Inspection on 17/01/06 for Fraryhurst

This inspection was carried out on 17th January 2006.

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

Fraryhurst 08/12/06

Fraryhurst 30/05/06

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

CARE HOMES FOR OLDER PEOPLE Fraryhurst Prinsted Lane Prinsted Emsworth Hampshire PO10 8HR Lead Inspector Mrs S Rodgers Unannounced Inspection 17th January 2006 10:30 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 Fraryhurst DS0000065077.V273217.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. Fraryhurst DS0000065077.V273217.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Fraryhurst Address Prinsted Lane Prinsted Emsworth Hampshire PO10 8HR 01243 372024 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) Springfield Health Services Limited Manager post vacant Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Fraryhurst DS0000065077.V273217.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Up to 27 male and/or female service users in thecategory Old Age, not falling within any other category, may be admitted/accommodated. No persons under the age of 65 years may be admitted. Date of last inspection Not applicable Brief Description of the Service: Fraryhurst is a care home with nursing registered to provide services for up to twenty-seven residents in the category OP, Old Age not falling into any other category. The property is a large detached extended building sitting in it’s own grounds in the village of Southbourne. The home is situated in a residential area close to local shops. Bus and train services are close by. Accommodation is provided on ground and first floor level, the first floor is accessed via a vertical lift. The majority of rooms are for single occupancy however there are a number of double rooms. Fraryhurst is owned by Springfield Healthcare Services Limited. The responsible individual on behalf of the company is Mr Matthew Bennett. The registered managers post is vacant. Fraryhurst DS0000065077.V273217.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 6 hours. The current providers Springfield Healthcare Services Limited have recently purchased Fraryhurst and therefore this is the first inspection under the new ownership. Planning for this inspection was based on reviewing records such as the Statement of Purpose, Service User Guide and general correspondence. Since registration the new owners have implemented a programme of refurbishment. A number of bedrooms have been refurbished to a good standard. Carpet has been fitted to the lounge, hallways and some bedrooms. One bathroom has been changed into a new WC and a shower room has been provided in its place and one bathroom has had a new bath and hoist fitted. Residents and staff spoken with were positive about the recent improvements. During the course of the inspection the inspector toured the home and reviewed records. Residents and staff were spoken with in order to gain a sense of what it is like to live and work at the home. Residents spoken with generally confirmed that they are satisfied with the service being provided. Comments such as “It’s quite pleasant here, I’m happy, people are pleasant”, “Staff maintain your privacy and dignity” and “activities are provided but I don’t as a rule join in”. There were some negative comments regarding the recent changes, i.e. “ not so happy since the changes, some changes in staff”, “doesn’t seem so friendly” and the food has deteriorated”, however the inspector was advised that the management are holding a residents and family meeting in order that any teething problems can be addressed. Staff spoken with were very positive regarding the support they receive from the acting manager. One staff member said that “when she say’s she will do something she does it, we’ve got new hoists”. All three staff confirmed that they feel supported by the acting manager. They confirmed that they receive training and have appraisals at which time training needs are discussed. Further comments from both residents and staff will be included in the main body of this report. The registered provider is required to submit an action plan stating action to be taken and timescales in which compliance will be met by the 22 February 2006. What the service does well: Fraryhurst DS0000065077.V273217.R01.S.doc Version 5.0 Page 6 Residents were observed to be well cared for, staff were respectful towards residents and it was noted that staff knocked on doors prior to entering rooms. The general standard of cleanliness was good. What has improved since the last inspection? 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. Fraryhurst DS0000065077.V273217.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 Fraryhurst DS0000065077.V273217.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): 3,6 The pre admission assessment enables the management to determine that the needs of person admitted to the home can be met. Fraryhurst offers long term/and some short-term stays however intermediate care is not provided. EVIDENCE: The pre admission assessments seen on all new admission indicate that health, personal and social of a prospective residents reviewed, information gained at this time is used to devise a care plan for the prospective resident prior to them being admitted to the home. From touring the home and speaking with the acting manager the inspector was able to determine that intermediate care is not offered at Fraryhurst. Fraryhurst DS0000065077.V273217.