CARE HOMES FOR OLDER PEOPLE
The Suffolk Private Retirement Home 9 Sea Road Felixstowe Suffolk IP11 8BB Lead Inspector
Jill Clarke Unannounced Inspection 30th April 2007 10:10 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 Suffolk Private Retirement Home DS0000068303.V338221.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. The Suffolk Private Retirement Home DS0000068303.V338221.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service The Suffolk Private Retirement Home Address 9 Sea Road Felixstowe Suffolk IP11 8BB 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) 01394 282972 01394 274485 SJR Care Limited Mrs Tracey Bright Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places The Suffolk Private Retirement Home DS0000068303.V338221.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 7 February 2007 Brief Description of the Service: Suffolk Private Retirement Home is a care home for older people. The home is located on the sea front at Felixstowe. It can accommodate up to a maximum of 23 older persons. The home has no garden area for recreational purposes, but there is a small paved area immediately outside the front door, where service users sit in fine weather. Immediately opposite is the sea front, which includes an esplanade, seating, and gardens. The home is spread out over five floor levels – a basement comprising laundry, staff area, and storage. The ground floor comprises of a kitchen, 2 lounges, dining room, 2 toilets, and a small office. A further three floors have bedrooms, bathrooms, toilets, a sluice room, and the Manager’s office. The floors above ground floor level are accessed by either staircases, or a shaft lift. Details of current fees were not made available at the last key inspection date 13/7/06 the fees were £331 - £385. The Suffolk Private Retirement Home DS0000068303.V338221.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, undertaken over 7 hours, which focused on the core standards relating to older people. The report has been written using accumulated evidence gathered prior to, and during the inspection. Commission for Social Care Inspection (CSCI) feedback cards were sent to the home at the beginning of April. This gave an opportunity for residents, relatives, visitors and staff to give feedback on how they thought the service was run. At the time of writing this report, no completed surveys had been received. The registered Manager was present throughout the inspection, however during the afternoon, due to staff shortages was required to worker as a carer and prepare the evening meal. Due to previous concerns over the standard of the environment, the Manager gave the inspector a comprehensive tour of the building, which took in all the communal rooms, laundry, kitchen, bathrooms, toilets and majority of the bedrooms. Records viewed included, care plans, staff recruitment and training records, Fire Risk Assessment, Fire Log book, Statement of Purpose and medication records. Discussions with the people living at Suffolk Private, identified that they preferred to be known as residents, this report respects their wishes. What the service does well: What has improved since the last inspection? The Suffolk Private Retirement Home DS0000068303.V338221.R01.S.doc Version 5.2 Page 6 The home has taken action to address 10 out of the 14 requirements made following the February random inspection. Work undertaken includes keeping a record of all complaints made, purchasing a quality assurance system to support them in monitoring the level of service they provide, covering over an air vent – to reduce drafts, and keeping more detailed records. 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. The Suffolk Private Retirement Home DS0000068303.V338221.R01.S.doc Version 5.2 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 Suffolk Private Retirement Home DS0000068303.V338221.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. (the home does not offer intermediate care therefore standard 6 was not assessed) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective people wishing to use this service, will have their needs assessed and be given information on the home, to support them in identifying if the home will meet their needs. However, they cannot be assured that the information has been updated. EVIDENCE: During the random inspection undertaken on the 7 February 2007, the home was asked to update the information given in their Statement of Purpose and Service User Guide, and forward a copy to the Commission. This showed that most of the points had been covered and updated, however more information needs to be included: • • The experience the manager has in care/running homes Room sizes to be included in the Statement of Purpsoe
DS0000068303.V338221.R01.S.doc Version 5.2 Page 9 The Suffolk Private Retirement Home • • • Fees payable and arrangements in place for charging and paying for any additional services to be included in the Service Users Guide. The number of care staff on during the day states 3 not 2. The information on staffing levels is confusing for the reader, for example night staff ‘one and two nights a week’. In the back of the ‘Service Users Guide’ 4 residents have given their views on the home, usually the full name of the resident has been given. Discussion with the manager did not clarify if the residents had given their permission to have their surname printed. The manager did say that the views had been obtained some time ago. In addition to these documents, the home has an information file located in the entrance hall, which gives further information on the local amenities, such as places of worship, local taxi and bus services. It would also be useful to include the estimated costs of a single/return trip to the local shops and amenities. The home’s