Inspection on 11/07/05 for 21 Frome Court House

This inspection was carried out on 11th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

21 Frome Court House 10/12/07

21 Frome Court House 23/07/07

21 Frome Court House 23/01/07

21 Frome Court House 19/07/06

21 Frome Court House 26/04/05

21 Frome Court House 21/10/04

21 Frome Court House 07/06/04

21 Frome Court House 26/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 21 Frome Court House Thornbury South Glos BS35 2BU Lead Inspector Wilfried Maxfield Announced 11 July 2005 09:30 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. 21 Frome Court House D56_3401_FromeCourt_232376_110705_Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 21 Frome Court House Address Thornbury South Glos BS35 2BU Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01454 281445 0117 9709301 Aspects & Milestones Trust Ms Bibi Affoze Bahadoor PC Care home 12 Category(ies) of LD Learning disability (2) registration, with number LD(E) Learning dis - over 65 (12) of places 21 Frome Court House D56_3401_FromeCourt_232376_110705_Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: May accommodate 2 persons aged 45-65 years requiring personal care only. May accommodate up to 12 persons aged 65 years and over requiring personal care only. Date of last inspection 26 April-2005 Brief Description of the Service: Frome Court House is a detached former purpose-built childrens home located in a residential area of Thornbury. The home is operated by the Aspects and Milestones Trust and provides care and accomodation for 12 residents with a wide range of physical and learning disabilities. Arranged over three levels the home offers single occupancy rooms for all service users. There are a range of shops within walking distance and Thornbury boasts a wide choice of other services such as medical, further education, places of worship and community activities. The home is comfortable, provides plenty of space and is well furnished. There is a large enclosed garden to the sides and rear. 21 Frome Court House D56_3401_FromeCourt_232376_110705_Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was conducted over one day. The requirements and recommendations made as a result of the last unannounced inspection, dated 26th of April 2005 were discussed with the Registered Manager and their adequate implementation followed up. The Registered Manager was present for the entire visit and helped to focus the inspection on the home’s policies and procedures, care planning and organisational management and systems such as staffing, training and supervision. Samples of care plans/person centred plans were discussed. In addition, care planning documentation including residents’ files were audited and policies and procedures for updating and maintaining these was discussed with the manager. The visit included an extensive tour of the premises and review of equipment. Three members of staff were formally interviewed. Discussions with this group centred on their knowledge of formal assessments and day-to-day needs of residents. Interaction of staff with the residents who were present for some of the day was also observed. In spite of the considerable communication problems experienced by the residents at the home staff were able to facilitate meaningful and insightful contact between the inspector and the residents. The Commission received a number of ‘Comment Cards’ from relatives, residents and one General Practitioner in contact with the care home prior to this announced visit. Views from these were incorporated into this report The Commission received regular monthly Regulation 26 visit reports in 2005. Issues identified by the home’s appointed visitor were discussed with the manager and, whenever appropriate, incorporated in this report. What the service does well: Frome Court staff team cares for a client group with complex needs. As residents get older these needs increase; a fact that the home recognizes and manages exceedingly well. Relationships between staff and residents are good. Frome Court House is a clean, homely and well cared for environment. It is of a generous size providing ample space in both private as well as public spaces. 21 Frome Court House D56_3401_FromeCourt_232376_110705_Stage4.doc Version 1.30 Page 6 The primary and general care needs of residents are well taken care of and always given priority. The inspector was left in no doubt that this was a very experienced and dedicated staff team. The way the home has carried and lived with the recent death of a service user is commendable. What has improved since the last inspection? This was a well-prepared inspection and the team had invested an impressive amount of work in rectifying and improving on fragile areas identified during the last inspection. The considerable improvement in staff morale since the last inspection is bound to reflect on all levels of care and thus will be of benefit to all residents. Equally, residents’ wellbeing will benefit from the positive atmosphere in the home which results from a more positive leadership style. Staff talked about the way in which they felt respected, consulted and led by the registered manager. Residents’ lifestyles are now more fulfilling because the range of opportunities, including access to the local community and amount of external leisure activity has greatly increased. Residents will benefit because of the positive effects of a larger and therefore less pressurized staff group. A successful recruitment drive has seen staffing numbers increase considerably. This includes much-needed domestic support. Residents needing urgent attention in the rooms will now feel safer because health and safety issues relating to the call system have been fully addressed. Now that a warning light for the room of a hearing impaired resident has been installed his safety and privacy has increased. The needs of a recently admitted resident can now be better met because the assessment requirements with regards to his care