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The health, personal and social care needs of residents are addressed. Resident’s health care needs are met. Appropriate systems are in place for the receipt, recording, storage, handling, administration and disposal of medication. All care needs are carried out in an appropriate manner ensuring that they dignity and privacy of residents are maintained. EVIDENCE: Care plans were reviewed. They clearly identified the individual needs of residents. Care plans contained all relevant information, including risk assessments for manual handling and nutritional information. Care records clearly record visits by GP’s and other health professionals. The home has an agreement with a local pharmacy that supplies the home with prescription medication. The pharmacist will visit the home twice a year to inspect the homes systems. A system is in place to check medication coming into the home, a senior nurse signs in confirmation that they have been checked and records the number of tablets/quantity of medicine received. Fraryhurst DS0000065077.V273217.R01.S.doc Version 5.0 Page 10 The home has a contract with a waste disposal company with regards disposal of unwanted medication. Medication is dispensed directly form their containers. Records of medication administered to residents were in good order. The M.A.R sheets clearly indicate any known allergies, a photograph of each resident is attached to their medication charts that assists new staff with identification of residents. Trained nurses administer all medication; records of their signatures and initials are kept in the medication file. All medication is kept in lockable facilities. During the course of the inspection the inspector was able to observe staff maintaining resident privacy and dignity by knocking on doors prior to entering their rooms. Fraryhurst DS0000065077.V273217.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 15, Residents are enabled to develop an individual lifestyle within their own capabilities and preferences. Residents are able to maintain contact with family and friends. A varied diet is offered. EVIDENCE: Residents spoken with confirmed that the home runs a programme of social activities. The programme for forthcoming events is displayed within the home. Activities include reflexology, physiotherapy and music and movement. One member of the care team has responsibility for delivering some of the activities programme. She has 3 mornings allocated a week from the hours of 8.45 to 12.45 Residents confirmed that they are enabled to maintain contact with family and friends. They said that their visitors are made to feel welcome by staff and are always offered tea or coffee when they visit. During the course of this inspection the inspector observed that four visitors attended the home. One visitor was spoken with. She confirmed that she was generally satisfied with the services being provided and felt able to approach staff with any queries. She also felt that the forthcoming resident and family meeting was a positive move. Fraryhurst DS0000065077.V273217.R01.S.doc Version 5.0 Page 12 Residents who were asked confirmed that they feel able to make choices with regards their daily lives, they also told the inspector that “you can choose to take part in organised activities or not”. Menus demonstrate and residents confirmed that they could have a cooked breakfast each morning if they choose. Alternatives to the main meal are available, residents are informed of the next days choice menu each afternoon. The majority of residents spoken with said that the meals provided were of a good standard however, one resident did feel that there has been a slight decline in meals provided since the recent changes. The inspector saw the midday meal being offered on the day of inspection it looked well cooked and appetising. Cleaning schedules are in place and food temperatures (hot and cold) and fridge and freezer temperatures are recorded. Food store cupboards appeared appropriate stocked. The inspector was told that there are plans to refurbish the kitchen as part of the refurbishment programme. Fraryhurst DS0000065077.V273217.R01.S.doc Version 5.0 Page 13 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): 16,18 The homes complaint procedure clearly informs residents and relatives of their right to raise concerns. Systems are in place to protect residents from abuse. EVIDENCE: A complaints procedure is in place that describes the action residents or their relatives should take if they have reason to make a formal complaint. The document clearly advises of the timescales in which the complaint will be dealt. There have been no formal complaints since the new providers have been registered with the Commission. Policies and procedures are in place for staff to follow with regards action to take should they suspect abuse of a resident. Staff spoken with were able