Inspection on 20/02/06 for Freeman House

This inspection was carried out on 20th February 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Freeman House 28/10/08

Freeman House 03/11/06

Freeman House 17/08/05

Freeman House 10/02/05

Freeman House 10/08/04

Freeman House 03/02/04

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

CARE HOMES FOR OLDER PEOPLE Freeman House Radburn Way Letchworth Hertfordshire SG6 2LH Lead Inspector Mrs Alison Butler Unannounced Inspection 20th February 2006 10:00 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 Freeman House DS0000019390.V282192.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. Freeman House DS0000019390.V282192.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Freeman House Address Radburn Way Letchworth Hertfordshire SG6 2LH 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) 01462 488000 01462 488064 www.quantumcare.co.uk Quantum Care Limited Nina Parry Care Home 48 Category(ies) of Dementia - over 65 years of age (48), Old age, registration, with number not falling within any other category (48), of places Physical disability over 65 years of age (48) Freeman House DS0000019390.V282192.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th August 2005 Brief Description of the Service: Built circa 1965, Freeman House is a large three storey building located in a residential neighbourhood of Letchworth close to local shops and amenities. The home is furnished to a good standard and provides a comfortable and reasonably homely environment that belies the rather stark external appearance. Accommodation is provided on three floors served by a lift. There are communal lounges and a kitchenette/dining room on each floor as well as a functions room on the ground floor. All bedrooms are singles, although provision can be made for couples who wish to share. There are three shower facilities but no en-suite facilities in bedrooms. Additional rooms comprise a hairdressing room, staff room and various offices. Accommodation can be provided for visitors if required. There is a car park to the front of the building and a pleasant garden to the rear. The home provides a growing range of weekly activities, with visits from outside entertainers, days out and regular social events. Freeman House DS0000019390.V282192.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted with the manager, deputy, staff and residents in the home. There were 47 residents including 1 in hospital at the home. The focus of this inspection was to inspect the core standards that were not covered and to follow up on the requirement left at the last inspection. Staff were interacting well with the residents. The atmosphere of the home was relaxed and welcoming. What the service does well: What has improved since the last inspection? What they could do better: Additional work is required around medication to ensure that storage is in line with the manufacturers instructions to keep medication in good condition and that it remains effective. Staff should sign and date any changes to the administration sheet that allows an audit trail. Residents who self-administer their medication must sign to say they have received the medication and ensure that the risk assessment is more detailed for the individual. Freeman House DS0000019390.V282192.R01.S.doc Version 5.1 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. Freeman House DS0000019390.V282192.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 Freeman House DS0000019390.V282192.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): These standards were not inspected on this occasion. EVIDENCE: Please refer to the inspection report dated 17th August 2005 for comments. Freeman House DS0000019390.V282192.R01.S.doc Version 5.1 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&9 Care plans are in place for each resident covering the full range of personal, health, social and emotional needs. A safe medication system is in place although a requirement has been made with regard to the storage and additional information added to the recording sheet. EVIDENCE: Care plans contain comprehensive information on the resident’s needs and what action staff need to take to ensure their needs are fully met. Medication was examined and the storage was noted to above the required temperature of 20°C as per the manufacturers instructions on some bottled medication. Where changes or additional information has been recorded on the administration sheet this must be signed and dated by the author. The resident who self medicates must sign to say she has received her medication from the staff to ensure a full audit trail. Their risk assessments must contain further detail around who else may be at risk, the checks that are to be made when and by whom etc. Freeman House DS0000019390.V282192.R01.S.doc Version 5.1 Page 10 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): Not inspected on this occasion. EVIDENCE: Please refer to the inspection report dated 17th August 2005 for comments. Freeman House DS0000019390.V282192.R01.S.doc Version 5.1 Page 11 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 Robust procedures are in place to ensure the protection of the residents. EVIDENCE: A copy of the complaints procedures is available. Residents spoken to were clear who they would speak to if they were un happy about any aspect of their care. Staff cover training in the protection of vulnerable adults. Staff are aware of the whistle blowing policy and the Hertfordshire Adult Protection procedures and what they would do if an incident of abuse had occurred.. Freeman House DS0000019390.V282192.R01.S.doc Version 5.1 Page 12 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 home is clean, well maintained and regular maintenance checks are carried out on service and equipment. EVIDENCE: New chairs have been purchased in the ground floor lounge, curtains for the ground floor bedrooms have been hung, a number of new commodes have also been purchased. The ground floor carpet is due to be replaced by the end of April 06. Adequate laundry facilities are in place to meet the resident’s needs. Residents all looked well dressed and were very happy with the laundry service. Policies and procedures are in place to prevent the spread of infection. Freeman House DS0000019390.V282192.R01.S.doc Version 5.1 Page 13 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, 29 & 30 The procedures for the recruitment of staff are robust and offer protection to the people living in the home. The numbers of staff and their deployment are sufficient to meet the personal needs of the residents. EVIDENCE: The two staff files examined showed that all relevant checks had been carried out prior to them commencing employment. Adequate numbers of staff were deployed to meet the personal care needs of the residents at the time of this inspection. There is a daily activities co-ordinator who covers 37 hours a week and ensures that a programme is in place and is done on a monthly basis. Residents felt they were treated with respect and stated, “they are very good at helping us”. Staff are provided with a full induction programme on commencing employment. There is an on-going training programme which ensures that staff maintain there skills and keep up dated with practice. The home have over 50 of staff with an NVQ 2 or above with another 3 staff working towards an NVQ award. Freeman House DS0000019390.V282192.R01.S.doc Version 5.1 Page 14 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): 33 & 35 Good systems are in place for the monitoring of care and to ensure the home is run in the best interests of the residents. Policies and procedures are in place to safeguard residents financial interests. EVIDENCE: A spot check was carried out on residents monies held by the home and these were seen to be well recorded with appropriate receipts obtained. The home has carried out a questionnaire to relatives, residents and other stakeholders, the manager has yet to collate the results and forward the report to the Commission. Freeman House DS0000019390.V282192.R01.S.doc Version 5.1 Page 15 The company must continue to ensure the Commission receive the regulation 26 reports on a monthly basis as there has on a number of occasions where reports have not been sent on a regular basis (the last report was received in October 2005). Freeman House DS0000019390.V282192.R01.S.doc Version 5.1 Page 16 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X 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 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X X Freeman House DS0000019390.V282192.R01.S.doc Version 5.1 Page 17 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 OP9 Regulation 13(2) Requirement The manager must ensure *the correct storage of medication is maintained as per the manufacturers instructions. *Residents who self medicate must sign to say they have received their medication. *Staff must sign and date any changes or additions on the administration sheet. *Risk assessment for the individual who self medicates must be more detailed in covering the risks. Timescale for action 31/03/06 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 Freeman House DS0000019390.V282192.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 Freeman House DS0000019390.V282192.R01.S.doc Version 5.1 Page 19 - 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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