Statement of Purpose clearly states their admission procedure, which includes a pre-assessment ‘carried out by a representative of the home’. From records seen the manager had undertaken this prior to residents moving into the home. The home sends a letter to confirm that they are able to offer the level of care that the prospective resident is looking for. Times spent with 1 resident, confirmed that they had been to look around the home, and were pleased with their room. Residents felt that the staff had the skills and training to meet their physical care needs, but would like more social stimulation (see daily Life and Social Activities section of this report). Time spent talking to staff showed that they had a good insight into the residents they were looking after. They felt they had received a good induction and training to support them in gaining the skills to undertake their role. The Suffolk Private Retirement Home DS0000068303.V338221.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can expect the care they receive to be based on their personal choices and preferences, which is undertaken in a dignified way. EVIDENCE: At the February 2007 inspection, it was identified that ‘care planning had improved overall’. During this inspection, the 4 resident’s care plans looked at, gave information on their ‘preferred daily routine’. They were informative and individualised, giving the reader a good insight into how the resident liked to start their day. For example ‘wakes up at 8 am, however likes to rest in bed and have breakfast in their room’. It went on to say that the resident ‘will advise on a daily basis what assistance was required’. The way the guidance for staff was written showed that the residents had been involved, and that residents were being promoted to maintain their independence. The home, due to its layout is unable to accommodate people who use a wheelchair, therefore residents tend to be more ambulant, and able to freely move around the home using the stairs or passenger lift.
The Suffolk Private Retirement Home DS0000068303.V338221.R01.S.doc Version 5.2 Page 11 Time spent talking to 5 residents, and information held in their care plans showed that they required minimal assistance from staff with their personal care. Comments included “staff make bed, wash back” and “staff like to know when I get in and out of the bath”. Two of the resident’s care was tracked during the inspection, which involved reading their care plans, talking with the residents to hear their views on the level of service provided, and talking to staff about their assessment of the persons needs. Information gained through the ‘tracking’ showed that the care plan reflected their wishes, and the level of support currently being given. This included information on the resident’s mobility and any special dietary, and communication needs. Records showed when the resident had been offered a bath, and risk assessments contained guidance for staff stating that they should ‘promote dignity and independence at all times – avoid embarrassment’. The care plans would benefit from having an index at the front, and all set out the same way, to make it easier for the reader, and to be able to locate information quickly. Information held also included visits by Doctors and Community Nurses visited, when the resident saw a chiropodist, dentist or had their hearing or eyes tested. One resident said that they were going to have their hearing tested the next day. The ‘preferred daily routines’ gave information on washing and dressing, focusing on how much the resident could do for them self. However, discussion with 1 resident whose care was not being tracked, mentioned that they had asked staff to cut their finger nails, but this had not happened. Care records did not identify what assistance had been given to support the resident in keeping their nails, as they would like. With the resident’s permission, the request was passed onto the staff. Although residents had not taken up the opportunity to complete the CSCI feedback surveys, residents spoken with during the day were generally happy with the support they were being given with their personal care. They felt staff ensured their dignity and privacy was maintained, and sensitive to their sensory needs. A good example of this is how the home allocates their shared rooms. Unless it is requested, such as for “married couples”, the rooms are left as single occupancy. One resident has signed to say that they did not want to be checked during the night, which staff observed Care plans also asked residents about their cultural, faith/religious needs including any information on specific celebration associated with their culture/faith. The Suffolk Private Retirement Home DS0000068303.V338221.R01.S.doc Version 5.2 Page 12 Residents were having their weight recorded, but no nutritional assessment was being used to help identify any concerns on admission, and support staff in monitoring residents’ long term nutritional welfare. Good practice was seen with staff completing a ‘medication profile’ for each resident, which gave information on what medication they are on, and the reason they are taking it. During the February inspection a Carer was observed following safe practice when giving out medication, by ‘administering medication and completing records individually rather than in multiples’. During this inspection the manager was supervising a new member of staff who was giving out medication, until they received their formal training (which they had been booked onto). All prescribed medication is written on the Medication Administration Records (MAR), supplied by the dispensing pharmacist every 28 days. Records showed that staff had been completing them to confirm medication had been given to the resident, or as