Inspection on 09/08/05 for Freegrove

This inspection was carried out on 9th August 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

Freegrove 12/08/08

Freegrove 01/09/06

Freegrove 05/12/05

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, Hants SO41 8DU Lead Inspector Keith Hopkins Unannounced 09/08/05 13:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 H54 s11914 Freegrove V237561 090805.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Freegrove Address 60 Milford Road, Pennington, Lymington, Hampshire, SO41 8DU Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Peter Goodfellow, Mrs Helen Goodfellow, Mrs Charlotte Duffin. Mrs Angela Andrews CRH 17 Category(ies) of DE(E), OP registration, with number of places Freegrove H54 s11914 Freegrove V237561 090805.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 12/10/04 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 H54 s11914 Freegrove V237561 090805.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Four hours were spent visiting the home, during which time the opportunity was taken to look around the building, view records and policies and to talk to the owner, and briefly with other staff on duty. Most of the residents were observed making use of communal areas and their bedrooms, and a small number were using facilities in the garden. Three residents were spoken with in private in their bedrooms. What the service does well: What has improved since the last inspection? What they could do better: The home’s complaints procedure needs updating to include reference to CSCI, and also an appropriate timescale for dealing with any complaints. Freegrove H54 s11914 Freegrove V237561 090805.doc Version 1.40 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 H54 s11914 Freegrove V237561 090805.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Freegrove H54 s11914 Freegrove V237561 090805.doc Version 1.40 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 standard(s) Outcomes for this group of standards were not inspected on this occasion. EVIDENCE: Freegrove H54 s11914 Freegrove V237561 090805.doc Version 1.40 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 standard(s) 7, 8, and 10. Residents are well looked after in respect of their health and personal care needs, and have their privacy and dignity respected by staff. EVIDENCE: Care plans contain a good level of detail with a clear plan of action to meet needs and are reviewed monthly. Residents are able to sign their care plan if they wish to. The three plans examined also contained information regarding access to specialist health care staff. A chiropodist visits the home although some residents prefer to be visited by the one they used prior to admission. Residents are able to choose which doctor they are registered with. A mobility assessment is undertaken and recorded, together with a risk assessment. One resident confirmed that a particular special need regarding her mobility had been addressed following assessment, and that a ramp from her patio door into the garden had been provided. The inspector observed that individual aids, such as walking frames, were provided where necessary. Freegrove H54 s11914 Freegrove V237561 090805.doc Version 1.40 Page 10 Observation during the inspection showed that staff have a good awareness of how to protect residents’ privacy and dignity. They were seen to knock on doors and await a response before entering and spoke to residents in a respectful way. One resident told the inspector that she only had to ‘ring the buzzer’ for a member of staff to attend to any requests for help she might have. Freegrove H54 s11914 Freegrove V237561 090805.doc Version 1.40 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 standard(s) Outcomes for this group of standards were not inspected on this occasion. EVIDENCE: Freegrove H54 s11914 Freegrove V237561 090805.doc Version 1.40 Page 12 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 standard(s) 16 and 18. Residents are confident that any concerns they might have will be dealt with, and are protected from abuse. EVIDENCE: The home has a complaints policy and procedure, although the procedure needs some minor adjustments to be fully accurate. The need to incorporate an appropriate time scale was discussed with the registered person, who agreed to do this. A copy of the procedure was contained within residents’ files, alongside the contract, and all three residents spoken with privately said that they had no complaints. One resident said that she ‘only has to ring the buzzer’ and that staff would then come to help her. Another resident said that the staff ‘were helpful’. Residents appeared to have a good level of confidence in bringing any minor grumbles to the attention of staff. The home has dealt with two complaints in the last twelve months, both in a timely manner. There is an adult protection procedure in place, and available to staff, which includes information as produced by the local Social Services Department. Following an issue raised at the previous inspection, and subsequently dealt with through Adult Protection Procedures, the registered person demonstrated a greater awareness of the need for any similar instances to be dealt with more formally through such procedures. Freegrove H54 s11914 Freegrove V237561 090805.doc Version 1.40 Page 13 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 standard(s) 19, 20, 21, 23, 24, 25 and 26. A comfortable clean and safe 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 there is a programme of redecoration and refurbishment in place, with some carpeting in communal areas having been replaced and some bedrooms redecorated since the most recent inspection. There is a communal bathroom with a separate toilet on the ground floor and a communal bathroom with separate toilet on the first floor. These bathrooms are equipped with aids and suitable for residents’ use. There is a shaft lift between floors. Freegrove H54 s11914 Freegrove V237561 090805.doc Version 1.40 Page 14 The home has a large lounge/diner and a separate lounge used as a quiet room. These rooms are adequate, fully furnished and meet residents’ needs. Three residents’ bedrooms were inspected, the residents who had chosen to use these rooms that afternoon rather than the communal areas being happy for the inspector to do this. Two were adequately furnished and looked homely, as the residents occupying these had been able to bring items of their own furniture and possessions with them. Both of the residents in these rooms said how nice their rooms were. The third resident had chosen not to personalise her room to any great degree but nevertheless said that she was quite satisfied with it, as did the other two residents in respect of their rooms. The two double bedrooms are only occupied on a single basis. All areas of the home smelled pleasant and were cleaned to a high standard. There are suitable laundry facilities and the home has a policy for dealing with hazardous substances. There are large and attractive gardens to the front and rear of the building, appreciated by residents one of whom said that she enjoyed the view and another who said she liked going into the garden. Lighting and ventilation within the home were adequate. Freegrove H54 s11914 Freegrove V237561 090805.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, and 30. Staff at the home are soundly recruited, trained, and are employed in sufficient numbers to meet residents’ needs. EVIDENCE: The staff rota indicated there to normally be two carers on duty during the day, supported by management and other ancillary staff. There are two members of staff on a ‘waking duty’ at night. During the inspection staff were observed to be attending to residents’ needs in a calm and unhurried manner. Staff on duty were observed during the inspection to be providing assistance to residents in a kind and dignified manner. Two staff files examined indicated a sound recruitment process, and evidence of written references being obtained, together with CRB checks. Staff documentation examined confirmed attendance on a variety of short courses, including training in First Aid, Moving and Handling and Infection Control. Residents commented variously that staff at the home were ‘nice’ and ‘helpful’ Freegrove H54 s11914 Freegrove V237561 090805.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Outcomes for this group of standards were not inspected on this occasion. EVIDENCE: Freegrove H54 s11914 Freegrove V237561 090805.doc Version 1.40 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 3 3 x 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 x x x x x x x x Freegrove H54 s11914 Freegrove V237561 090805.doc Version 1.40 Page 18 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation Requirement Timescale for action 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 Good Practice Recommendations Freegrove H54 s11914 Freegrove V237561 090805.doc Version 1.40 Page 19 Commission for Social Care Inspection 4th Floor, Overline House Blechynden Terrace Southampton, Hants 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. 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