planning have been greatly improved. Equally, there is an enhanced likelihood that all other residents’ needs will be better met because general record keeping and care documentation has improved. Residents will be better protected and the inspection process greatly assisted because staffing details, although still not complete, are now kept at the home. 21 Frome Court House D56_3401_FromeCourt_232376_110705_Stage4.doc Version 1.30 Page 7 Residents’ dignity and choices with respect to their funeral wishes and other concerns relating to terminal care and death as outlined in NMS (National Minimum Standards) 21 are now better recognised and protected because the registered manager has developed a system to obtain residents’ funeral wishes. Now that the home has started to monitor and audit its care plans at regular 6 monthly intervals there will be an increased awareness on how residents’ needs change and develop. Equally, auditing of records will impact on overall improvements in care. This needs to be ongoing but a good start has been made. Behaviour management of residents will be better understood and dealt with because staff training in ‘positive response’ has now been booked for October 2005. 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. 21 Frome Court House D56_3401_FromeCourt_232376_110705_Stage4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 21 Frome Court House D56_3401_FromeCourt_232376_110705_Stage4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 5 The home has made considerable progress in documenting the assessed needs of its newly admitted residents. However, in the case of the most recently admitted resident a fully completed care plan still needs developing. EVIDENCE: A copy of the Statement of Purpose and a Service User Guide were in place for inspection. Since the last inspection the registered manager has audited and updated a number of residents’ care records. The last unannounced inspection had identified significant shortcomings in this area (See also NMS (National Minimum Standards) 6). One requirement had to be made in relation to documenting the admission of one resident. The home was reminded that it should only accommodate new admissions after their needs have been fully assessed. In the case of the resident in question care needs had been insufficiently (or not at all) recorded at the time. This was of a much better standard now and the home complies with the relevant sections of NMS 2 and Regulation 14. There was also good evidence that the home manages to involve and engage the resident in question in the main elements of planning her care. This is in spite of her considerable communication difficulties and includes the development of an individual care plan as required in NMS 6. 21 Frome Court House D56_3401_FromeCourt_232376_110705_Stage4.doc Version 1.30 Page 10 However, a fully completed care plan was still not available for inspection. In spite of this, staff interviewed were able to explain how assessed needs were implemented and confirmed that the resident had settled in well. Aggressive incidents mentioned in the last report had also almost ceased. Communicating with the resident confirmed that she was happy and contented. Contracts outlining the terms and conditions applicable to the home and the residents were available for inspection on individual residents’ files. 21 Frome Court House D56_3401_FromeCourt_232376_110705_Stage4.doc Version 1.30 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, 9, 10 Most individual resident’s plans are of good quality and some excellent progress has been made in making care plans available for all residents. This process needs to be ongoing in order to complete plans for all at the home. Residents are given good opportunities to participate and influence the running of the home. EVIDENCE: Two requirements were made relating to NMS 6 at the last inspection: 1. Standard 6, Regulation 15: This requirement reminded the home that it needed to ensure that individual care plans are available for all of its residents. There was good evidence now that the home has begun to implement successful strategies to comply with this requirement. In the case of one resident’s file the inspector noted that a previously missing care plan had now been replaced with a document constructed using the Person Centred Planning (PCP) method. The plan was of good quality. 21 Frome Court House D56_3401_FromeCourt_232376_110705_Stage4.doc Version 1.30 Page 12 The Registered Manager explained that a PCP facilitator was now assisting her and the staff team to adapt the principles of this method and use these for the benefit of all residents and the planning and management of their care. A rolling program to review all care plans was in place. More training sessions were planned in order to ensure that everyone was able to understand and support this approach. In spite of the good progress made, the requirement is made again in order to ensure that the current progress continues until all plans have been completed to a satisfactory standard. This is also as a result of further evidence showing that some individual plans are still unnecessarily brief to the point of being incomplete. 