Inspection on 11/10/05 for The Saffrons

This inspection was carried out on 11th October 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 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

The Saffrons 27/06/08

The Saffrons 26/09/06

The Saffrons 16/06/05

The Saffrons 09/12/04

The Saffrons 07/07/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE The Saffrons 20 Saffrons Road Eastbourne East Sussex BN21 1DU Lead Inspector Jon Wheeler Announced Inspection 11th October 2005 09:30 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 The Saffrons DS0000021262.V249427.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. The Saffrons DS0000021262.V249427.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Saffrons Address 20 Saffrons Road Eastbourne East Sussex BN21 1DU 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) 01323 720430 dagmarwilliams@btinternet.com Mr Richard Williams Mrs Dagmar Williams Mrs Dagmar Williams Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places The Saffrons DS0000021262.V249427.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of residents to be accommodated is nineteen (19) 16th June 2005 Date of last inspection Brief Description of the Service: Saffrons is registered to provide residential care for nineteen older people. It is a three-storey building, situated in an attractive, quiet residential area of Eastbourne, with the front of the building overlooking Saffrons Park. The home is within walking distance of Eastbourne town centre, the local amenities and the railway station. There are 13 single rooms and 3 double rooms. Communal areas include a lounge and dining room. There is a well-maintained enclosed garden to the rear, which is accessible to all service users. A lift enables access to all floors, although two rooms have a short flight of steps leading to them. There is a well-kept secluded garden to the rear of the property. The Saffrons DS0000021262.V249427.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. What the service does well: What has improved since the last inspection? What they could do better: The service should ensure that all CRB and POVA checks are completed prior to new staff commencing employment. The Saffrons DS0000021262.V249427.R01.S.doc Version 5.0 Page 6 The manager should ensure that there is a programme of regular formal supervision for all staff, to enable them to raise any issues about the service and to provide consistent care. All wedges should be removed from fire doors, and where fire doors are kept open, they should only be done so once fitted with approved automatic door closing devices, as has been fitted to other doors in the home. The kitchen should be renovated and worn carpets replaced to ensure the health and safety of the service users and staff. The service should review its programme of activities to ensure all the needs of the service users are met. 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 Saffrons DS0000021262.V249427.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection The Saffrons DS0000021262.V249427.R01.S.doc Version 5.0 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 the following standard(s): 1, 3, 4, 5, 6. Service users are provided with sufficient information and are able to visit the home to enable them to make informed choices about the home. The service has a robust pre-admissions process to ensure the needs of all prospective new service users can be met. EVIDENCE: A recently updated statement of purpose and service users guide was available, which clearly identified the structure and range of services provided in the home. There was documentary evidence of comprehensive pre-admission assessments being carried out prior to admission. The manager/proprietor described the range of needs the home was able to meet and also where she felt it was not appropriate to admit people whose needs she felt they could not adequately meet. The manager said she generally completed the preadmission assessments, either at the home of the prospective service user, or visiting them if they were in hospital prior to moving in. The Saffrons DS0000021262.V249427.R01.S.doc Version 5.0 Page 9 Three service users spoken with all stated that they had been given the opportunity to visit the home before they moved in. The proprietors confirmed that prospective service users and their families are encouraged to visit the home before deciding if they want to move in. The home does not offer intermediate care. The Saffrons DS0000021262.V249427.R01.S.doc Version 5.0 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 the following standard(s): 7, 8, 9, 10. Care plans were accurate and up to date and enabled the staff to identify and meet the needs of the service users. The safety and well-being of service users is addressed by the safe storage and accurate dispensing and recording of medication. Service users are treated with dignity and respect by the staff team. EVIDENCE: There was documentary evidence that the care plans had been regularly reviewed and contained up to date and relevant information. Each care plan identified the needs and required support of each service user. There was evidence of staff making daily recordings for each service user to identify any changes in needs or to highlight any issues affecting their well-being or care. Some service users spoken with said that they used a range of health services, with the help and support of the home. Documentary evidence in the care plans demonstrated the range of health services accessed when needed, including G.P.s, District Nursing and a variety of specialists. The Saffrons DS0000021262.V249427.R01.S.doc Version 5.0 Page 11 Medication is stored securely and had been dispensed and signed for accurately, in line with the service’s policy and procedure. There was evidence that staff were doing a refresher course in the administration and dispensing of medication. Staff were able to describe in detail the process of the dispensing and recording of medication. Service users said they were treated with dignity and respect by the staff. They reported that the manager/proprietors and staff respect their choices and rights and are respectful to them. Service users are able to have privacy in their bedrooms and staff were observed knocking on doors before entering bedrooms. The Saffrons DS0000021262.V249427.R01.S.doc Version 5.0 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 