otherwise stated by the code used. Separate record books were kept to record all medication received into and out of the home. The pharmacist supplies the majority of the medication, held on behalf of the residents in ‘blister packs’. The packs are stored in a specialist lockable trolley, which can safety be transported around the home. A sample check of medication, not supplied in the blister packs was checked against the homes records. However, due to the home not having a system in place to show any medication brought forward from the previous month, or when the box was first open, it would have taken too much time out of the inspection to be able check back when the resident was first admitted to, enable an accurate check. In stead a residents supply of Temazepam was checked against the homes records, which was correct. This was easier to undertake as the home treat the medication as a controlled drug, with the safe practice of keeping a running balance of the amount of tablets held. Although the home held no controlled medication at the time of the inspection, they have the systems in place to ensure the medication is securely stored, and safety administered. The room storing the medication was found to be very warm, there was no thermometer to confirm that the temperature of the room, and evidence that medication is being stored below 25°C. It is mentioned in the random report that a photograph of the resident is going to be included in with their MAR chart, which is seen as good practice. This has not been undertaken as yet – however the manager was working on downloading the digital photographs onto the computer to print out, when the inspector arrived. The Suffolk Private Retirement Home DS0000068303.V338221.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People can choose where they prefer to eat their meals, and are supported to maintain their independence, and keep links with their family and friends. However, people cannot be assured that they will be offered sufficient stimulating activities, and social interaction if they are unable to arrange it themselves. EVIDENCE: During the last key inspection in July 2006, the judgement was made ‘residents can expect to be able to live as independently as they wish, however less able residents have more limited choices due to staffing numbers and lack of appropriate meaningful activities’. The random visit in February 2007 showed that people, through resident meetings had been discussing ideas about activities and outings. This was seen as a positive move forward. However minutes from the last meeting held in March stated ‘none of the residents wished to attend the meeting as they advised they could speak to us on a daily basis’. One resident confirmed that they did not attend the residents meetings “as nobody goes”. The Suffolk Private Retirement Home DS0000068303.V338221.R01.S.doc Version 5.2 Page 14 Comments from residents during the inspection included “only thing lacking is activities”, “if it wasn’t for the television – would get buried alive”, and “every day the same” and that they missed the “Quizzes” that use to regularly take place. Further discussions with 2 of the residents identified that an ex-member of staff used to come in on their day off and arrange the quiz that they enjoyed. They said that they had not had “Bingo in a long time”. The information board in the entrance hall gave information on the day’s activity – which was music being played whilst the residents eat lunch. The home’s Statement of Purpose stated that ‘ there is an activities programme in the home based upon the interests of the service users currently residing in the home’. The residents said that there is a “nice” church service every 2 weeks, which they went too. This reflected the information given in the ‘activities sheet’ held in care plans, where staff keep a record of activities individual residents join in with/undertake. From the 3 resident’s activity sheets looked at, 1 had attended an exercise session in March; another had attended a Sing-a Long, during April. Their activities sheet showed that they had attended church services or family had visited. One care plan held a completed ‘activities Questionnaire’ (which was not dated) where the resident had said they preferred ‘one to one’ activities, arranged for both ‘in or outside’ the home. Time spent in the non-smoking lounge showed it was too small to be able to set out with tables for residents to be able to play cards, board games or craftwork. The dining room was set up ready for the next meal. One resident sat at the dining room table all afternoon, their care plan stated that they preferred to sit at the table. Staff when working in the dining room, instigated conversations with the person. Whilst information in care plans gave a good insight on the routines of the day, they did not go into depth on social interaction / stimulation they preferred to join in with, to give meaning to their day. Staff did mention 1 resident who helped fold napkins. One resident had booked a taxi to go shopping which they said was a regular occurrence, or they liked to find a “bench and sit and read their book” along the sea front. Time spent with the resident, showed they were quite independent and arranged their own stimulating activities to fill their day, including meals out. Information held in care plans, and feedback from residents, showed that they can receive their visitors at any time, and enjoyed the family contact, and being able to go out with them. They felt able to exercise choice over when they wanted to get up, go to bed, have their meal, which was further evidence in their care plans (preferred routines). Residents said they would recommend the home to others – the only shortfall they felt was in the lack of stimulating activities.
