Inspection on 19/12/05 for Firgrove House

This inspection was carried out on 19th December 2005.

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

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

Other inspections for this house

Firgrove House 06/03/08

Firgrove House 05/01/07

Firgrove House 27/06/05

Firgrove House 06/01/05

Firgrove House 11/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Firgrove House Station Road Yate South Glos BS37 4AH Lead Inspector Odette Coveney Announced Inspection 19th December 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Firgrove House DS0000003323.V263452.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Firgrove House DS0000003323.V263452.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Firgrove House Address Station Road Yate South Glos BS37 4AH 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) 01454 310636 01454 310636 Mr Kenneth Roberts Mrs Jennifer Roberts Mr Kenneth Roberts Care Home 20 Category(ies) of Dementia (2), Old age, not falling within any registration, with number other category (18) of places Firgrove House DS0000003323.V263452.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th June 2005 Brief Description of the Service: Firgrove House is situated in Station Road at Yate. It is within walking distance of local amenities including shops, post office and public house. The home is made up of the Main House and smaller Coach House and provides care for up to twenty older people including two with Dementia. The Main House is on three floors and offers places for fourteen older people while the Coach House has room for six. Firgrove House was registered with Avon Health Authority as a Nursing Home and with South Gloucestershire Council as a residential care home until December 2001 when an application was made to vary the conditions of registration so that all places are for residential care and nursing care is no longer provided. The house is decorated in a homely way with comfortable furnishings. In the Main House there is a lounge with adjacent conservatory and separate dining room. The Coach House has a lounge/dining room. All of the bedrooms are for single occupancy except for two that are for two people. There are ample bathrooms and WCs, the Coach House having some rooms with en-suite and the Main House with 3 ensuite facilities. Firgrove House DS0000003323.V263452.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection conducted as part of the annual inspection process to examine the care provided, and monitor the progress in relation to the three requirements and four recommendations from the last inspection that was conducted in June 2005. Prior to the inspection the inspector received a completed pre inspection questionnaire, which provided information about the establishment, policies and procedures, management and staffing arrangements. There was information about those receiving a service at the home. Information was also provided about healthcare and visiting professionals. The inspection took place over seven hours. During the process eight residents, three staff and both the registered provider and deputy manager were spoken with. The inspector looked around both buildings and a number of records were examined. What the service does well: What has improved since the last inspection? The deputy manager and staff at the home have worked diligently in order to meet the three requirements and four recommendations from the last inspection that was undertaken in June 2005. The safety of those living, working and visiting the home has improved in respect of fire safety as the home has completed a fire risk assessment and has improved the recording of fire training. Firgrove House DS0000003323.V263452.R01.S.doc Version 5.0 Page 6 Safety of residents has been further improved since the home completed a risk assessment on the use of a handrail by an individual’s bed and also as the homes medication policy includes what to do in the event of errors and the development of a lone working policy. Residents can be assured that their wishes and choices in the event of death will be respected as the home has sought and recorded these for those living at Firgrove House. Residents can be assured that lost property in the home is accounted for as this is recorded and stored safely. 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. Firgrove House DS0000003323.V263452.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Firgrove House DS0000003323.V263452.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 Information is provided to residents in order that they are aware of their rights and responsibilities, however some additional information is required for the statement of purpose. No one is admitted to the home without having their needs assessed and that they have been assured that these will be met. Clear contractual arrangements are in place. EVIDENCE: The home has a service users guide and a statement of purpose, these work in partnership together and are given to individuals enquiring about the services and facilities, which are provided at the home. The statement of purpose records that the philosophy of care includes that ‘The right to choose a home in which they would feel content and happy should be everyone’s privilege’. Information within these documents includes an introduction into the facilities and the building, staffing arrangements and staff training, the care provided and assessment of individuals needs. The documents are well written and are detailed, however, it is required that the home’s statement of purpose is amended to incorporate the categories of registration of those who are able to Firgrove House