Inspection on 05/05/09 for Friary Fields Care Home

This is the latest available inspection report for this service, carried out on 5th May 2009.

CQC found this care home to be providing an Good service.

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

Friary Fields Care Home 17/04/07

Friary Fields Care Home 15/06/06

Friary Fields Care Home 30/11/05

Friary Fields Care Home 01/07/05

Friary Fields Care Home 28/06/04

Friary Fields Care Home 05/03/04

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Friary Fields Care Home 21 Friary Road Newark Nottinghamshire NG24 1LE Lead Inspector Rebecca Shewan Key Unannounced Inspection 5th May 2009 09:20 DS0000008764.V375308.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Friary Fields Care Home DS0000008764.V375308.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Friary Fields Care Home DS0000008764.V375308.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Friary Fields Care Home Address 21 Friary Road Newark Nottinghamshire NG24 1LE 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) 01636 706 105 01636 702 747 ashvin.ramchurn@ntlworld.com Mr Leckraz Ramchurn Mrs Devhootee Ramchurn Mr Leckraz Ramchurn Mr Ashvin Ramchurn Care Home 34 Category(ies) of Dementia (31), Old age, not falling within any registration, with number other category (3) of places Friary Fields Care Home DS0000008764.V375308.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Rooms 10, 11 and 12 are not to be used for people with dementia due to their close proximity to a staircase. Only residents who are assessed as being able to call for assistance should be placed in rooms on the 2nd floor. Within the total number of beds, a maximum of 31 may be used for service users included within the category DE over 60 years old Within the total number of beds, a maximum of 3 may be used for the category OP 1st April 2008 Date of last inspection Brief Description of the Service: Friary Fields is owned by Friary Fields Limited and is a family-run care home. It provides personal care and accommodation for up to thirty-four older people of both sexes, thirty-one of who may be over the age of 60 years and may have dementia. The home provides short and long term care and will accept emergency admissions. It is situated in the riverside town of Newark, less than half a mile from the town centre. Shops, market, churches, library, theatre, pubs and historic sites of interest are some of the facilities and activities available in the town. The residents are housed in twenty-eight single and three double bedrooms. Six of the single and one double have en - suite facilities with toilet and washbasin. Communally, there are two lounges and an attractive, large conservatory on the ground floor. There is also a lounge on the first and second floors. The two dining areas are attached to the two ground floor lounges. There are nine toilets, five bathrooms and one shower room. A passenger and a stair lift give access to most rooms on the two upper floors although some rooms are only accessible via the stairs. The garden has been landscaped, has a potting shed and provides a secure outdoor area. There is car parking space for up to eight cars. The fees range from £338 to £415 per week, with extra charges for hairdressing (£4- £20), chiropody (£8), Newspapers/magazines (Varied), private transport (Varied), toiletries (varied), TV License Fee (£5) and Broadband/Telephone (Varied). Friary Fields Care Home DS0000008764.V375308.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This unannounced inspection took place during the morning and afternoon of the 5th May 2009. Incident reports and previous inspection reports, held by the Care Quality Commission, were read before the inspection. The inspection of the home took seven and a quarter hours. Records such as care plans, staff files and medication records were also viewed. Twenty nine service users (known as residents) were accommodated at the home at the time of the inspection. A tour of the whole home was undertaken and the Registered Managers, a Senior Carer, a Carer Assistant, the Chef, one relative and one resident were spoken with. What the service does well: Potential new residents benefit from a pre- admission assessment that allows for only those who needs can be met, being admitted to the home. The health needs of residents are well met with evidence of good multi disciplinary working taking place. Staff provide personal support to residents in such a way that promotes and protects residents privacy and dignity. Residents benefit from an activities calendar that is stimulating and arranged according to their choice. Residents experience mealtimes that are unhurried, whilst all meals are home cooked with an alternative option being available for each mealtime. Residents can be assured that there is an efficient complaints procedure in place and that the homes processes and staff training should protect residents in the event of an allegation of abuse. The location and layout of the home are suitable for its stated purpose. All areas of the home are accessible to residents. Residents experience the benefits of a staff team that have the necessary skills and experience to the meet their needs. Staff training is on going and is appropriate to the level of needs of current residents. The management and administration of the home is good, with evidence of consideration being given to residents and/or relatives opinion at all times. Friary Fields Care Home DS0000008764.V375308.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Friary Fields Care Home DS0000008764.V375308.