demonstrate their understanding of different types of abuse. All were clear of the action they would take should they suspect a colleague of abusing a resident. Fraryhurst DS0000065077.V273217.R01.S.doc Version 5.0 Page 14 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): 19,26 The location and layout of the home appears appropriate to the needs of the current residents. The home was generally clean and hygienic. EVIDENCE: A refurbishment programme has recently been implemented; every effort is being made to reduce any inconvenience to residents. Communal areas have recently been redecorated and re carpeted. The home was clean and free from offensive odours. A number of aids and adaptations are in place to enable service users access to various parts of the building. Residents who were asked confirmed that they are able to furnish their rooms with their own belongings giving them a personal and homely atmosphere From touring the building the inspector was able to determine that the standard of cleanliness through out the home was of a good standard. Fraryhurst DS0000065077.V273217.R01.S.doc Version 5.0 Page 15 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 The home is staff with the appropriate skill mix of staff. Care staff are not trained to NVQ level 2 or equivalent in sufficient numbers. The home has a recruitment procedure. The registered providers need to ensure that staff are competent to do their job. EVIDENCE: Duty rotas indicate that there is 1 registered nurse on all day and 3 carers; there is 1 registered nurse on duty at night plus 2 carers. The inspector was advised that inexperienced staff would only be on duty with experienced staff. Ancillary staff are employed to carry out domestic duties and there is one cook and kitchen assistant on duty daily. The acting manager told the inspector that the number of carers would increase by one during the day when the home admits further residents. Although the home employs a number of experienced staff records indicate that at present the home only has 5 carers out of 17 who hold an NVQ level 2 award that does not meet the 50 ratio required. A training and development programme should be implemented to address this. All new staff must receive induction training in line with the Skills for Care specification. Fraryhurst DS0000065077.V273217.R01.S.doc Version 5.0 Page 16 The homes recruitment procedure is in place. The acting manager has recently carried out an audit of the recruitment checks. Records seen indicate that appropriate checks are carried i.e. references, Criminal Records Bureau checks and checks against the Protection of Vulnerable Adults register. Fraryhurst DS0000065077.V273217.R01.S.doc Version 5.0 Page 17 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): 31,35,38 The registered providers are in the process of trying to recruit a manager. Systems are in place to safeguard the financial interest of residents. Systems are in place to promote the welfare of residents. EVIDENCE: At present the manager’s post is vacant. The inspector has been kept in form via the regulation 26 reports and general correspondence of progress. The position continues to be advertised. Residents spoken with confirmed that they or their relatives maintain their own personal finances. Systems are in place to hold small amounts of money in safekeeping. Records of transaction and receipts are kept. Records seen appeared in good order. Fraryhurst DS0000065077.V273217.R01.S.doc Version 5.0 Page 18 Records indicate that staff receive training in all safe working practices. Maintenance records demonstrate that the health and safety of residents is maintained. The home has contracts with waste disposal contractors to dispose of clinical and medical (medication) waste. Annual maintenance checks are carried out for all equipment listed in standard 38.3. Each employee has a Health and Safety handbook and health and safety training is provided. Risk assessments have been carried out for safe working practices, however the acting manager advised the inspector that risk assessments for the physical environment have not yet be completed. Fraryhurst DS0000065077.V273217.R01.S.doc Version 5.0 Page 19 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X X X 3 X X 2 Fraryhurst DS0000065077.V273217.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? NA 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 OP31 OP30OP28 Regulation 8 18 (1) (C) Requirement The registered provider shall appoint an individual to manage the care home The registered person shall ensure that persons employed to work at the care home training appropriate to the work they are to perform. The registered person shall ensure that all parts of the home to which residents have access are so far as reasonably practicable free from hazards to their safety. Timescale for action 22/02/06 22/02/06 3 OP38 13 (4) 22/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Fraryhurst DS0000065077.V273217.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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 Fraryhurst DS0000065077.V273217.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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