DS0000003323.V263452.R01.S.doc Version 5.0 Page 9 be cared for at the home, this document must also include information to show that nursing care is not provided at the home. Both Mrs Roberts and Mrs Beer were very clear and had a consistent approach about the home’s admission procedure and whom the home is able to provide a service for. Clear policies about the homes admission procedure are also in place, this records that individuals are given the opportunity to visit the home prior to admission and when admitted have a months trial to ensure the placement is an appropriate one. In place were assessments that had been completed by the placing care manager prior to individuals being admitted to the home. A relative told the inspector about the admission process for their relative into Firgrove House. They confirmed they had received information about the home and the service provided prior to their visiting. They confirmed their relative visited the home prior to their admission and had a trial period for a month in order to determine if the place was able to meet their relative’s needs. They said that Lorraine Beer had been very supportive and informative throughout the process and that this has continued. The inspector saw that all residents are issued with a contract upon becoming a permanent resident at the home. Copies of the contracts are held at Willow Cottage. Mrs Roberts explained that contracts are reviewed and updated on an annual basis. The inspector saw that contracts had last been reviewed in April 2005. Mrs Roberts said that the contracts outlined the arrangement of the terms and conditions of service provided at the home. Information seen within these documents included the arrangement for fees and what these did and did not include, how individuals would be supported within aspects of their daily life, such as medication and how they would be supported by the home with any queries or complaints they may have. Firgrove House DS0000003323.V263452.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 11 Individual’s health, personal and social needs are well met, recorded and reviewed on an ongoing basis. Residents are assured that at the time of their death their wishes will be respected. EVIDENCE: There was clear evidence within care records that evidenced that individuals are supported by staff in order to make decisions about their lives, that they have been given appropriate assistance and that support had been tailored to the needs of the individuals in order that they can make an informed decision. It was clear that where able individuals had been consulted and their input within assessment processes had been recorded in care records. Each person’s plan sets out the in detail the action which needs to be taken by staff to ensure that all aspects of health, personal and social care needs of residents are met, records were seen to be detailed. Staff knowledge on individual’s expectation’s and support was sound and care plans are reviewed and updated on a regular monthly basis. Firgrove House DS0000003323.V263452.R01.S.doc Version 5.0 Page 11 There was a record of visits to the doctor and other primary healthcare support and these were up to date and sufficiently detailed. The inspector saw correspondence from health professionals, including consultants to evidence that advice is sought when necessary from specialists. The inspector saw that support is also accessed from specialist services, when required, examples of this includes district nursing services, hospital out patients, chiropody and dentist, demonstrating a ‘multi disciplinary’ approach. Where they are able staff escort residents to hospital appointments in order to support them. A visitor to the home said that their relative is well supported by staff at the home, and that the staff have developed a sound understanding of their relatives needs including communication needs, which at times were difficult. This visitor also said that his relative’s health had stabilised at the home and when there had been a change in their relative’s health they had been consulted and kept well informed. Full medication administration, practices and recording were not reviewed at this inspection as these were found to be satisfactory at the previous inspection. The home has in place a clear medication policy a recommendation was made at the last inspection that this policy should include what to do in the event of errors. This had been completed and clear information had been added to the policy, the guidelines for staff as to what they were to do had been well written. Information as to resident’s wishes and requests in the event of their end of life were well recorded. Both Mrs Roberts and Mrs Beer were able to give good examples of how the home has supported individuals with terminal care at the home with the support of community nursing teams and individuals general practitioners. A sensitive and empathetic approach and understanding in this area was shown by both managers. Firgrove House DS0000003323.V263452.