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 Friary Fields Care Home DS0000008764.V375308.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 & 6 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has processes in place for assessing potential new resident’s with services being offered to only those resident’s whose needs can be met. EVIDENCE: One of the home’s two Registered Managers carries out pre- admission assessments. Copies of care management assessments from the placing authority are obtained, where these exist. The Registered Manager addresses any issues, which are highlighted within this assessment. Documented records are maintained of all correspondence with the placing authority. Records inspected showed that pre- admission assessments are carried out on all new and potential residents. Documentation relating to the most recent admissions to home were viewed and found to have been completed fully and conducted Friary Fields Care Home DS0000008764.V375308.R01.S.doc Version 5.2 Page 9 with the involvement of the resident and/or their representatives (where applicable). Following the inspection of April 2008, pre admission assessments have been further developed to include identification of any diversity or cultural needs of individuals as well, as any religious needs. The new documentation in place should be updated to identify the place where the assessment was conducted. Therefore a Recommendation has been made. Following the inspection of April 2008, evidence has been provided to the commission, which ascertains that the bedroom identified in the conditions of registration is suitable to meet the needs of the individual discussed at the inspection. Records viewed detailed that a further review had been conducted and that the bedroom remained suitable for the individual. Therefore the previous inspection Requirement has been met in full. Intermediate care is not provided by this home. Emergency admissions are accepted by the home, though the Registered Manager reports these are infrequent and would always be with a clear pre admission assessment and SNAP overview in place before the potential new resident would be admitted to the home. There is a clear Emergency admission policy in place. Friary Fields Care Home DS0000008764.V375308.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are offered a good provision of health care and personal support by the home. All care is administered in way that protects residents privacy and dignity. Medication procedures ensure that medication are stored and administered safely. Whilst improvements are required to ensure that omission codes are utilised effectively and in accordance with those specified on the Medication Administration Record (MAR) Sheet. EVIDENCE: Following the inspection of April 2008, the registered managers have ensured that the previous inspection Requirements that Care plans and risk assessments are in place for the management of challenging behaviours, which inform staff, how to meet the individual needs and which promote consistent Friary Fields Care Home DS0000008764.V375308.R01.S.doc Version 5.2 Page 11 practice and that care plans and risk assessments are in place for all individual healthcare needs and how these are monitored and met have been met in full. It was observed that a new care plan and risk assessment format had been implemented since the previous inspection. Care plans were sampled and it was evidenced that they were comprehensive, detailed in content and covered all aspects of resident’s needs. Care plans are written to allow the assessor to gain a good overview of individuals medical, mental health, social and personal care needs and provide the assessor with a clear overview of the Residents current needs, limitations and required assistance. Residents involvement in the care plan review process was also evident. Care plans are reviewed on a monthly basis and are updated to accurately reflect any change in needs. Risk assessments for falls, harm or injury, nutrition, hoisting, wheelchair use, medication, infection risks and challenging behaviour were viewed and found to be comprehensive in detail. Monthly reviews of such documentation were also noted. It was evidenced from the care plans and risk assessments sampled that the front page was the only one named for the individual service user, therefore a recommendation has been made. Care plans also include records of the individual residents Mental Capacity, visits conducted by Healthcare professionals and family/friends. Therefore the previous inspection Recommendations that continue to develop the care plans to ensure all individual and specific needs are evaluated in detail and that this is undertaken on a monthly basis, further improve record keeping practices to ensure all care plans and risk assessments are dated when completed, incorporate health Action Plan/Profiles within care plans and which running records of interventions and professional visits can be easily accessed and audited and introduce nutritional screening tools and risk assessments for assessing individual at risk of developing pressure areas have been met in full. Residents are registered with one GP from one of four local surgeries. District Nurses, the Stoma Nurse and the Continence Nurse all attend the home as needed and are accessed either via the GP or directly by the staff of the home. Domiciliary opticians attend the home and private appointments to local opticians are also supported. Dentist treatment is arranged via private and/or NHS surgeries. There are both types of surgeries available locally. Home dental visits are also conducted as required. Access