2. Standard 6, Regulation 14: This requirement wanted the home to review residents’ individual care plans regularly every six months and update them accordingly. There was now good evidence on file to show that the home had started to implement the requirement from the last inspection to review and record changes in the care plan on a six monthly basis. Responsibility for this has been given to individual key workers. It is recommended that the Registered Manager monitor this strategy in order to achieve good quality and consistent practice. More care needs to be taken to record all significant data, such as who updated the record and when. Good evidence that the home reviews the plan with the residents was available on most but not all files. This was also the case for all information that demonstrated that changes had been communicated with residents and the staff group. The requirement made at the last inspection is made again in order to support the home to achieve a better standard. A third requirement, closely related to the previous two, highlighted the fact that missing care plans would be avoidable if the filing system were regularly audited to alert to shortcomings. Evidence that regular audits are now in place is commented on in the relevant section of this report. As in the previous inspection, staff interviewed demonstrated a positive approach and had all the required skills in order to be able to provide residents with information, assistance and communication support to make decisions about their lives. Equally, comprehensive risk assessments in respect of each individual in the home were in place. Residents’ files were stored safely in the office and staff were aware of the organisation policy on confidentiality. 21 Frome Court House D56_3401_FromeCourt_232376_110705_Stage4.doc Version 1.30 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 13, 14, 15, 16, 17 Since the last inspection the home has improved its staff resources to support residents to participate in the local community and have access to a range of appropriate leisure and entertainment facilities. Relationships between staff and residents are good with reasonable levels of independence, individual choice and freedom of movement. Residents enjoy a healthy diet. EVIDENCE: The home has had considerable difficulty to evidence its ability to support residents as outlined in NMS 12, 13 and 14. During the time of the last inspection staff shortages were such that the home seemed unable to ensure that residents participated regularly in the local community or were adequately supported to pursue interest outside of the home. Activities of any kind seemed a rarity and staff and residents commented negatively about this important area. Peer and culturally appropriate activities seemed hardly on the agenda. 21 Frome Court House D56_3401_FromeCourt_232376_110705_Stage4.doc Version 1.30 Page 14 Together with the recovery in the overall staffing situation the home has managed to improve its program of activities and social inclusion. Evidence of structured activities and outings was much more forthcoming on this occasion. This was confirmed in interviews with staff and residents. Nevertheless, some criticism of the home’s capacity for community links and social inclusion remains, as is evident in ‘Service User Comment Cards’ that were received prior to this inspection. A significant number of residents indicated that the home only ‘sometimes’ provides for sufficient activities (four of the eight residents replying). Out of all the areas the ‘Comment Card’ investigates ‘activities’ was by far the only one with such a number of negative replies. It is apparent that the home is making significant attempts to comply with the two requirements (NMS 13, 14. Regulation 16) made at the last inspection and the requirements are not made again as a result of this visit. However, a recommendation is made that the home needs to remain proactive in this area. The home has managed to install a light warning system for the room of a hearing impaired resident and consequently has complied with a previous recommendation. Respectful, positive interactions between staff and residents were noticeable throughout this inspection. Boundaries of personal privacy are well understood and bedrooms and bathrooms only entered with permission. There was good anecdotal evidence and sufficient recording to deduce that families and friends are welcomed and their involvement in daily routines and activities is encouraged. There was good opportunity to discuss dietary arrangements with the cook on duty. A healthy, balanced and nutritious diet is offered. Residents are involved in planning, preparing and serving meals. 21 Frome Court House D56_3401_FromeCourt_232376_110705_Stage4.doc Version 1.30 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20, 21 Personal and healthcare support are of a good quality. Healthcare needs are well assessed. Records relating to individual residents’ healthcare requirements are well maintained. The home is commended for the way it supported the recent death of a resident. EVIDENCE: The home operates a designated key worker system. Each individual has a key worker, who is empowered to make certain that residents’ individual choices, likes and dislikes are heard and recorded and that all aspects of care are delivered in a sensitive and flexible way. Key workers interviewed commented that in their view this was to help residents to sustain as much independence as possible. Staff interviewed had a good understanding of the needs of the individuals living at the home and spoke very knowledgably of specific support given to individuals. All staff, including the Residential Manager commented on the increasing demands on the staff group for specialist interventions. Most of these tasks are increasing because the population of residents at the home is becoming older. 21 Frome Court House D56_3401_FromeCourt_232376_110705_Stage4.doc Version 1.30 Page 16 Age-related needs of older residents include increased hoisting, additional feeding and attention to diet by professional dieticians; following physiotherapist instructions for daily exercises; more personal hygiene needs; increased continence management; and greater demands on staff for ‘moving and handling’. The management of the home needs to be mindful of these increasing ‘nursing type’ tasks and considerable stresses on its staff group. For instance, additional training might become necessary in the future. Individual working records set out preferred routines and likes and dislikes of residents. There was good evidence that the home works closely with advocates, family, friends and relevant professionals and that this is in the best interest of individual residents and with their consent. Recording of medical and health input including