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Resident’s lifestyle matches their expectations and preferences and satisfies their social and recreational interests and needs. Residents are supported to exercise choice and control over their lives. EVIDENCE: On the day of the inspection children from the local primary school visited thee home to perform a Christmas carol concert for the residents, residents joined in with the singing and told the inspector how much they enjoyed the children visiting them at the home. Another resident told the inspector about ‘Paul’ an entertainer who comes to the home every Wednesday and Friday to play music and sing; residents said that entertainment provided at the home was ‘marvellous’ ‘excellent quality’ and ‘good fun’. Posters were on prominent display and were bold in design in order to notify residents and family members of forthcoming events. The home also maintain a log of events that residents had participated in, recent activities included local clubs and social group, church and shopping. Entertainment provided at the home has included a ‘wartime’ entertainer and a Hawaiian singer. Entertainment has also been given by residents who live at the home. Residents told the inspector one of the best events at the home was when a resident played the harmonica and recited poetry. Firgrove House DS0000003323.V263452.R01.S.doc Version 5.0 Page 13 Residents spoken with complemented the hairdresser who provides a service at the home every Tuesday. Both Mrs Roberts and Mrs Beer said that resident’s routines at the home are flexible and that residents are encouraged to make choices and decisions about their life. Mrs Beer said that residents can chose what to eat, where to eat, what to wear, who to see, when to get up and when to go to bed and that residents routines are usually what they used to do before they moved into Firgrove, although they do change on a day to day basis, it was dependent on the needs and wishes of those living at the home. Resident meetings are held at the home every three months and provide a formal forum in which issues can be discussed; a staff member said that residents are encouraged to set the agenda for the meeting and to discuss areas which are relevant to them and their life. Residents said that they enjoyed these meetings and that they served a useful purpose. Firgrove House DS0000003323.V263452.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18 Residents are confident that their complaints would be listened to and taken seriously and staff demonstrated a clear understanding in this area with clear policies and procedures in place. Those living at the home are protected from the potential of abuse due to staff training and understanding in this area. EVIDENCE: The home has in place procedures for responding to suspicion or evidence of abuse or neglect to ensure the safety and protection of individuals, this includes a protection of vulnerable adults policy and a ‘home’ abuse’ document. A staff member was asked what their actions would be should they have any concerns over a staff member’s approach and manner, they were very clear on their responsibility to ensure the protection of those within their care and would have no hesitation to report to their line manager. A copy of the homes complaints procedure was on prominent display at the home. Information on how individuals are able to raise issues or make a complaint was seen in individual contract agreements, the statement of purpose and the service users guide, with information including the arrangements for contacting the commission if individuals were not happy with the outcome of a complaint. Residents at the home told the inspector they had no complaints and that if they had any concerns they would speak to the manager or staff. One of the residents said that they had complained in the past and the situation had been dealt with appropriately. The inspector saw that there had been a complaint made in the home earlier this year, the information seen showed that the Firgrove House DS0000003323.V263452.R01.S.doc Version 5.0 Page 15 manager had dealt with the situation in a professional and effective manner, the manager confirmed what had happened and what actions had been taken to prevent further re-occurrence and to ensure the satisfaction of the complainant. Mrs Beer has also been supportive of relatives and has provided information to them in order that they can make a complaint with the commissioning department of social services. It was found at the last inspection that some items of jewellery were being kept in the safe; these items had been there for some time and had not been claimed. It was recommended at the last inspection that ‘lost’ property be recorded and accounted for. This has been completed. The Commission for Social Care Inspection has received notification of incidents that have affected individual’s wellbeing at the home, the information provided shows that individuals had been supported in an appropriate manner. All staff have received protection of vulnerable adult training. Mrs Beer has provided this. Information seen of the course content along with Mrs Beers’s explanation and knowledge in this area demonstrated that this subject had been fully explored and covered with staff. Firgrove House DS0000003323.V263452.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25, 26 The relationships between staff and those living at the home are good, and this creates a warm, supportive, safe environment, which promotes a good quality of life for the individuals living at Firgrove House. Some improvements have been made in respect of redecoration of areas within the home; however further attention is required in other areas in order to maintain standards and to improve hygiene control. EVIDENCE: Firgrove House is a residential care home for older people. The home is made up of the Main House and smaller Coach House and provides care for up to twenty older people including two with Dementia. The Main House is on three floors and offers places for fourteen older people while the Coach House has room for six. Since the last inspection there has been some improvements within the main house with the lounge, dining room and hallway being redecorated, new flooring laid and new dining furniture being purchased. The residents living