Inspection on 26/01/06 for Frenchay Mews

This inspection was carried out on 26th January 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 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

Frenchay Mews 20/01/09

Frenchay Mews 06/02/07

Frenchay Mews 30/09/05

Frenchay Mews 01/02/05

Frenchay Mews 17/08/04

Frenchay Mews 24/02/04

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Clouds House

Closereach

Westcliffe House

Hilldales

Longreach

Chandos House

Cherry Orchards Camphill Community Ltd

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

CARE HOME ADULTS 18-65 Frenchay Mews 35-37 Lower Church Road Weston Super Mare North Somerset BS23 2AQ Lead Inspector Caroline Baker Announced Inspection 26th January 2006 09:45 Frenchay Mews DS0000008124.V271592.R01.S.doc Version 5.0 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 Frenchay Mews DS0000008124.V271592.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 Adults 18-65. 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. Frenchay Mews DS0000008124.V271592.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Frenchay Mews Address 35-37 Lower Church Road Weston Super Mare North Somerset BS23 2AQ 01934 624330 01934 624330 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) Mrs Anne Edwards Mrs Anne Matthews Care Home 19 Category(ies) of Past or present alcohol dependence (19), Past or registration, with number present drug dependence (19) of places Frenchay Mews DS0000008124.V271592.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Manager should commence NVQ4 Care Management training in 2003 and complete this before 2007. 30th September 2005 Date of last inspection Brief Description of the Service: Frenchay Mews is one of two homes owned by the Frenchay Group FRESH, and offers a person-centered programme for individuals working towards recovery from addiction. It is sited in the seaside town of Weston Super Mare, close to local amenities. It is registered with the Commission for Social Care Inspection (CSCI) to provide a service for up to 19 younger adults aged between 18 and 65. The provider is Anne Edwards and the registered manager is Anne Matthews. The service provides single and shared accomodation. Communal space is adequate. Toilet and bathing facilities are adequate. Frenchay Mews DS0000008124.V271592.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The last inspection was unannounced and took place on 30th September 2005. At that inspection three requirements were identified and two recommendations were made. This announced inspection took place from 09:45hrs (2.5 hours) and was conducted by Caroline Baker. At the time of this inspection the requirements had been complied with the recommendations had been actioned. The Commission sent comment cards to the home for residents to use to record their views on the conduct and provision of the service. Twelve comment cards were returned. Fourteen residents were staying at the home. The home can accommodate up to nineteen residents, however, has not exceeded seventeen. An assessment of the premises took place where a selection of bedrooms, bathrooms and communal areas were seen. All of the residents and staff were spoken with. The registered manager was available throughout the inspection. Records relating to the residents, staff and health and safety were examined. What the service does well: The home provides excellent information for residents in the format of a Statement of Purpose (Welcome Pack) giving prospective residents a full guide to the home and its philosophy. Residents told inspectors that there were no surprises. Residents are fully assessed on referral to the service and have an opportunity to visit the home to complete the assessment before admission. A call contact system is then put into place to ensure residents and the service know when the admission will be. As well as considerable group therapy the programme also provides I:I counselling weekly or more if required, topic workshops, and diary groups for example. The home was warm and homely with a happy relaxed atmosphere. Staff morale appeared very good. The interaction between staff and residents was happy and relaxed. Frenchay Mews DS0000008124.V271592.R01.S.doc Version 5.0 Page 6 Residents are able to access the community after one week of stay unescorted if they wish. The home ensures that all service users have access to appropriate health care professionals and will offer support to attend appointments where appropriate. Feedback from residents was very positive with regard to all aspects of the provision of counselling and support at the home. They understood the rules and boundaries and accepted them as part of the intense programme offered at the home. Residents stated that the counsellors were very good, and the home was well maintained. Comments received from residents via comment cards included: ‘the place seems ok. The staff seem dedicated and hard working and the conditions are fine’ and ‘the house, the staff, the programme are all excellent they compliment each other perfectly’. The discharge rate at the home was low indicating a good success rate. 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. Frenchay Mews DS0000008124.V271592.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Frenchay Mews DS0000008124.V271592.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1; 2; 3; 4 and 5. Residents are provided with the information they need to enable them to make an informed choice about staying at the home. The home was able to demonstrate that residents are fully assessed prior to admission to ensure their needs can be met. The home has systems in place to introduce prospective residents to the home and other residents prior to admission. EVIDENCE: The home has a detailed Statement of Purpose (Welcome Pack), which is provided to all potential residents. It provides details of the homes philosophy, therapeutic programme, facilities and timetable of activities. Residents consulted during this inspection felt that the information provided reflected service provision and enabled them to make an informed choice regarding admission to the programme. A telephone referral normally starts the process to admission to the home and the programme. Referral forms were seen completed and assessment forms for three residents as part of the inspection process. Frenchay Mews DS0000008124.V271592.R01.S.doc Version 5.0 Page 9 All potential residents are invited to the home for an assessment meeting following the initial referral, which is conducted, by one of the qualified counsellors at the home. Residents consulted confirmed this process. They are able to stay for a meal and meet other residents. A detailed assessment form is completed and takes into account pattern of addiction, physical and mental health, significant others and family and also any special needs. Evidence was seen that the home had clear criteria for admissions. Where required staff will liaise with other health professionals in deciding whether a placement is appropriate. The homes residential contract for clients has been updated since the last inspection. It reflects clearly the rules and restrictions, and other written information regarding the programme, and other facilities so that residents can take it away with them to read and comprehend prior to admission. Residents consulted confirmed this. Frenchay Mews DS0000008124.V271592.