Inspection on 31/05/05 for Suffolk Court

This inspection was carried out on 31st May 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

Suffolk Court 10/11/08

Suffolk Court 15/11/07

Suffolk Court 24/01/07

Suffolk Court 30/11/05

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Suffolk Court Silver Lane Yeadon Leeds LS19 7JN Lead Inspector Chris Levi Unannounced 31 May 2005 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 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 CS0000033240.V178700.R01.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Suffolk Court Address Silver Lane Yeadon Leeds LS19 7JN Telephone number Fax number Email 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 Care home 40 Category(ies) of Physical disability (1) Old age (40) registration, with number of places Suffolk Court CS0000033240.V178700.R01.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 17th November 2004 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 CS0000033240.V178700.R01.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced. It started at 9.15am finishing at 4.30pm. The person in charge at the time of the inspection was Mrs Fiona Wood, who has yet to be registered with the Commission for Social Care Inspection, as the manager of Suffolk Court. Most of the day was spent talking to 12 residents and 7 staff about living and working at Suffolk Court. The views of a number of visitors are included in the report. People living at the home liked to be referred to as residents in the inspection report. Some documents were inspected including, care plans, staff recruitment files, medication records, minutes of meetings with residents and staff and maintenance records. The inspector looked around part of the building. The atmosphere within the home was open, friendly and welcoming. The person in charge was given feedback about the inspection findings at the end of the inspection. What the service does well: What has improved since the last inspection? There has been some improvement in the quality of recording relevant information in residents care plans by staff. Suffolk Court CS0000033240.V178700.R01.doc Version 1.30 Page 6 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. Suffolk Court CS0000033240.V178700.R01.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Suffolk Court CS0000033240.V178700.R01.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,5. 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. Effective systems are now in place to assess service user needs before admission, and the manager is aware of the requirement to accept residents within the registration categories. Only permanent residents are given written copies of terms and conditions and fees payable. EVIDENCE: The manager has recently started to assess people before they move into the home to ensure their needs can be met. The “Easycare” pre admission documentation reviewed, that is completed by external professionals was noted to be incomplete. This can create difficulties for staff when planning for residents cares needs. Again, the manager was reminded about the current registration categories to ensure no new residents are admitted with a primary diagnosis of dementia. She continues to work with external health professionals to rehouse a number of residents whose needs can no longer be met at Suffolk Court. The dependency levels of residents remain high. Suffolk Court CS0000033240.V178700.R01.doc Version 1.30 Page 9 On the day of the inspection a family was visiting the home before a planned respite visit. Staff spent time explaining the service, showing the family the building and providing information in a friendly professional manner. All permanent residents or their relatives are given a licence agreement that gives information about their rights and responsibilities whilst living at Suffolk Court. It is recommended they respite residents are also issued with a contract. The providers Leeds Social Services provide written information to residents about annual fee increases. A number of contracts and fee increase letters were seen during the inspection. Suffolk Court CS0000033240.V178700.R01.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10. Staff at Suffolk Court meet the health and care needs of the majority of residents. However, a number of residents now require levels of specialist care that cannot be provided by staff at the home. Generally, medication for permanent residents is managed in a safe and professional way by staff. A review of the management of respite resident’s medication is required as it is unsafe. It was observed and confirmed by a number of residents that they are treated with dignity and respect by staff at Suffolk Court. EVIDENCE: Written information about residents care needs has improved since the last inspection. Three care plans were looked at. One contained clear detailed information about the residents care needs. Two were of a lesser standard. The new manager is working with staff to ensure they understand the need to record relevant information about residents care needs. A number of reviews had been recorded. One was lacking in detail considering the dependency needs of the resident. Suffolk Court CS0000033240.V178700.R01.doc Version 1.30 Page 11 Written risk assessments were missing these included mobility and nutritional assessments in a number of care plans where information indicated a risk to the residents. A district nurse visiting a number of residents said “staff are helpful, and we communicate any changes in treatment to staff before we leave the building” Two doctors visited residents during the inspection and consulted with residents in the privacy of their own rooms. The manager said no resident had pressure sores at the time of the inspection. Residents and visitors spoke highly about staff. One visitor said she valued the way staff treated her father, not only with dignity, but also with good humour and shared banter. No changes have been made to the ordering and administration of medicines to residents since the last inspection. Staff do not give homely remedies to the residents, on the instruction of the providers. A recent pharmacy check was satisfactory. The medicine administration records were satisfactory for permanent residents. However, concern was raised that medication brought in by a respite resident did not identify what drugs were being administered by staff. This is dangerous practice and must be reviewed. Suffolk Court CS0000033240.V178700.R01.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15. Residents are given opportunities to choose how they spend their day. Some levels of social activities are offered but this should be increased to maximise the opportunities for residents to participate in social interaction. Visitors are welcomed to the home at any time. Residents are consulted about how they wish to live their life on a daily basis. Residents enjoy food served at Suffolk Court. EVIDENCE: In discussion with residents they said, “nothing goes on here” and “ I would like more things to do.” The atmosphere in the main lounge did not create opportunities for social interaction between residents, most of whom were asleep for most of the day. In discussion with the manager this has been identified and proposals to identify residents interests and introduce a range of social activities is underway. A number of visitors said they visit regularly and staff make them welcome. One said “the new manager has made a number of positive changes.” Residents confirmed they are able to spend the day as they chose within the home. One resident was going out with her family and looking forward to her trip out. The residents enjoy food served at Suffolk Court. The chef now uses a range of