in the coach house have benefited from the corridor being redecorated, new carpets and a toilet area being retiled and repainted. Firgrove House DS0000003323.V263452.R01.S.doc Version 5.0 Page 17 There are sufficient bathing and toilet areas for resident’s use, all within close proximately to resident’s communal areas. A number of bedrooms have en suite facilities. A bathroom on the first floor of the main house had worn enamel, although this poses no danger to the residents it is not attractive and it is recommended that this is re enamelled, the footplate of the bath chair in this bathroom would also benefit from this. A requirement was made at this inspection that the home must make suitable arrangements to reduce the risk of infection; this was because when a tour of the home was undertaken there was faeces on the walls in the toilet area. When this was pointed out Mrs Beer made a prompt response to rectify this and make the area clean. Since the last inspection the kitchen area has been refurbished with new units, appliances and flooring. Staff said that the improved area had benefited all. During the inspection the kitchen door was observed being propped open with no staff member in the vicinity to close the door in the event of a fire alarm sounding. It is required that a self-closure is fitted to this door. The kitchen was found to be clean and tidy. There was plenty of food in the fridge and freezer with items in these areas stored and labelled appropriately. Dry foods were stored in plastic containers, however there was no information to show when these packets had been opened. It is recommended that these containers are dated to show when the foods are to be used by. Radiator covers are in place to protect residents from the risk of burns however during a tour of the home it was found that a cover in one of the resident’s room had become detached from the wall, it is recommended that this be reattached to ensure the safety of the individual in that room. Resident’s bedrooms are appropriately furnished with residents being encouraged to bring in personal effects in order to make their room more ‘homely’. Rooms seen had appropriate furniture and fittings with photographs, plants, pictures and ornaments enhancing these rooms. Firgrove House DS0000003323.V263452.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Residents living at Firgrove House are supported by appropriate staff in respect of numbers, skill mix, and competency. Staff training is well recorded and the home ensures that all staff have received sufficient training. Residents are further protected by the home’s recruitment and selection policy and practices. EVIDENCE: There is a full complement of staff at Firgrove; there have been no staff vacancies for some time. Mrs Roberts said that there are no staff being disciplined under the home’s procedure and also said that the staff employed at the home were ‘stable’, ‘competent’ and a good team’. Each individual has a key worker to support them with the manager being involved with the overall monitoring of individual care. It was clear that staff have developed relationships with individual’s and have worked together with them and others in order to identify the needs of a resident and then support the person in achieving their goals and future aspirations. There was information in individual care plans these provided information to guide staff to the appropriate level of support that individuals require. Clear job descriptions are also given to staff, these outline individual’s roles, responsibilities and what is expected of them. Firgrove House DS0000003323.V263452.R01.S.doc Version 5.0 Page 19 Those living at the home can be assured that staff employed have been done so following clear and robust recruitment practices and the implementation of organisational policies and procedures. The inspector saw that the home has in place employment documents for staff, these were available and viewed at the inspection, this included references, completed application form a criminal records bureau check and contracts of their employment terms and conditions. Staff members spoken with were able to demonstrate a clear understanding of their role and responsibilities within the team and their own personal role and accountability. The inspector reviewed the induction which had been undertaken by the most recently appointed staff member at the home and covered areas such as fire and safety, moving and handling, familiarisation with the building and emergency procedures. The deputy manager updated the induction programme in October to include the reporting of accidents, medication and residents admission to hospital. Information contained within the induction programme showed that staff are given copies of the confidentiality policy and the staff code of conduct. There are times when staff work alone at The Coach House, therefore a recommendation was made at the last inspection that a lone working policy is developed, the inspector saw that the home has worked diligently to undertake this. The policy was implemented in June 2005 and covered security arrangements; this new policy had been relayed to staff during a staff meeting, supervision and information held within the communications book. The significance of a National Vocational Qualification is well promoted at the home with six staff that have achieved a qualification at level three, promoting independence. Three staff are currently being supported to achieve this award. The deputy manager has achieved a National Vocational Qualification at level four in care management, is an assessor for this process supporting candidates in the home. There are also a further two NVQ assessors at the home with one of these staff members working towards their NVQ at level 4. The atmosphere at the home at the time of the inspection was calm and relaxed with individual’s looking clearly at ease and ‘at home’. Training records demonstrated that staff are supported to undertake sufficient, appropriate training in accordance with their role and responsibilities. Firgrove House DS0000003323.V263452.R01.S.doc Version 5.0 Page 20 Firgrove House DS0000003323.V263452.