Inspection on 30/05/06 for Fraryhurst

This inspection was carried out on 30th May 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Fraryhurst 08/12/06

Fraryhurst 17/01/06

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 30th May 2006 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 Fraryhurst DS0000065077.V291954.R01.S.doc Version 5.1 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.V291954.R01.S.doc Version 5.1 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.V291954.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Up to 27 male and/or female service users in the category 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 17th January 2006 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. The weekly fees range from £420 to £680. Extras include hairdressing, chiropody and newspapers. The most recent inspection report is displayed in the hallway of the home. Residents and relatives are to be informed of this in the homes Statement of Purpose and Service Users Guide. 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.V291954.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 6.5 hours. Planning for this inspection was based on reviewing the previous inspection report, the Responsible Individuals monthly reports and general correspondence. 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. Comments will be included in the main body of the report. One requirement remains outstanding from the last inspection, and two requirements have been identified at this inspection. The providers are requested to advise the Commission of action to be taken and anticipated date that compliance will be achieved by the 8 July 2006. What the service does well: What has improved since the last inspection? The registered providers are in the process of implementing a training and development programme in order to achieve having a competent and qualified staff team. The standard of the physical environment continues to improve. New furniture, soft furnishings and general equipment are being provided. Since the last visit the atmosphere in the home has become more relaxed, positive and jovial. Staff appear to be confident and carry put their duties in a positive manner. Fraryhurst DS0000065077.V291954.R01.S.doc Version 5.1 Page 6 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.V291954.R01.S.doc Version 5.1 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.V291954.R01.S.doc Version 5.1 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 quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prior to moving into the home a pre admission assessment is undertaken on all prospective residents to ensure that the service can meet their needs. Intermediate care is not provided. EVIDENCE: The care plans of four residents were reviewed. For those residents who moved into the home after April 2002 pre admission documentation is kept on their individual care plans. The assessments take place in the prospective residents own home, hospital or in another care setting. One resident spoken with told the inspector that a senior member of staff visited him in his own home to carry out the assessment. The assessment follows the criteria set out in the National Minimum Standards for example, personal care, diet, weight, sight, hearing and communication, mobility, medication, hobbies and personal safety. Information gained at the pre admission assessment is used to form a basic care plan so that staff are aware of individual care needs on Fraryhurst DS0000065077.V291954.R01.S.doc Version 5.1 Page 9 the day of admission. It was confirmed by the person assisting with the inspection that intermediate care is not provided. Fraryhurst DS0000065077.V291954.R01.S.doc Version 5.1 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, 9, 10 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans record the health and social care need of residents. Systems are in place to promote the health and social care need of residents. The homes policies and procedures for the management of medication promote safe practices. Residents feel they are treated in a respectful manner. EVIDENCE: Four care plans were reviewed in detail. The documents contained basic information required. The care plans set out the health, personal and social needs of residents and how they will be met i.e. any assistance required, manual handling assessment. It was noted that care plans are reviewed monthly. Fraryhurst DS0000065077.V291954.R01.S.doc Version 5.1 Page 11 The care plans clearly record their General Practitioners address and telephone number. Visits from the Doctor and other health professionals are recorded in the care plan. Systems are in place for the receipt, recording, storage, handling, administration and disposal of medication. All medication is stored in a lockable cupboard. The home has a contract with a local pharmacy. Trained nurses dispense medication from individual containers. The Medication Administration Record sheets record that medication is checked in. Staff sign the Medication Administration Record sheet at the time of administration of medication. Records seen at this visit were in good order. There was no evidence of stockpiling medication; the medicine cupboard was clean, tidy and orderly. The home has a contract with a wasted disposal company who dispose of medication no longer required. Records of all medication disposed of are kept. Residents spoken with confirmed that they feel that their privacy and dignity is maintained. One resident sharing a double room confirmed that ‘dignity and privacy is maintained, when personal care being given staff make sure the screen is in place’. The inspector was also told that staff generally knock on doors prior to entering their rooms. During the course of this visit the inspector observed staff carrying out their duties and noted that they do take care to maintain the privacy and dignity of residents by knocking on doors, making sure doors are closed when carrying out care tasks and by asking residents in a sensitive manner if they need to go to the toilet.’ Fraryhurst DS0000065077.V291954.R01.S.doc Version 5.1 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 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with a range of planned programme of activities. Residents are encouraged to maintain contact with family and friends and are able to access the community as they wish. The meals provided are of a high standard. EVIDENCE: Residents spoken with confirmed that they feel able to maintain an individual lifestyle within the home. Those who were asked confirmed that they can ‘get up and go to bed when I want .’ They confirmed that they are offered a range of activities that include movement and music, bingo, reflexology, arts and crafts and entertainers. A summer BBQ and a summer garden party are in the process of being organised for this summer. Residents said that they are able to take part in the organised activities or pursue their own interests as they wish. Fraryhurst DS0000065077.V291954.R01.S.doc Version 5.1 Page 13 Residents are able to maintain contact with family, friends and the community. One resident told the inspector that ‘I go to the day centre two times a week’. Those spoken with say that they feel that they have some control over their daily lives. The response to meals provided ranged from good to adequate. A four-week rotating menu is followed. Residents confirmed that they are given a choice of menu at the midday and evening meal. The inspector noted that should a resident wish they could have a cooked breakfast each morning. All confirmed that they felt they had enough to eat. One resident told the inspector ‘ now have a new dining room which means lounge not so cluttered. Meals nice, nice variety. I get enough to eat.’ The kitchen area is due to be decorated. The kitchen looked clean and well organised, a cleaning schedule is followed. Store cupboards were appropriately stocked. Meat, vegetables, milk and bread are delivered twice a week and dry stores once a week. The cook on duty at this visit confirmed that she has received fire safety instruction and has been put on the forthcoming first aid training. Fraryhurst DS0000065077.V291954.R01.S.doc Version 5.1 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, 18 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously and are managed within an appropriate manner. Systems are in place to promote the protection of vulnerable adults. EVIDENCE: A complaints procedure is in place. The procedure informs residents and their relative who they should address their concerns to in the first instance and timescales in which a response will be made. The procedure contains the address and telephone number of the Local office of the Commission for Social Care Inspection so that in the event that they are not satisfied with the outcome of the homes investigation they can contact Commission directly. A complaints folder was available. There has been one complaint since the last inspection that was dealt with within timescales. Training records evidence and staff confirmed that they receive training in adult protection procedures. All three staff spoken with formally at this inspection are aware of the indicators of abuse. Both confirmed that they would report any suspected incidents of abuse to the manager. Fraryhurst DS0000065077.V291954.R01.S.doc Version 5.1 Page 15 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 quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The general physical standards of the home are improving. The home is clean, pleasant and hygienic. EVIDENCE: The lay out of the home appears appropriate to the needs of the current residents. The refurbishment programme is still ongoing. The bedrooms and communal areas that have been refurbished have been done so to a good standard. However rooms that have not been refurbished remain in an adequate state of repair. The entrance hall and communal lounge look clean bright and cheerful. New soft furnishings and carpet have been fitted in the lounge. The garden area is accessible. The fire warning system is checked regularly and fire extinguishers are readily available at various points in the home. Fraryhurst DS0000065077.V291954.R01.S.doc Version 5.1 Page 16 Laundry facilities appear adequate for the needs of the current residents. Hand washing facilities and protective clothing are available for staff. Policies and procedures are in place for staff to follow for the control of infection and safe handling of clinical waste. The home has a contract with a clinical waste disposal company. The home was found to be clean and free from offensive odours. Fraryhurst DS0000065077.V291954.R01.S.doc Version 5.1 Page 17 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 quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is staffed with the appropriate skill mix of staff. 50 of Care staff are not trained to NVQ level 2 or equivalent. A recruitment procedure is in place. The registered providers need to ensure that staff are competent to do their job. EVIDENCE: Duty rotas seen indicated that there were sufficient staff on duty to meet the needs of the current residents. There are generally 4 staff on duty in the mornings 1 trained nurse and 3 carers. In there afternoon this number is 1 trained nurses and 2 carers. At night there are 2 carers and 1 trained nurse. There is a suitable mix of trained nurses, senior carers and carers. Sufficient numbers of ancillary staff are employed in the home. Since the last inspection all staff have had appraisals at which individual training and development plans have been devised. 13 care staff are employed. 5 currently hold a National Vocational Qualification level 2 or 3. A further 5 staff are being enrolled on a National Vocational Qualification course level 2 in the near future. The providers are aware of the requirement to have 50 of the care team trained to National Vocational Qualification Level 2 or Fraryhurst DS0000065077.V291954.R01.S.doc Version 5.1 Page 18 equivalent by December 2005. To date the percentage of carers holding a National Vocational Qualification is approximately 38 . A requirement has not been made in respect of this standard as action is being taken. The providers advertise vacant posts in the local papers; if possible prospective staff are asked to make and informal visit to the home to collect the application form. If this is not possible an application is posted them. All prospective employees have a formal interview; references and an Enhanced Criminal Records Bureau check are sought. One new member of staff has been employed since the last inspection. Upon review of the application it was noted that only one reference for this individual has been received. All new staff receive induction in line with Skills for Care requirements. Records of induction training are held in individual training and development files Fraryhurst DS0000065077.V291954.R01.S.doc Version 5.1 Page 19 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, 33, 35, 38 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A manager is now in post. Systems are in place to safeguard the financial interest of residents. Systems are in place to promote the welfare of residents, however risk assessments for the physical environment have not been completed. EVIDENCE: A manager is now in post however an application for the individual to be registered with the Commission has to date not been submitted. Staff spoken with said that ‘ the new matron is brilliant, when you need someone to talk to she there and listens.’ The inspector was not able to talk with the new manager, as she was not on duty at this visit. Fraryhurst DS0000065077.V291954.R01.S.doc Version 5.1 Page 20 The homes quality assurance and quality-monitoring audit is process. Questionnaires will be sent out to stakeholders in the near future and an audit of internal systems is to take place in the near future. Mr Bennett the Responsible Individual on behalf of the company carries out monthly visit to the home and talks with residents, visitor and staff and reviews the maintenance programme and records in order to gain a view on services being provided. Since taking ownership the company has also had residents and relatives meeting to gain their views and inform them what is happening in the home. Minutes of meetings are kept. Although a formal quality audit has not been finalised and a published report is not available a requirement has not been made in respect of this standard as the home has been under new ownership for approximately 8 months. However should this not be completed by the next visit a requirement will be made. Residents manage their own finances or have relatives/representatives who do so on their behalf. The home does provided a service so that small money can be held in the homes safe. Records of money credited and debited are recorded and records of transactions are kept, .e. receipts and signatures of the person receiving cash. Records indicate that staff receives 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. 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 still not been completed as they are being completed used as a training tool for the new manager. Fraryhurst DS0000065077.V291954.R01.S.doc Version 5.1 Page 21 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 3 14 3 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 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X X X 2 Fraryhurst DS0000065077.V291954.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP31 Regulation 8 Requirement The registered provider shall submit an application to register the manager with the Commission. 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. All recruitment checks must be carried out prior to a new member of staff commencing employment. Timescale for action 08/07/06 2. OP38 13 (4) 08/07/06 3. OP29 19 (5) Schedule 2 (5) 08/07/08 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.V291954.R01.S.doc Version 5.1 Page 23 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.V291954.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!