The Suffolk Private Retirement Home DS0000068303.V338221.R01.S.doc Version 5.2 Page 15 Lunch was served in the dining room, which has views of the sea front and described by a resident as being “quite cheerful”. Tables were laid attractively, including tablecloths, mats, napkin rings and glasses. Meals were pre-plated, with staff who wore disposable gloves, busy serving and clearing plates throughout the meal. Staff said they wore the gloves to “stop our hands getting messy”. The atmosphere was semi relaxed, with music playing in the background; some residents were conversing, and others sitting on their own. Menu choices for lunch were Gammon with Cauliflower Cheese and peas or Soup. One resident said they preferred to have a “big breakfast, small lunch and big tea”. Another said they preferred to go down for breakfast and lunch, but have tea in their room. From discussion with residents, it was clear that staff were very flexible, in supporting residents to eat where they wished. Sample of menus seen showed that lunch choices over the past view days included Roast Pork, Fish & Chips, Chicken Curry and ‘Full English’. Desserts choices included Strudel and cream, and Bread & Butter pudding. Fresh fruit is available for residents to help themselves to in the dining room, and staff said “bananas were always offered for breakfast”. One resident commented on the “excellent food”, and also said that the “new weekend Cook was excellent”. One resident had their own microware, freezer and kettle in their room, which enabled them to be more independent, and “cook a meal if they wished when they had been out”. Residents confirmed they were offered plenty of hot and cold drinks during the day, one resident showed that their drinks were “backing up”, as they pointed to the 2 cold drinks in front of them. To gain feedback on their meal service, the home sent out ‘meals and quality’ questionnaires in February. Residents were asked to give a score from 1 to 10 (10 being the highest) if they liked the menu choices, if they felt meals were well presented, if they enjoyed the meals, if the portion size was adequate and if the ‘meal times are to your liking’. Seven had been returned, with all but 2 of the scores falling in the 10 to 7 category. One ‘6’ had been given in the presentation category. One resident had scored a ‘1’ against adequate portions, commenting that there was ‘not enough for tea’. Future inspection will look at how the home has used this information to address any shortfalls. For tea, there was sandwiches, which were prepared by the manager. During the afternoon residents were asked their choice of fillings, which included chicken mayo, cheese and onion, egg & cress, jam, peanut butter and chocolate spread. One resident who came into the dining room before tea, said they were hungry. The Manager straight away offered to toast them a fruit bun – which the resident enjoyed. Previous days Tea choices included Sausage Rolls & Crisps, Spam, Omelette and Crumpets. The Suffolk Private Retirement Home DS0000068303.V338221.R01.S.doc Version 5.2 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can expect their complaints to be listen too, and staff respond appropriately. EVIDENCE: The home’s complaint procedure is included in both the Statement of Purpose and Service Users Guide. The procedure informs people who to complaint to, and the timescales for acting on their concerns. Both documents also give the reader information on what to do if they are ‘not satisfied’ in the way the compliant has been handled, which includes contacting the CSCI to seek further advice. However, although the address and been given in the Statement of Purpsoe, they have not included the contact number – which they have rightly given in the Service Users Guide. Following the February inspection, the home was asked to ‘ensure that the complaints log is kept up to date and includes all concerns raised’. This had been undertaken, and showed that the home had received 3 complaints since March 2007. The CSCI had been made aware of 2 of the complaints (see Environmental section of this report) made by the resident concerned, which enabled them to check with the home to confirm what action had been taken to address them. Records held also confirmed what action the home had taken, which was within required timescales. The home had also instigated a Vulnerable Adult referral, which at the time of the inspection was still being investigated. With the resident contacting the CSCI direct, and the Manager