milk including full fat, for residents who are low in weight. There was evidence of a well-managed plan of care offered a service user who had difficulties Suffolk Court CS0000033240.V178700.R01.doc Version 1.30 Page 13 eating. The Dr visited him and was pleased with the improvement in his general condition. New menus have been introduced; these are to be reviewed with residents in the near future. A recent residents meeting had identified that they thought the dinner plates were too small. The manager said she would be ordering bigger sizes so that residents could choose the size of plate depending on their appetites. It is recommended that the kitchen is deep cleaned as the walls and canopy are dirty. Suffolk Court CS0000033240.V178700.R01.doc Version 1.30 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 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: Written information is displayed in the hallway about how to make a complaint. No complaints have been recorded since the last inspection. The book used to record complaints should ensure confidentiality of information. Staff have had training in awareness of adult abuse and understood the term whistler blowing. Residents and visitors said they would talk to the manager if they had any concerns. Suffolk Court CS0000033240.V178700.R01.doc Version 1.30 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 standard(s) 19,21,23,24,26. Systems are in place to ensure the environment is safe, but also welcoming and comfortable. Residents move freely about the home, making decision about where they spend their day. 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. All residents’ rooms have en-suite toilets with bathing facilities situated in both floors. It was noticed that the fridge in the upstairs dining area needs replacing, as it is rusty. The upstairs corridor carpet is worn and dirty and should be replaced. Fire safety equipment is in place and up to date. Staff receive regular training in fire safety in the building. The laundry was in full working order and free from health and safety risks. The domestic staff are clear in their responsibilities about working safely with cleaning equipment and products. Suffolk Court CS0000033240.V178700.R01.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30. The providers Leeds City Council Social Service Department have a robust interview process when recruiting staff. However, this is undermined by the department’s practice of allowing employees to commence employment before all relevant checks are complete. This could result in an employee inappropriately working with vulnerable adults. This practice should stop. Staffing levels have improved since the last inspection. New staff are provided with a comprehensive induction training programme to ensure they are competent to do their jobs. EVIDENCE: The new manager has increased staffing levels on the evening shift following concerns raised by staff about their ability to meet resident’s needs. There have also been changes to daily routines that both staff and residents said improved the quality of service. The recruitment files of three staff members were looked at. They contained relevant documentation including, notes of interview, application form, two written references, and a copy of hours to be worked. The practice of staff commencing before information regarding a Criminal Records Bureau check was evidenced. This was confirmed by the manager, who said she was following the instructions of the providers Leeds City Council Social Services department. New staff undertake a thorough induction programme to ensure they are competent to provide care to residents. A staff member said she has attended training on caring for people with dementia and found it helpful. NVQ training Suffolk Court CS0000033240.V178700.R01.doc Version 1.30 Page 17 for care staff continues and the department has identified ways to speed up the time it takes to achieve this award. Suffolk Court CS0000033240.V178700.R01.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36,38. Residents and staff are consulted about the standards of service. The manager is experienced in managing services for older people. She has yet to be registered with the Commission for Social Care Inspection. The health and safety of residents and staff is promoted. The home has no formal systems in place to monitor quality of services. Staff receive regular supervision they value, as it provides opportunities to discuss their professional development. EVIDENCE: Since the new manager started work at Suffolk Court she has consulted regularly with residents and staff about the services provided by staff. A number of changes have been discussed and introduced. This includes a room where staff can work on care plans and training. Staff said they found this useful, as it was a quiet area to work. Residents had just agreed that they would appreciate a cup of tea in bed before they get up. Suffolk Court CS0000033240.V178700.R01.doc Version 1.30 Page 19 The home manager provided written minutes of meetings held with residents, and staff confirmed all changes to services have been discussed and agreed by residents and staff. Residents said “Fiona is very approachable”, “she will do anything to help me” a member of staff said “she has learned a lot from the new manager.” One to one supervision sessions continue for staff. This provides them with opportunities to discuss care practices and personal development. One member of staff said, “she valued the sessions.” The manager said new documentation has recently been issued to all Leeds Social Service managers about the introduction of a quality audit system. As yet there is no formal method of evaluating the quality of services at Suffolk Court. Staff do regular health and safety checks on the building to ensure it is safe for residents and staff. It was noticed that the hairdressing equipment did not have labels to indicate they had been electrically tested for safe use. The manager said she would check with the contractors who undertake the work one a year. Other portable electrical appliances had evidence of testing. Suffolk Court CS0000033240.V178700.R01.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x 3 N/A 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 3 x 3 x 3 3 x 3 STAFFING Standard No Score 27 3 28 x 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 3 2 x x 3 x 3 Suffolk Court CS0000033240.V178700.R01.doc Version 1.30 Page 21 yes 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 7 Regulation 15 Requirement Identified risk for residents must be assessed and supported by a plan of action to minimise the risk. Increases in social activities are required. Receipt and management of medication for respite residents must be made safe. New staff must not commence employment before CRB clearance is received. The manager must be registered with the CSCI as manager of Suffolk Court. The providers must introduced a system to audit the quality of services offered by the home. Timescale for action 30th June 2005 2. 3. 4. 5. 9 29 31 33 13 19 9 24 30th June 2005 30th june 2005 30th July 2005 30th August 2005 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 2 15 19 Good Practice Recommendations respite residents should be offered a contract identifying the terms and conditions during their stay. The kitchen should be deep cleaned. The providers should replace the carpet on the upstairs CS0000033240.V178700.R01.doc Version 1.30 Page 22 Suffolk Court corridor. Suffolk Court CS0000033240.V178700.R01.doc Version 1.30 Page 23 Commission for Social Care Inspection Aire House Town Street Rodley LS13 1HP 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. 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