to audiology, physiotherapy, Occupational Therapy and the Dietician are sourced via the GP. The home has a Chiropodist who attends the home every six to eight weeks and as required. The home has established good links to Byron House where they are able to access the Consultant Psychiatrist, the Community Psychiatric Nurse and the Mental Health Team. Friary Fields Care Home DS0000008764.V375308.R01.S.doc Version 5.2 Page 12 Following the inspection of April 2008, the registered managers have ensured that the previous inspection Requirements that that appropriate medication management systems are in place; By using a medication trolley in the home to ensure medication is not left unattended, ensuring two people check and sign handwritten prescription entries on the medication records and by having a clear audit trail of medicines received in the home have been met in full. The home has good procedures in place for the monitoring and recording of all drugs administered and those entering and leaving the home. The stores for medication were viewed and these were found to be maintained in a clean and orderly manner. Mar sheets were viewed and it was evidenced that O omission codes had been entered onto several sheets. The MAR sheet details that where an O code is utilised the O should be defined. It was observed that this section was blank and that no definition for the omission had been recorded. Therefore an immediate Requirement was made. Staff were observed providing personal support to residents in such a way that promoted and protected their privacy and dignity. It was observed that residents bedroom doors were knocked before staff entered them and that residents were called by their preferred choice of address. Therefore the previous inspection Recommendation that the practice of staff promotes privacy and dignity for people living in the home at all times has been met. Friary Fields Care Home DS0000008764.V375308.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are able to enjoy a full and stimulating programme of activities to choose from. The home provides a wide range of social, cultural and recreational facilities, including specialist diets to residents, with resident’s choice and wishes being respected. EVIDENCE: Residents are consulted regarding their social and leisure interests. The Registered Manager reported that there is not a published list of activities in place, due to the residents requests and behaviours being taken into account on a daily basis when activities are being organised. Records are maintained of all activities conducted. Activities include: Reminiscence sessions, board games, arts and crafts, music and movement sessions, 3 visiting musical people (1 with a puppet, 1 yester year songs and 1 piano player), motivational classes (memory games). All service users birthdays are celebrated with a cake and a party. The Registered Manager reported that himself and a Senior Friary Fields Care Home DS0000008764.V375308.R01.S.doc Version 5.2 Page 14 Carer had recently completed training in Dementia Care Mapping and that as a result the activities within the home will be reviewed, to ensure that offer residents appropriate stimuli. Further staff will receive training in this matter over the next twelve months. Therefore the previous inspection Recommendation that training for staff in activities for people with Dementia would improve the lifestyle of people living in the home has been met. Resident’s religious wishes are observed and arrangements are in place for residents to receive Holy Communion, if they wish. Discussions with the Registered Provider/Registered Manager highlighted that although the current residents had similar religious beliefs, the home would welcome any potential new resident who has special cultural/religious/spiritual beliefs and would make provision to accommodate their needs. The management of the home believes in promoting an equal and diverse culture among staff and residents. Outings such as trips to lunch with relatives and visits at weekends with relatives are positively encouraged. Residents, where able, are encouraged to attend the local market town. There are currently no day centre attendees at present. Contact with family and friends is positively encouraged with visitors being able to attend the home at any time and in accordance with the resident’s wishes. Care plans are utilised to record when a resident has received visitors. Therefore the previous inspection Recommendation that contact with relatives/friends and representatives is recorded within the care records, in conjunction with appropriate implementation of care plans for this purpose has been met. Menus are planned with residents input. The home’s menus are devised on a four week rolling programme. All meals are home cooked with an alternative option available for each mealtime. Meals can be taken in the residents bedroom or in the communal dining room. Medical, therapeutic or religious diets are provided as needed. Drinks and snacks are available at all times. The meal served during the inspection was ample in quantity and attractively presented. The lunchtime meal was observed to be unhurried. Menus were observed and these were found to be somewhat limited in variety, through discussions with the Registered Manager and the Chef it was highlighted that the menus reflect resident choice and that residents had disapproved of changes to menus in the past. The Chef and Registered Manager have a meeting planned, to discuss how the homes food supplies are ordered and how the quality of food can be improved. Variety in menus will also be discussed, with new choices being implemented gradually and with residents input. Therefore the previous inspection Recommendation that the service could also be improved by the production of innovative menus, visual cues for eating areas, the provision of choice options and finger food options has been partially met. Friary Fields Care Home DS0000008764.V375308.