The Suffolk Private Retirement Home DS0000068303.V338221.R01.S.doc Version 5.2 Page 17 instigating the vulnerable adults procedures when they had concerns, showed that both residents, and staff, are aware of who to contact. The complaints book had not been indexed by giving complaints a allocated number/page number, which would make it easier to locate, and monitor any trends in the complaints being made. Training files seen, showed that the staff had attended Adult abuse training as part of their induction. The Suffolk Private Retirement Home DS0000068303.V338221.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24 and 26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although staff are working towards it, people still can not be assured that the home has got a robust system in place for the reporting any hazards, and maintaining the internal premises to a good, safe, homely, well maintained standard. EVIDENCE: Previous key inspection reports have raised concerns over maintenance of the home. The February inspection identified the on-going refurbishment work which included redecorating/refurbishment of ‘many of the bedrooms’, which included new curtains, bedspread, wardrobe, chest of drawers, lockable bedside unit, and “comfortable” armchair. Information supplied by the owners, and discussion with the manager confirmed that quotation were being obtained to upgrade the kitchen. The Suffolk Private Retirement Home DS0000068303.V338221.R01.S.doc Version 5.2 Page 19 Time spent with the residents confirmed that the bedrooms looked brighter, although some said that they were not involved in selecting the colours of the curtains, and bed cover “which is removed in the afternoons at 3”. Although some residents said that they would not have chosen the colours themselves, they agreed it brightened up the home. One bedroom, which had been redecorated, had a large water mark from a leak in the bedroom above, which had happened soon after the work was done, which spoilt the look of the room. Another bedroom visited later in the day had a soiled continence pad and underwear on the carpet near the door. There was no container seen for the resident to place this in, and there was no staff seen working in that area. Residents spoken with were happy with their bedrooms, which they had made homely and comfortable – and said it met their needs. The bathrooms, were very bare and cold looking, with no effort made to make them a relaxing, welcoming place to bath in which did not fit with discussions with staff identified how much the residents “enjoy their bath”. The tour of the building which due to previous concerns over the environment took in 10 of the bedrooms, bathrooms, toilets, sluice, laundry, staff room, lounges and dining room. The wipeable covering over the wooden toilet seats had peeled away, exposing wood; therefore staff would not be able to keep these clear of bacteria. The u-bend of some of the toilets were heavily stained, from what looked like a build up of lime scale and bacteria. Communal Toilets were in need of redecoration, and minor repairs such as broken tiles needing to be replaced. The U-bend of the toilets were heavily stained/discoloured. When trying to lock one of the upstairs communal toilets, it was found that the lock would not slide cross, therefore not ensuring a person’s privacy could be maintained. One resident’s hand basin had a sink plug – but no chain. Another had black stains on the carpet around the pedestal of the sink, which the manager said is going to be replaced. Where areas had been re-decorated it looked fresh and clean, however, this showed up even more the areas that through wear and tear are in need of redecoration. Information provided by the owners showed that they had just completed ‘£20,000 worth of improvements in new furniture, carpets and soft furnishings and redecoration’. They went on to say that in the period from Oct 06 to July 07 they would be spending a further £5,000 to £8,000, on improving the kitchen, and a further £5,000 on furnishings and refurbishment. The home does not employ a handy person, instead they call in a “local handyman” when they need them. This led to discussions in the importance of having a system to report day-to-day breakages/hazards, and recording when they are dealt with. Following their Fire safety Audit in November 2006 undertaken by a member of the Fire and Rescue Service, the home was sent a ‘Notification of Fire Safety Deficiencies’, which gave a ‘schedule of work required’. This included ensuring
The Suffolk Private Retirement Home DS0000068303.V338221.R01.S.doc Version 5.2 Page 20 the Intumescent strips and smokes seals on fire doors met the required standards. Whist walking around the home it was noticed that the seals on one fire door had paint on, and the strip on the bottom of the door was coming away. The manager said that the work had not yet been completed, and someone was coming later that week to discuss the work. The home has a Fire Risk Assessment in place, which the manager said had since been seen by the Fire Officer, who had “asked for a few bits to be added – otherwise okay”. On arrival, the fire door leading down to the laundry, and staff smoking area was found to be held back by a ‘door wedge’, which meant if the fire alarms were set off, the fire door would not be able to close. This was pointed out to staff, but was still found to be in situ at the end of the inspection, and the manager