medical and general health review sheets was seen to be of a very good standard. All residents are registered with local GP practices. Residents receive additional support when required and to ensure that all health, emotional, and behavioural needs are met. This support has included: dietician, urologists, diabetic clinic and consultant physiologists. None of the residents manage their own medication. Medication is monitored and altered in accordance with medical instruction. Medication records were checked and found to be correct. Fluid charts, weight charts and records of epileptic seizures are maintained at the home for those residents for which it is appropriate. The ‘Parker Bath’, in place to assist with bathing, was still in use at the time of this inspection but was about to be replaced due to its age and frequent reliability issues. A modern ‘Rhapsody Bath’ was due to be installed in August 2005, following this visit. A hoist is available to assist with manual handling tasks; this was found to be in working order. Specialist aids are available to service users who have been identified with a specific need. The home is to be commended about the way it supported a recently deceased resident. This was done with the utmost care and dedication. This emotional time has also guided the home to review the way it reviews and plans for residents’ wishes concerning their death. A pro-forma “Information in the event of my death” has been devised and forms a part of a counselling conversation on this topic. 21 Frome Court House D56_3401_FromeCourt_232376_110705_Stage4.doc Version 1.30 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 23 The home’s complaints and POVA (Protection of Vulnerable Adults) procedures are robust and sound and staff are aware of the different stages, time scales and other relevant processes involved. EVIDENCE: The home recorded no complaints in the last 12 months. Staff interviewed were clear about the organisation’s procedures and well informed about the role of CSCI in the complaints process. The home’s policies include full details of the Commission. A complaints procedure, which includes contact details for the Commission and is in a user-friendly format, is available to Service Users and their representatives. The home’s adult protection procedures were not inspected. Good evidence was provided that the Trust systematically trains its entire staff group on this topic. Members of the staff team at Frome Court are regularly updated in the organisations ‘Vulnerable Adults Alerter’ training. 21 Frome Court House D56_3401_FromeCourt_232376_110705_Stage4.doc Version 1.30 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26, 27, 28, 29 Frome Court House is homely and comfortable, it is well decorated and maintained and is suitable for its intended purpose. However, the home needs to be more aware of health and safety in the garden area and keep it free from clutter and rubbish. EVIDENCE: The home now accommodates 11 service users with one vacancy available at the time of inspection. Premises are suitable for the number of residents; safe, comfortable, bright airy and clean. The home has a spacious dining area located adjacent to the domestic style kitchen. There was sufficient seating for all residents. There have been no changes since the last inspection of the recreational and dining space provided at the home. A sun lounge adjacent to the dining room provides additional seating. The home has two lounge areas, one large lounge with appropriate furnishings; the other lounge provides a quieter area for service users. In this room are board games; puzzles, videos and books available for residents. 21 Frome Court House D56_3401_FromeCourt_232376_110705_Stage4.doc Version 1.30 Page 19 All rooms have furnishings of a good standard. The bedrooms seen were spacious and all have single occupancy. They had good lighting, ventilation and individually controlled heating. Rooms do not offer en-suite facilities but are within close proximity of a bathroom. Toilet and bathroom facilities are located on the ground and first floor of this home, all of which are located near service users bedrooms; accessible toilets are also near the dining rooms and other toilet facilities. Areas are accessible for service users. Radiators had covers. There is a large well-established garden. It is enclosed and has level access. While some parts of the garden seemed reasonably well maintained, other parts seemed neglected. This included the glasshouse, which had fallen into disrepair and fragments of glass were littering parts of the garden and adjacent garage space. This was considered an urgent health and safety risk and work to remove the glass fragments started on the day of the inspection. Except for the garden no other areas of safety concern were noticed. Service records inspected were all updated and well maintained. Previous reports from the local fire office and environmental health department were inspected. The home has a planned maintenance and renewal program. 21 Frome Court House D56_3401_FromeCourt_232376_110705_Stage4.doc Version 1.30 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35, 36 An experienced staff team is aware of and supports the home’s aims and values. Qualification and competency of the team is good with the group benefiting from ongoing training and development. A recent recruitment drive has dramatically improved staffing numbers. EVIDENCE: Formal interviews with staff and the Registered Manager confirmed that Frome Court maintains clear lines of accountability as well as good arrangements for supervision and training. The staff team is dedicated to the task, experienced and supports the aims of the Trust. Training and development records were inspected and found to contain documentation and accounts of relevant and regular training updates. The overall experience, training and competence of the team is of a good standard with overall achievements and qualifications being in line (and better) with current expectations. A number of staff have accomplished a NVQ (National Vocational Qualification) at level 3, while others have been given ample opportunity to obtain this qualification and have consequently enrolled on a program. 