776.R01.S.doc Version 5.0 Page 14 residents were looking forward to a Christmas sale to raise funds for some of the cost of the planned Christmas party. Suffolk Court DS0000033240.V261776.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. The home provides clear information on how to make a complaint about the service. It includes reference to the Commission for Social Care Inspection if people want to take a complaint outside the home. Systems are in place to protect residents from abuse. EVIDENCE: One complaint has been recorded since the last inspection. The documentation was looked at and was recorded correctly. The outcome of the investigation has yet to be provided to the complainant. Talking to the residents and visitors they said they felt comfortable to discuss with the manager, any issues that may cause them concern. The home has a clear procedure to deal with allegations of abuse. Staff receive training to help them understand the types of abuse that may occur. One staff member said,” I found it really helpful, I did not realise some of the examples given at the training were considered abusive.” She also gave accurate information as to what she would do if she believed an abusive incident occurred within the home. Suffolk Court DS0000033240.V261776.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,26. Systems are in place to ensure the environment is safe, but also welcoming and comfortable. EVIDENCE: The home has a number of lounges on the ground and first floor and residents said they could choose where they spend their day. Two areas have been altered since the last inspection. The kitchen area of the upstairs dining room has been refurbished and has a dishwasher incorporated into the units, reducing the need to transfer dirty dishes to the main kitchen downstairs. As previously identified a partition has been put up in one of the small lounges. This provides opportunities for non smokers to use part of this lounge. The upstairs corridor carpet is worn and dirty and should be replaced.
Suffolk Court DS0000033240.V261776.R01.S.doc Version 5.0 Page 17 The home was clean and free from odour. Suffolk Court DS0000033240.V261776.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28,29. The providers, Leeds City Council Social Service Department have robust policies and procedures when recruiting staff. Staff receive effective training relevant to caring for older people. EVIDENCE: Leeds Social Service department has recently changed the recruitment procedure to include a satisfactory CRB report, before the employee commences work at the home. This was evidenced during a review of a staff members recruitment file. The number of staff with NVQ level 2 is 7. The manager said two other care staff are on the fast track route and hope to complete in the near future. This will bring the percentage to 50 of all care staff with NVQ level 2. Suffolk Court DS0000033240.V261776.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): 31,32,33,35. The manager is experienced in managing services for older people. She is committed to providing an open and consultative approach within the home for residents, visitors and staff. She has yet to be registered with the Commission for Social Care Inspection. Quality monitoring of the service is incomplete and provides no outcomes for improvement. Robust systems are in place to ensure that residents monies held at the home are secure, but accessible when needed. EVIDENCE: As identified in the previous report Mrs Wood has yet to be registered as manager of Suffolk Court with the Commission for Social Care Inspection. Her application sent in January 2005 has not yet been returned to the CSCI.
Suffolk Court DS0000033240.V261776.R01.S.doc Version 5.0 Page 20 Mrs Wood is an experienced manager who has a very open and inclusive style of management, examples of which were observed during the inspection. She is well respected and known not only to residents and staff but also visitors. During the past three months the two senior officers have been away from the home. Mrs Wood has prioritised the care of residents during this time. As such some paperwork is incomplete. She is planning this will be addressed when the senior officers return full time to the home. Staff said,” she is approachable and will help wherever she can”. Residents, relatives and staff completed a number of questionnaires about quality standards at the home in January 2005. However, there was no evidence that this information had been evaluated and an action plan produced to improve the service. The home has a robust procedure for managing resident’s money held at the home. Residents have a locked drawer facility in their own rooms. However, some residents and relatives prefer that the home hold their personal money. The systems for managing this facility were looked at in detail. Two residents personal allowance money was checked. Both had inaccurate balances. One was quickly rectified, as it was an addition error. The homes administrator will identify the other in a routine weekly audit tomorrow. There was evidence that any errors in the recording systems due to human error are quickly identified due to a number of cross checking systems completed by a small number of nominated staff every week. The system is such that a resident can, at anytime of day, access money held on their behalf. This is good practice. The current recording sheet relating to monies received for personal allowances for named residents should be revised as it breaches resident’s confidentiality. Suffolk Court DS0000033240.V261776.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 3 3 3 X X N/a 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 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 x 28 2 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 4 2 3 3 x 3 x Suffolk Court DS0000033240.V261776.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 OP7 Regulation 15 Requirement Identified risk for residents must be assessed and supported by a plan of action to minimise the risk. Care plans must reflect the residents needs.( identified in the previous report) 50 of care staff must achieve NVQ level 2 The manager must be registered with the CSCI as manager of Suffolk Court. The providers must introduce an effective system to audit the quality of services offered by the home. Timescale for action 30/12/05 2. 3. 5. OP28 OP31 OP33 18 9 24 28/02/06 30/03/06 30/03/06 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. 2. Refer to Standard OP2 OP35 Good Practice Recommendations respite residents should be offered a contract identifying the terms and conditions during their stay. An alternative monitoring form relating to residents money
DS0000033240.V261776.R01.S.doc Version 5.0 Page 23 Suffolk Court 3. OP19 should be devised to ensure residents confidentiality. The providers should replace the carpet on the upstairs corridor. Suffolk Court DS0000033240.V261776.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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