was asked to remove it, before the inspector left the building. A previous complaint from a resident concerned the water from their hand basin not draining freely away, noise from the air lock in the plumbing system, and being unable to alter the radiator control. All had been sorted by the home, except the noise form the airlock, due to the age of the house and pipe work. The plumber had been consulted, and there was nothing else they could do. The inspector ran the hot water in 5 of the bedrooms, and on releasing the plug found the water drained quickly away. Twice the sound from the air lock was heard – but soon disappeared once the water had run for a few seconds. The temperature of the hot water was not tested, however it was found to be comfortable to the hand. The manager confirmed the temperature of the hot water is checked regularly to ensure it is with a safe range, and individual thermostatic controls have been fitted. The Suffolk Private Retirement Home DS0000068303.V338221.R01.S.doc Version 5.2 Page 21 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People can expect to be looked after by trained, skilled staff, however they cannot be assured they would be in sufficient numbers to support them with their social needs. EVIDENCE: Discussions with the Manager in February made clear that ‘the home is only suitable for relatively independent residents, mainly due to the homes environment and positioning. Care plans and discussions also reflected that many of the residents required little support with their personal care, and the more able could take themselves out. However, where residents are unable to get out, and need the support of the home to give stimulation and meaning to their day, not all residents said this was happening (see Daily Life and Social Activities section of this report). On the day of the inspection, both of the afternoon staff listed on the information board, were not the staff that came on duty. Instead the shifts were covered by the Manager, and Deputy Manager. With only 2 on duty, the minimum that needs to be left in a home to support residents, no one could be taken out if they wished, and with the Manager preparing tea – this left no time for instigating activities. Due to the short notice given of the staff not undertaking their shift, the manager said that they had been unable to get agency cover – which they would normally try to do.
The Suffolk Private Retirement Home DS0000068303.V338221.R01.S.doc Version 5.2 Page 22 The staff rota shows that there is no kitchen or domestic cover after 2pm. Therefore it is normal practice for care staff to prepare a light tea, lay tables, and clear up after – whilst supporting residents with their personal and social needs. At 4.15 whilst talking to a resident in their bedroom, it was noted that they had old curled up sandwiches in their room left over from lunch time. From the staffing rota, the normal staffing level is given as 2 carers on duty throughout the 24-hour period; there are no additional staff on during peak times or to provide social activities/intervention. At the time of the inspection, the home had 3 vacancies, therefore gave a staffing ratio of 1 carer to 10 residents. The Manager works extra to the rota (8am – 4pm) to be able to undertake their management/administration responsibilities, and is supported 1 day a week by the Deputy Manager, who otherwise works as ‘hands on’ care. The minimum number of carers to be left in the building to assist residents would be 2, therefore the current staffing level does not allow for staff to take people out or support residents to have individualised social interation where assistance is needed. Staff are further taken away from spending time with residents, during the afternoon/evening when they are required to pre-pare and serve, clear up after tea. A new member of staff, who was also new to care, said they had been given a “fantastic” induction, that they “wouldn’t do anything until “ until they “were 100 sure”. Two staff are currently enrolled on the ‘Common induction Skills for Care’ course through a training centre, which provides training in the core skills (Value base, skills development, communication, Health & safety, Adult abuse). The Manager is then required to back up the work being taught during the training days, through monitoring work place practice and signing off the training book. Information supplied by the home showed that that they currently have 50 of their carers trained to national Vocational Level (NVQ) 2 or equivalent. No carer staff are currently undertaking their NVQ training, however discussion with 1 carer showed their commitment/motivation to apply, and take this qualification in the future. The February inspection, identified that the people undertaking risk assessments had not had sufficient training to undertake this. The manager confirmed that both they and the deputy are to undertake risk assessment training. With only 1 member of staff leaving in the last 12 months, this shows that the home has maintained a stable workforce. The personnel records of 2 staff employed since the last key inspection, showed good practice with the use of a ‘recruitment’ check list. This supported the home in monitoring that all the required paperwork had been received, and checks undertaken before staff starts work. File held 2 written references, job description, and paperwork to