21 Frome Court House D56_3401_FromeCourt_232376_110705_Stage4.doc Version 1.30 Page 21 Supervision and PDPR (Personal Development and Performance Review) records show regular staff supervision frequencies. Staffing arrangements have been problematic over a period of time as highlighted in previous reports. While a core of the staff team has remained stable for some time, the home has found it difficult to attract and recruit new staff. In a recent recruitment drive the management has visited a recruitment fair in Poland and managed to employ a considerable number of experienced staff as a result. On the day of the inspection none of the new staff were available for interview but all had, according to the manager, arrived from Poland the previous day and started to settle in the accommodation that the Trust had rented for them. The home is mindful of the fact that integrating such a large amount of staff will create difficulties. A mentoring scheme has been put in place to help facilitate this process. 21 Frome Court House D56_3401_FromeCourt_232376_110705_Stage4.doc Version 1.30 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 40, 41, 42 The manager of the home needs continued support to complete the National Vocational Qualification Level 4 in Management. The home is currently not quality monitoring its own service nor is it auditing staff files satisfactorily. Policies and procedures urgently need updating. EVIDENCE: There can be no doubt that the home is well managed and that the registered Manager fully ensures that the responsibilities as outlined in NMS (National Minimum Standards) are fully adhered to. A leadership concern mentioned in the last inspection report (“It is important that the management of the home keep an open and transparent culture and encourage staff to voice concerns”) seems resolved. In fact, staff morale seemed high and staff generally spoke highly of recent developments in this area and praised the manager for her efforts. 21 Frome Court House D56_3401_FromeCourt_232376_110705_Stage4.doc Version 1.30 Page 23 However, issues exist around the re–deployment of one assistant manager. They seem unresolved and a burden on the management team for some time. It is recommended that the team and the member of staff receive additional support to resolve possible issues and questions. The manager provided good evidence that she was monitoring the quality of service delivery through staff meetings, service user meetings and care reviews. Regulation 26 visits are completed every month. In spite of this requirements made in previous reports for the home to comply with Regulation 35 and review the quality of care at the home at regular intervals still apply. There is still no continuous, objective and verifiable method being used by the Trust to involve residents in monitoring and quality assessing the service they are receiving (preferably by a professionally recognised quality assurance system). Policies and procedures required by regulation and set out in Appendix 2 of the National Minimum Standards are currently being updated by the Trust. Procedures for the guidance of staff are in need of urgent updating. Record keeping was of a generally good enough standard. This did not include the staffing information held at the home. Information held was not sufficient in order for the inspection process to be able to assess whether the home followed recruitment procedures that protect residents. The home complies with the health, safety and welfare standards as outlined in NMS 42. 21 Frome Court House D56_3401_FromeCourt_232376_110705_Stage4.doc Version 1.30 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 x 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x 3 3 3 3 x Standard No 11 12 13 14 15 16 17 3 x 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 1 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 21 Frome Court House Score 3 3 3 4 Standard No 37 38 39 40 41 42 43 Score 3 3 1 1 1 3 x Version 1.30 D56_3401_FromeCourt_232376_110705_Stage4.doc Page 25 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard 24 34, 41 Regulation 13 17 Requirement All parts of the home and garden areas need to be free from hazards to residents safety. Staff employment records to be kept in the home as required by Schedule 4 of the Care Homes Regulations 2001. Policies and Procedures set out in Appendix 2 of the Regulations need to updated and kept in the home. The home needs to ensure that service user plans are available for all residents. The home needs to keep its care plans under regular six monthly review. The home needs to ensure that records are updated and audited regularly. Timescale for action Immediate 1st of November 2005 1st of November 2005 1st of November 2005 1st of November 2005 Ongoing 3. 40 12 4. 5. 6. 6 6 41 15 14 17 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 18, 19 Good Practice Recommendations Because of its aging population of residents the Version 1.30 D56_3401_FromeCourt_232376_110705_Stage4.doc Page 26 21 Frome Court House 2. 3. 33, 35, 36 33, 36 management of the home needs to be mindful of increasing ‘nursing type’ tasks and considerable stresses on its staff group. The home needs mindful of the fact that integrating a large amount of new staff will require additional monitoring, supervising and mentoring tasks. The team needs additional support to resolve issues and questions arround the assistant managers post. 21 Frome Court House D56_3401_FromeCourt_232376_110705_Stage4.doc Version 1.30 Page 27 Commission for Social Care Inspection 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 21 Frome Court House D56_3401_FromeCourt_232376_110705_Stage4.doc Version 1.30 Page 28 - 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. 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