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Resident’s benefit from a robust and efficient complaints procedure, whilst the homes procedures, processes and staff training should protect resident’s in the event of an allegation of abuse. EVIDENCE: The home has an established complaints procedure in place. The home has received one complaint within the past twelve months, which has been recorded as addressed. The complaint has now been resolved and the Registered Manager took appropriate action, to address the concerns raised. Criminal Record Bureau (CRB) checks have been carried out on all existing staff. Both CRB and Protection of Vulnerable Adult (POVA) checks are carried out on all new staff. Staff have attended training in the Safeguarding of Vulnerable Adults within the last twelve months. This was evident from the staff files were viewed. There have been three Safeguarding Alerts raised by the home in last twelve months. Each of which have been resolved and appropriate strategies implemented to address any issues raised during the investigation processes. Therefore the previous inspection requirement that Friary Fields Care Home DS0000008764.V375308.R01.S.doc Version 5.2 Page 16 you must make the appropriate safeguarding referral to Adult Social Care and Health in respect of the above event has been met in full. Friary Fields Care Home DS0000008764.V375308.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 & 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides accommodation for residents that is safe, and well maintained, whilst infection control procedures are adhered to at all times. Whilst some improvement is required to ensure that all areas of the home are kept odour free and fit for purpose for all residents. EVIDENCE: The location and layout of the home are suitable for its stated purpose. The home is well maintained and all areas of the home, including the garden, are accessible to residents. The home has an ongoing plan of refurbishment in place. It was observed that the previous inspection Recommendation that the concrete path leading from the ramp to the seating area in the garden, which Friary Fields Care Home DS0000008764.V375308.R01.S.doc Version 5.2 Page 18 is uneven and therefore may present a trip hazard to people using it should be attended has been met. There is a clear system in place for the recording of all repairs and maintenance required, it was evidenced that these records are updated when all works/repairs have been completed. Therefore the previous inspection Recommendation that the systems for day to day repairs and general maintenance in the home be improved and produce a development plan for cyclical and ongoing decoration and improvement has also been met in full. Following the inspection of April 2008 the Registered Managers have made improvements to that ensure that people living in the home would benefit from sensory stimuli and clearer signage of facilities such as toilets and that they undertake and document a security review of the premises, which includes an assessment in respect of the ground floor windows and take any appropriate action in respect of fitting restrainers. Documented records of all security checks, maintenance and repairs were viewed and it was observed that restrainers had been fitted where appropriate. From the tour of the premises it was evident that all rooms were clearly signed with both words and pictures. The home has an infection control policy in place and staff are trained in infection control procedures, staff training records viewed confirmed this. Staff were observed adhering to infection control procedures. There is a daily cleaning schedule in place. It was evident that the smaller lounge/dining area had a malodour of urine present. Discussions with the Registered Manager confirmed that the issue arises from a particular resident and that despite continence reviews and a strict cleaning schedule the problem of malodour persists. It was also discussed that whilst the individuals dignity must be preserved it is important that the environment is deemed fit for purpose for all residents, taking into account that some may lack the capacity to express their wish not to be seated in this room. Therefore a Requirement has been made. Friary Fields Care Home DS0000008764.V375308.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a staff team that have the necessary skills, training and experience to the meet the needs of current residents. EVIDENCE: A competent staff team, sufficient in number, meets the resident’s needs. There is a staff rota in place, which details staff hours of working; there is a need for this to be updated to include staff job designations. Therefore a Recommendation has been made. The home has a permanent staff team of two Registered Managers, eight Senior Carers, eleven care staff, one Chef, one cook, an administrator and two Domestic Assistants. The management of the home are committed to training staff in National Vocational Qualification (NVQ). Ten care staff are NVQ, level 2 or above, trained in care and two care Assistants are currently completing the NVQ level 2, in care training. The Cook is trained to NVQ level 2 in Food and Catering and the Chef is due to commence NVQ level 2 or 3 in Food and