The Suffolk Private Retirement Home DS0000068303.V338221.R01.S.doc Version 5.2 Page 23 validate the person’s identity, including Criminal Bureau Record (CRB) checks. The application forms did not give the applicant full employment history, which was not help by the form itself, which only had space to write 3 previous employment down. There were no recent photographs held on file. The manager said they would be addressing this, by taking staff photos with the new digital camera. Good practice was seen with a letter confirming their employment, and that required paperwork had been obtained. The Suffolk Private Retirement Home DS0000068303.V338221.R01.S.doc Version 5.2 Page 24 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, 36, 37 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People can not be assured that the staff are following safe fire procedures, which could potentially put people at risk. EVIDENCE: The February inspection confirmed that the Registered Manager, Tracey Bright, ‘was still working towards their NVQ4 qualification, but indicated this had been delayed because they had so far had 8 assessors since starting. The manager is looking to complete the qualification this year. A member of staff said that they were not “afraid to ask the manager” anything, and found the management staff approachable. This reflected the comments made by a resident who described the manager as “very good”. They went on to say that all the staff were “good” and “did their best”.
The Suffolk Private Retirement Home DS0000068303.V338221.R01.S.doc Version 5.2 Page 25 The last 2 inspection reports showed that there has been an outstanding requirements for the home to ‘establish a formal system for reviewing and improving the quality of care provided’ and once completed produced a report for people using the service to read. This inspection found that the home has now purchased a quality monitoring system, which looks at all aspects of the service provided. The manager said they needed time to work through the monitoring system, and until they had completed this, would not be able to produce a report. Taking into account that the system had been purchased, the time limit for the report to be completed by, has been extended (see requirement section of this report). The home has completed 1 quality assurance survey, to gain feedback on the meals provided (see Daily Life and Social Activities section of this report), which they are yet to analyse and make available the results for people using the service to read. As stated earlier, at the time of writing this report no CSCI surveys had been returned. The July 2006 inspection, where CSCI surveys had also been sent to the home, only 1 staff questionnaire had been returned. The manager said that this reflected what they had come across, with residents feeling that they do not need to complete questionnaires/attend meetings as they can give feedback on a daily basis. Files showed that staff were receiving regular supervision, where the supervisor completes a supervision template, which covers the areas to be discussed which includes, ‘Philosophy of home/care and career development’. The home does not hold money in safe keeping for residents. Record keeping was generally found to be of an adequate standard, however a major shortfall was identified in the maintaining the required Fire Records. A check was made of the fire log book, which gives the homes legal obligations in testing the fire systems in place, which includes weekly checks of the fire alarm system, to ensure it is in safe working order. Records showed that the system had not been checked on a weekly basis since January, although it was noted the system had been serviced on the 2/4/07. The home was informed that they must take immediate action to test the system, and also ensure that fire doors were not wedged open (see environment section of this report) The February 2007 inspection evidenced that the home had addressed requirements made following the July 2006 inspection. Health & Safety certificates were now being kept in one folder, and a diary was being used to monitor when renewal and checks on equipment were required. The manager confirmed that Portable Appliance Testing was undertaken regularly, and the ‘sticker’ label on bath hoist confirmed that the hoist was being serviced every 6 months. Staff records looked at showed that they had received manual handling training, and Food hygiene. The Suffolk Private Retirement Home DS0000068303.V338221.R01.S.doc Version 5.2 Page 26 Whilst there was evidence that residents