the following standard(s): 12, 13, 14, 15. Residents are generally provided with a suitable range of activities. Visitors are made welcome and are encouraged to visit residents in the home. Service users are able to make choices in all aspects of their lives. The home provides a varied, appealing and nutritious diet. EVIDENCE: There was documentary evidence of a range of activities provided in the home. and use Some of the service users said they were able to go out from home and use the shops and facilities in the local community. All the service users spoken with said they were able to choose if they wanted to attend the activities provided. Some stated that whilst they were made aware of activities, they chose to stay in their bedrooms to read, watch television or listen to the radio. During the inspection, a representative from a local church came in to the home to take a service. Other activities provided include an exercise group, a craft session and a reminiscence group. Two service users and two relatives stated that whilst there were activities in the home, they would like some more “intellectual and mentally stimulating e options”. It is recommended that the home again reviews the range of the activities to meet the needs of the service users in the home. The Saffrons DS0000021262.V249427.R01.S.doc Version 5.0 Page 13 Feedback from relatives and comments from service users confirmed that visitors are made welcome in the home. Relatives commented that the proprietors of the home and the staff team are friendly, caring and helpful. Service users said that they were able to choose their daily routines, the food they eat, if they attend activities and whether they would like to go out or not. All service users spoken with said that they were able to bring in their own possessions in to the home, to personalise their room. There is information available on the home’s notice board about accessing independent advocacy support, should service users require it. There was documentary evidence of a varied and nutritious menu. All service users spoken with said that the food in the home is good, and that they are able to choose an alternative, if they don’t want what is on the menu. The is a cooked lunch provided and a cooked snack at tea time, as well as a choice of between three and six desserts on offer each day. There was evidence of fresh vegetables and fruit being used in meals every day. The cook on duty was able to describe in detail the dietary requirements and preferences of each of the service users. There was documentary evidence of the home recording what each service user eats every day. The Saffrons DS0000021262.V249427.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18. There is an effective complaints procedure that ensures any complaints or concerns are dealt with effectively and sensitively. The legal rights of the service users are protected and policies, procedures and training for staff ensure the protection of service users. EVIDENCE: All service users spoken with said that they felt able to raise any concerns or complaints with the proprietors and the staff. There was documentary evidence of a complaints book, where any concerns or complaints were recorded and resolved swiftly and effectively. Whilst there was an effective complaints policy in the home, it had not been updated to include information about the Commission for Social Care Inspection. Two relatives in their feedback said that they had raised minor concerns with the proprietors, which they felt had been dealt with quickly and effectively. One service user said that he had raised a minor complaint, which he felt had been investigated thoroughly by the proprietor and resolved effectively. He also said that the service encouraged service users to raise any concerns or complaints that they had so that they could be resolved to ensure a good quality service. There was evidence that information is available in the home to enable service users to access advocacy support if required. All service users are able to register to vote, although it was reported that some had chosen not to register. The Saffrons DS0000021262.V249427.R01.S.doc Version 5.0 Page 15 The adult protection policy had recently been updated and staff were aware of how the policy worked in practice. One staff member spoken to had recent completed adult protection training. The Saffrons DS0000021262.V249427.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, 21, 22, 23, 24, 25, 26. Whilst the home is generally clean and tidy and offers a homely environment, some areas require repair and refurbishment. The safety of service users is not assured as some fire doors were wedged open. There are sufficient bathroom and toilet facilities that meet the needs of the residents. A range of aids and adaptations meets the needs of the service users. Residents are able to personalise their rooms. EVIDENCE: The home was clean and tidy at the time of the announced inspection. There are sufficient cleaning staff to ensure the home is kept clean and tidy. Residents have comfortable bedrooms which they are able to personalise with their own furniture, pictures and belongings. The home provides a comfortable and homely environment. Communal space in the home includes a lounge and a dining room. There is a well-kept enclosed garden at the back of the home, which is accessible to residents. Service users said they felt comfortable in the communal areas, but were also able to choose to spend time in their own bedrooms. The Saffrons DS0000021262.V249427.R01.S.doc Version 5.0 Page 17 There are sufficient bathing and toilet facilities in the home. Twelve bedrooms have en-suite facilities. There are a range of bathing adaptations including an assisted bath and a bath with a seat. Whilst there was evidence of an on-going maintenance programme in the home, some areas still need repairing or renovating. Temporary repairs had been made to a carpet on the ground-floor, but it still needs to be replaced. Some radiators in the home still require covering. It is a continuing requirement that the kitchen is refurbished. The proprietors reported that there are plans to build an extension to the home, and during that major building work, a new kitchen will be fitted, worn-out carpets will be replaced and new boilers fitted. A number of fire doors were wedged open. An immediate requirement was left for all fire doors to be kept closed. It was discussed that if fire doors are to be kept open, they should be fitted with approved automatic closing devices, as are fitted to some other doors within the home. The Saffrons DS0000021262.V249427.