Catering in the near future. A domestic is trained to NVQ level 2 in cleaning. Friary Fields Care Home DS0000008764.V375308.R01.S.doc Version 5.2 Page 20 Staff recruitment files were viewed and it was evidenced that these files contain all items required under the Care Homes Regulations 2001. The home has an Equal Opportunities policy in place and is an equal opportunities employer. Training records were observed and it was evidenced that the staff induction training is conducted in line with Care Skills Sector guidance. Mandatory training consists of Skills for Care Induction and foundation programme, Moving and Handling, First Aid, Safeguarding Vulnerable Adults, Managing challenging behaviour, Infection Control, Fire Safety, Health and Safety, Mental Capacity Act, Deprivation of Liberties and medication. Additional training is also provided in dementia, diabetes, nutrition, falls prevention and other subjects that arise from changes in residents needs. One of the Registered Managers and a Senior Carer has recently completed the Dementia Care Mapping training and has achieved basic user status. The home has also accessed a course in Dementia awareness, which will provide staff with a level 2 VRQ (Vocational Related Qualification). Friary Fields Care Home DS0000008764.V375308.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 & 38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents experience the benefits of a home that is well managed and administrated. The health, safety and welfare of residents and staff are protected at all times. EVIDENCE: One of the Registered Manager of the home is also the Registered Provider and has owned and managed the home for twenty two years. The Registered Provider/Registered Manager has achieved the NVQ level 5 in Operational Management and is a dual qualified Registered Mental Nurse and Registered Friary Fields Care Home DS0000008764.V375308.R01.S.doc Version 5.2 Page 22 General Nurse. The other Registered Manager has worked at the home for seven years and is RMA qualified, has a Ba Hons in finance and Law and has a Diploma in Management Studies and was previously a financial advisor. Staff and relatives spoken with said that the Registered Managers were friendly, approachable and always takes residents concerns or comments about the home seriously. A formal quality monitoring system is in place. Annual residents questionnaires are conducted, the results of which are correlated and published. Other stakeholder and relative questionnaires are also conducted on an annual basis. Regulation 26 visits not currently required as the Registered Provider/Registered Manager is in the home five days a week. Regulation 37 incident reports are sent to commission. Staff meetings are held six to eight weekly for Senior staff and six monthly for all other staff. The Registered Manager reported that minutes are maintained of all meetings held and that there are plans in place to hold more staff meetings in the future. The home does not take any responsibility for many of the resident’s finances and most residents have family, friends or representatives who protect their financial affairs. Personal allowance accounts are maintained for many of the current residents, detailed accounts of which are maintained. Two staff sign for all transactions. The Registered Manager reported that all monies are kept locked in the homes safe, in secure individual money bags and no monies are pooled together. Following the inspection of April 2008 the Registered Managers have ensured that the previous inspection requirements of the provider is required to send a list of all deaths, incidents, accidents, events or allegations of abuse that occur to any resident of the home and that incident Records must be kept as required by regulation have been met in full. Incident reports are provided to the Commission and detailed records are maintained by the home of all accidents/incidents that occur. The home’s AQAA and observations made on the tour of the premises provided evidence that fire drills, fire alarm testing and fire equipment checks, health and safety checks and water checks had been carried out. Friary Fields Care Home DS0000008764.V375308.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 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 Standard No Score 16 3 17 X 18 3 3 X X X X X 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 3 3 Friary Fields Care Home DS0000008764.V375308.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 OP9 Regulation 13 (2) Requirement That all O omission codes utilised on MAR sheets are defined appropriately, in order to ensure that residents are further safeguarded by the homes medication procedures and policies. This is an Immediate Requirement. That the smaller dining/lounge area is appropriately ventilated, kept free from malodour of urine and deemed fit for purpose for all residents. Timescale for action 06/05/09 2. OP26 23 (d) & (p) 12/05/09 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 OP3 Good Practice Recommendations That the new pre admission assessment pro forma is updated further to identify where the assessment took was conducted. DS0000008764.V375308.R01.S.doc Version 5.2 Page 25 Friary Fields Care Home 2. 3. OP7 OP7 That all pages of the care plans and risk assessments are named for each individual service user. That N/A is not utilised in the care plan to record that a resident is a non-believer in religion. Friary Fields Care Home DS0000008764.V375308.R01.S.doc Version 5.2 Page 26 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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