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 37, 38 Both the registered and deputy manager at Firgrove House are qualified, skilled and experienced. The management ensure an open and inclusive atmosphere is present in the home, which is run in the best interest of those living at the home. Health and safety of those living and working at the home is well managed however improvements are needed in respect of manual handling. EVIDENCE: Mrs Roberts is the registered provider and the registered manager of Firgrove House and also Willow Cottage and has been so for a number of years. Willow Cottage is another care home for older people within close proximity of Firgrove. Mrs Roberts has extensive experience within the care profession and has established a sound reputation within the area. Lorraine Beer is the deputy manager at Firgrove House and is given total autonomy to manage the home. Mrs Beer has obtained a National Vocational Firgrove House DS0000003323.V263452.R01.S.doc Version 5.0 Page 22 Qualification at level four in management, she has also achieved her registered managers award. Mrs Beer has been employed at Firgrove for over six years and has maintained her professional competency and has undertaken training in areas such as manual handling, first aid, dementia awareness and continence care. Mrs Beer also presents training to staff in the area of adult protection and has undertaken twelve sessions with staff this year alone. Mrs Beer is committed to maintaining standard at the home and has written a quality assurance plan for 2006 and this document included the homes arrangements for staff training, staff supervision, care planning, fundraising, relatives contact and activities and entertainment. The fire logbook is well maintained with clear information in place to demonstrate that fire fighting and detection equipment is checked at appropriate intervals by staff at the home and by specialist fire contractors. The last fire drill took place at the home on October 21st with good responses. Call bells are checked on a weekly basis, it was noted that these were responded to promptly when resident’s requested assistance. A trainee manager at the home discussed the home’s arrangements to control substances hazardous to health; this person has developed an information folder in order to guide staff and to ensure safe working practices. A requirement was made at the last inspection that the home develops a fire risk assessment. The home have completed this in conjunction with information provided by Zurich insurance, the assessment is very detailed and covers premises, sources of ignition, management systems and practices and included what the procedure is should a fire occur at night. A requirement was made at the last inspection that fire training records must clearly record who undertook the training. Records seen at this inspection showed that this is being undertaken. A number of risk assessments in respect of supporting resident’s to lead a full safe life were seen, these included safe handling and smoking. A requirement was made at the last inspection that the home must complete a risk assessment re the use of a handrail by an individual’s bed, a review of the resident’s file showed that this had been completed. It was however noted that not all of the resident’s had a manual handling assessment in place, one that was in place had not been reviewed since 2003. It is required that manual handling assessments are completed for all residents in order to fully demonstrate that all aspects in respect of this area have been evaluated with action plans recorded. The inspector viewed the organisational policies and procedures in place at the home, these are robust and provide sufficient information in order to direct and guide staff practice. The policies seen were appropriate to the service provided at the home. Firgrove House DS0000003323.V263452.R01.S.doc Version 5.0 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 2 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 X 3 3 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 3 3 3 3 X 3 2 Firgrove House DS0000003323.V263452.R01.S.doc Version 5.0 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. 2. 3. 4. Standard OP38 OP38 OP38 OP1 Regulation 23(4)a 13(3) 13(4) c 4(1) c Requirement Timescale for action 19/02/06 A self closer to be fitted to the kitchen fire door. To make suitable arrangements 19/12/05 to prevent the risk of cross contamination. Manual handling risk 19/02/06 assessments to be completed for all residents. Statement of purpose to include 19/01/06 the categories of registration and that nursing care is not provided. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP15 OP21 OP25 Good Practice Recommendations Dry foods to have the date when to be used by on them. Bath to be re enamelled. Radiator cover to be re attached. Firgrove House DS0000003323.V263452.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Bristol North LO 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 Firgrove House DS0000003323.V263452.R01.S.doc Version 5.0 Page 26 - 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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