physical care needs were being met, staffing levels were insufficiant to ensure that those residents needing support in social activities were being met (see staffing and daily life sections of the report). The Suffolk Private Retirement Home DS0000068303.V338221.R01.S.doc Version 5.2 Page 27 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 3 3 2 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 1 3 2 x 3 3 x 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 1 1 The Suffolk Private Retirement Home DS0000068303.V338221.R01.S.doc Version 5.2 Page 28 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 OP1 Regulation 5 (1) (b) (ba) (bb) (bc) (bd) Requirement The service users guide must contain information on fees, and how people will be asked to pay them, to ensure people know what they will be expected to pay. To ensure the safety of people living and working in the home, the owners must evidence that they have met the requirements and recommendations made by the Fire Authority. Repeat requirement. To ensure the safety of residents, the home must evidence that anyone who undertakes risk assessments has the training and competence to do so. Repeat requirement. To ensure people have a safe well-maintained environment to live in, locks on toilet doors must be working, and the home must have systems in place to ensure the home is kept well
DS0000068303.V338221.R01.S.doc Timescale for action 10/07/07 3. OP19 OP38 23 (4) 10/06/07 4. OP19 OP32 OP33 12, 13, 18, 19 10/07/07 5. OP19 OP10 23 (2) (b) 08/06/07 The Suffolk Private Retirement Home Version 5.2 Page 29 maintained, privacy respected and staff are aware of their responsibility in reporting any hazards or damages. 6. OP26 16 (2) (j) Worn toilet seats must be replaced, to ensure staff can keep them clean. The home must review their staffing levels, and skill mix, to ensure that they have sufficient staff on throughout the 24-hour period to meet residents physical and social care needs. A full employment history must be obtained for new staff, to enable the home to check any gaps in employment, and validate the reason they left previous jobs working with vulnerable people. 25/06/07 7. OP27 18 (1) (a) 25/07/07 8. OP29 19 (1) Schedule 2 (6) 01/06/07 9. OP19 OP38 16, 19 The owners must ensure that the 31/05/07 refurbishment of the kitchen takes place for the health and safety of staff and residents. This is a requirement made at the random inspection, which the home still has time to address. The home must supply CSCI with 01/08/07 a report regarding the quality of care provided, and also make the report available to residents, so they are aware of the findings, and where there are shortfall what the home is going to do to address them. Repeat requirement. To ensure the safety of people living in the home, Fire doors must not be wedged open and checks of the Fire alarm systems must be carried out.
DS0000068303.V338221.R01.S.doc 10. OP33 24 (2) 11. OP37 OP38 23 01/05/07 The Suffolk Private Retirement Home Version 5.2 Page 30 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations More information should be given in the Statement of Purpose and Service users guide on the relevant experience of the Registered Manager. Staff should look at updating feedback from people using the service, including when it was obtained and the home and give clearer information on the staffing levels. The home should look at using a recognise nutritional tool to support them on identifying any nutritional problems on admission, and part of the person’s on-going monitoring of their nutritional needs. Systems should be in place to monitor the temperature of the room where medication is held, to ensure it is not too warm, which could lead to deterioration in the content of the medication. To enable audit checks of medication to be undertake, the home should have systems in place to enable a accurate figure to be kept of any mediation not held in blister packs. The complaints procedure in the Statement of Purpose should also include the CSCI contact number. A index and numbering system in the complaints book would make it easier to see who has complained and when. The home should look at seeking further advice, to enable them to get the toilet u-bends clean, and lime scale free. To make a more relaxing environment for residents, they should look at how they can make the bathrooms more welcoming and homely. As part of their infection control procedures, where
DS0000068303.V338221.R01.S.doc Version 5.2 Page 31 2. OP8 3. OP9 4. OP9 5. OP16 6. 7. OP21 OP21 8. OP26 The Suffolk Private Retirement Home residents look after their own continence needs, they should ensure they have been supplied with an appropriate container to dispose of soiled pads. The Suffolk Private Retirement Home DS0000068303.V338221.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 The Suffolk Private Retirement Home DS0000068303.V338221.R01.S.doc Version 5.2 Page 33 - 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!