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): 27, 28, 29, 30. There are sufficient numbers of skilled, trained and knowledgeable staff to meet the needs of the service users. The safety of the service users is not assured as the service does not take up Criminal Bureau Checks prior to starting employment. EVIDENCE: The home is fully staffed, with three care staff on the morning shift and two care staff on the afternoon shifts. In addition, there is one cook and two cleaners during the morning. Service users and relatives reported that users needs are generally met by the staff team. Of the thirteen care staff in the home, four have completed relevant NVQ courses, with other staff undertaking courses. There was documentary evidence of induction training for new staff as well as update courses for the staff team on Moving and Handling, Fire Safety, Medication training, Food Hygiene, Adult Protection and on Care Planning. Whilst there was documentary evidence of recruitment procedures including application forms, references and interviews, the service does not routinely take Criminal Records Bureau checks prior to new staff commencing employment. It was discussed that the requirement is for all CRB checks to be completed and received prior to employment, to ensure the protection of service users. The Saffrons DS0000021262.V249427.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, 34, 35, 36, 37, 38. The home is well run by the experienced and skilled manager/proprietors. The home provides a caring and friendly environment, which is run in the best interests of the service users. There are sound financial procedures to safeguard the interests of the service users and ensure the financial viability of the home. Whilst there is generally good communication in the home, the service cannot guarantee consistent care of service users as there is no regular supervision for staff. Up to date policies and records address the rights and best interests of the service users. Whilst there are a range of health and safety checks, the safety of service users and staff is not assured as some fire doors were wedged open and some radiators still require covering. EVIDENCE: The home is efficiently and sensitively run by the manager/proprietors, who are both experienced and skilled in managing and running care homes, having owned the home for over ten years. The manager has an NVQ4 and a The Saffrons DS0000021262.V249427.R01.S.doc Version 5.0 Page 20 Registered Managers Award. Staff, service users and relatives all reported that the manager/proprietors are friendly, approachable and supportive. The proprietors have a clear ethos for the home, which respects and values the people living there. Service users and relatives confirmed that the proprietors of the home welcome comments about the home, as well as ensuring regular monitoring of the service provided. There was documentary evidence of an annual audit, which included feedback from service users and relatives about the quality of the service. In addition, the proprietors seek regular feedback from service users, as well as encouraging any concerns or complaints to be raised and then investigated by the robust complaints procedure. There was documentary evidence of a comprehensive business plan and audited annual accounts. The home does not hold any money for service users, but pays for some goods and services on their behalf and then bills the service users or their financial appointees. All money spent on behalf of service users is clearly receipted and billed. Whilst staff reported that the proprietors are approachable and supportive, there is no regular supervision for staff within the home. It was discussed that regular supervision would enable the manager and staff to raise and discuss any issues relating to the service. There was documentary evidence that all records required by regulation were up to date and that a sample of policies and procedures had recently been reviewed. There was documentary evidence of regular fire drills for staff and that the fire systems are regularly checked. There are also regular checks of the heating and lighting as well as temperatures taken of the water, the fridges and freezers. All electrical equipment had been tested and passed as safe within the last year. There is on-going work to cover all the radiators in the home. Those not covered have been risk assessed to address the health and safety of the service users. Some fire doors were propped open and an immediate requirement was left to ensure the props and wedges were removed. It was discussed that any fire door left open should only be done so once it has been fitted with an appropriate closing device, as has been fitted to some doors within the home. The Saffrons DS0000021262.V249427.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 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 2 3 2 The Saffrons DS0000021262.V249427.R01.S.doc Version 5.0 Page 22 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 OP19 Regulation 13 (4) Requirement The carpet identified during the inspection is replaced. (Previously unmet from inspection of 16.06.05) The kitchen is refurbished. (Previously unmet from inspection of 16.06.05) CRB and POVA checks will be completed prior to new staff commencing employment in the home. All staff receive regular, formal supervision. All radiators are appropriately covered to ensure the health and safety of residents. Door wedges are removed from fire doors. Timescale for action 01/04/06 2 3 OP19 OP29 16 (2) (g) 01/04/06 11/10/05 19 (1) (b) Sch 2 (7) 4 5 6 OP36 OP38 OP38 18 (2) 13 (4) 01/12/05 01/04/06 11/10/05 23 (4) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Saffrons DS0000021262.V249427.R01.S.doc Version 5.0 Page 23 1 2 OP12 OP16 The home reviews the range of activities it offers residents. The complaints policy is updated to include information about the Commission for Social Care Inspection. The Saffrons DS0000021262.V249427.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Saffrons DS0000021262.V249427.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. 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