Inspection on 05/12/05 for Freegrove

This inspection was carried out on 5th December 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

Freegrove 12/08/08

Freegrove 01/09/06

Freegrove 09/08/05

Freegrove 12/10/04

Freegrove 21/04/04

Freegrove 14/05/03

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

CARE HOMES FOR OLDER PEOPLE Freegrove 60 Milford Road Pennington Lymington Hampshire SO41 8DU Lead Inspector Keith Hopkins Unannounced Inspection 5th December 2005 14:00 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 Freegrove DS0000011914.V268295.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. Freegrove DS0000011914.V268295.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Freegrove Address 60 Milford Road Pennington Lymington Hampshire SO41 8DU 01590 673168 01590 679120 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) Ms Charlotte Duffin Mrs Angela Andrews Care Home 17 Category(ies) of Dementia - over 65 years of age (17), Old age, registration, with number not falling within any other category (17) of places Freegrove DS0000011914.V268295.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th August 2005 Brief Description of the Service: Freegrove is set in a residential area close to local amenities on the outskirts of the town of Lymington. It provides residential care for up to 17 elderly residents, some of whom have mild dementia. The home is on ground and first floors and there is a stairlift between these. There are a variety of aids and adaptations to allow residents to move about more independently. Thirteen of the bedrooms are single and two are doubles, although the doubles are only normally used as singles. Four of the single rooms and both double rooms have en suite toilets. There is a communal bathroom and separate toilet on the ground floor and a communal bathroom and separate toilet on the first floor. There is a large garden with several car parking spaces to the front of the property, and a large enclosed garden to the rear. Freegrove DS0000011914.V268295.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two and a half hours were spent visiting the home, during which time the opportunity was taken to look around the home, view records and policies and to talk to the owner and manager. The inspector also spoke privately with two members of staff and a visiting relative. Most of the residents were seen to be using the lounge, where a planned activity was taking place. Two residents were spoken with at greater length. What the service does well: What has improved since the last inspection? What they could do better: Staff need to be formally trained in dealing with medication and the manager would benefit from having an up-to-date job description. Freegrove DS0000011914.V268295.R01.S.doc Version 5.0 Page 6 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. Freegrove DS0000011914.V268295.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 Freegrove DS0000011914.V268295.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 and 6. The admission process is well managed and residents are given clear information regarding the service to enable an informed choice to be made. EVIDENCE: There is a clear understanding by the owner and manager of the type of resident suitable for the home and the inspector was informed of a recent instance where a potential resident was assessed and found to have needs which the home was unable to meet. Two assessments relating to more recently admitted residents were examined and contained a good level of detail to enable staff to meet identified needs. Staff spoken with confirmed their knowledge of the contents of these assessments. It is the home’s practice to offer a day’s stay prior to a trial period and there was evidence of this happening in the documentation examined. The home does not admit residents for intermediate care. Freegrove DS0000011914.V268295.R01.S.doc Version 5.0 Page 9 Freegrove DS0000011914.V268295.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): 9. Residents are protected by a policy and procedure for dispensing medication although enhanced safety is to be achieved through formal staff training. EVIDENCE: The home has a policy for dealing for dealing with medication and the procedure for dispensing medicines was explained to the inspector by the manager. The home uses a monitored dosage system and at the time of the inspection medicines were securely stored. Associated records were consistent with medicines having been given although an instance where a resident had not taken medication had not been recorded. The inspector was informed that no residents are currently able to deal with their own medication, and noted that should this be the case then documentation supporting this decision would be completed. Staff who are responsible for dispensing medication have been instructed in how to do this but are to receive more formal training later in the month. Freegrove DS0000011914.V268295.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 and 15. Residents enjoy varied lifestyles and undertake activities of their choice. The provision of a wide range of opportunities for stimulation is appreciated by residents, who also enjoy a varied and nutritious diet. EVIDENCE: At the time of the inspection several residents were enjoying a quiz and singsong in the main lounge, and others were relaxing in quieter areas around the building. A communion service is held every week and the inspector was informed that there was a good level of participation in the exercise class, which is held every two weeks. Arrangements are currently being made for Christmas, which will include a party and a visit from a church choir. Assessments made at the time of admission to the home covered preferences regarding recreation and leisure and the inspector noted, for example, one resident who ‘liked to go out’, and was informed that this resident did so with a friend. One resident who had chosen not to take part in the quiz and singsong said that she was ‘independent’. Freegrove DS0000011914.V268295.R01.S.doc Version 5.0 Page 12 A visitor to the home was spoken with in private saying that there were ‘lots of entertainments’, that she was ‘happy with the care’ and that her relative was ‘well looked after’. Visitors are welcomed at any time but asked to avoid mealtimes if possible. The inspector was informed that most residents received visitors, and that visitors would be offered a drink or a meal. The home’s menus were examined and were varied, the inspector being informed that there was currently no need for the preparation of any special diets. Preferences were known to the manager and the inspector noted that one resident had provided the home with a detailed list of likes and dislikes. Residents have a choice as to when they have breakfast and can have their meals in their room if they wish. Freegrove DS0000011914.V268295.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): Outcomes for this group of standards were not inspected on this occasion, as they were inspected on the previous inspection. EVIDENCE: Freegrove DS0000011914.V268295.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): 26. A comfortable and clean standard of accommodation with suitable facilities to meet residents’ needs is provided. EVIDENCE: The home is well maintained and suited to residents’ needs. It is decorated and furnished to a standard that creates a homely ambience and the inspector was informed of plans to redecorate and recarpet the lounge. The ‘tour’ of the building showed it to be clean and free from any unpleasant odours. The laundry is to benefit from a new washing machine, which was due to be delivered and installed on the day following the inspection. A new water boiler in the kitchen has freed up some staff time and improved efficiency. Freegrove DS0000011914.V268295.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): Outcomes for this group of standards were not inspected on this occasion, as they were inspected on the previous inspection. EVIDENCE: Freegrove DS0000011914.V268295.R01.S.doc Version 5.0 Page 16 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 and 38. The home is well managed with residents’ views being sought on a frequent informal basis. Financial interests are safeguarded and residents’ welfare is promoted through sound policies and procedures. EVIDENCE: The manager has a considerable number of years experience in a senior capacity, and is currently undertaking the Registered Managers Award. There are clear lines of accountability within the home with the inspector being informed that the manager and owner work closely together. The manager would benefit however from having a more detailed job description. Residents spoken with commented on how nice the home was, and are also consulted informally regarding the services offered on a regular basis. Freegrove DS0000011914.V268295.R01.S.doc Version 5.0 Page 17 The manager confirmed that there was no involvement by the home in residents’ financial matters, and explained that relatives were informed if expenditure was made on behalf of residents so that the necessary arrangements could be made. No immediately obvious hazards to health and safety were observed by the inspector during the inspection and staff commented that in general terms the building was a nice environment in which to work. A sample of policies and records required by regulation were inspected and were in order and up to date. This included the home’s fire and accident books. Freegrove DS0000011914.V268295.R01.S.doc Version 5.0 Page 18 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 X 8 X 9 2 10 X 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 X 17 X 18 X X X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Freegrove DS0000011914.V268295.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP99 Regulation 13 Requirement The registered person must ensure that staff are trained in dealing with medication. Timescale for action 31/12/05 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 OP3131 Good Practice Recommendations It is recommended that the manager has an up-to-date job description. Freegrove DS0000011914.V268295.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Freegrove DS0000011914.V268295.R01.S.doc Version 5.0 Page 21 - 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!