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6; 7; 8; 9 and 10 The home’s care planning system demonstrated that care plans are kept under review. Residents are involved in all aspects of life in the home. Residents were supported to make decisions and to live a lifestyle in accordance with their plan of care, and individual risk assessments were completed. The home demonstrates that it handles all information and records in line with the Data Protection Act 1988. EVIDENCE: Three individual residents’ care records were seen. They included client identification and assessment forms together with photographs of residents. A comprehensive assessment had been undertaken and care records confirmed regular 1:1 meetings with counsellors. Frenchay Mews DS0000008124.V271592.R01.S.doc Version 5.0 Page 11 The residents’ rights and responsibilities are clearly set out in the clients contract. Care records seen indicated that these are fully discussed in the individual residents first 1:1 counselling session. Within the therapeutic programme, the aim is to enable and empower individuals. Residents consulted indicated that the house rules and boundaries imposed, are necessary and fair for their well being. The day-to-day running of the home is allocated to the residents in regard to cooking and housework. Regular house-meetings are held to discuss rotas and duties placed on the residents. One resident is allocated group leader and they liaise on a daily basis with management. Individual detailed risk assessments were seen in the care records examined. It was evident as part of the programme that residents are encouraged and enabled, within the set boundaries, to be self-aware and afford themselves a greater choice in how they live without mood altering substances. If boundaries are compromised residents will receive a verbal warning. If they continue to break the boundary rules then a written warning follows. If they continue to break rules they would be discharged. Instant discharge would happen if residents used drugs, drank alcohol or had a relationship with another resident. Care records were stored in a confidential manner and residents know that they have a right of access to them. Policies were in place stating this. Frenchay Mews DS0000008124.V271592.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11; 13; 14; 15; 16 and 17. Residents benefit from good support, which enables them to personally develop, enjoy a range of leisure activities and to access local community facilities within set boundaries. Residents are offered a choice of menu and wholesome food. EVIDENCE: Residents told the inspector that they have the day-to-day responsibility for cooking for each other and undertaking therapeutic household tasks. Throughout the week there is a restriction on television viewing encouraging residents to spend more time in peer support and group activities. In the early part of the programme (the first week) residents only go out escorted but thereafter they can go out unescorted if they wish. This is built on value, honesty, and trust and rules are set out in the residents contract. Contact with family is restricted during the first two weeks but subsequent arrangements for visits and telephone calls are agreed with the Counsellor as part of the overall care programme. Frenchay Mews DS0000008124.V271592.R01.S.doc Version 5.0 Page 13 There are restrictions imposed during the programme to protect the interests of the individual and the group. House rules are made explicit on admission and breach of these usually leads to exclusion to the programme. Residents told the inspectors during a group discussion, that the rules were fair and essential to the integrity of the programme. There is a two-week rotating menu and residents prepare their meals themselves. Evidence was seen of a regular supply of fresh fruit and vegetables. All the residents consulted praised the provision of food. Frenchay Mews DS0000008124.V271592.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18; 19 and 20. Residents receive a very good level of support to meet their physical, emotional and health care needs. The homes procedures for the management, administration and recording of medication, were safe. EVIDENCE: At the time of this inspection there were no residents needing assistance with personal care. Two accidents had been recorded since the last inspection. Accident forms were stored in a confidential manner in line with Data Protection. The management of medication administration was good. Residents at the time of this inspection had the majority of their medication administered by the staff. Clear and accurate records were maintained in regard to administration. Since the last inspection and as required a homely remedies policy and selfmedication policy had been developed. The policies were detailed and clear. Frenchay Mews DS0000008124.V271592.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Appropriate steps were being taken to reduce the risk of harm or abuse to residents. EVIDENCE: All residents receive a copy of the home’s complaints procedure as part of their contract. Residents consulted told the inspector that they did not have any concerns and were able to talk through any concerns with the counsellors and manager, and that they would be acted upon. The home has a complaints record book and there had not been any recorded since the last inspection. Policies were in place for the protection of vulnerable adults. There had not been any adult protection issues raised. Since the last inspection, all staff had been checked by the Criminal records Bureau, through an enhanced disclosure. Clear evidence had been recorded. Frenchay Mews DS0000008124.V271592.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24; 25; 26; 27 and 30. Residents stay in a homely, clean environment where they can enjoy the privacy of their own bedrooms or socialise in a variety of communal areas. EVIDENCE: At the last inspection the environment was fully assessed. At this inspection the inspector assessed the dining area, lounge area, kitchen, laundry, 2 communal bathrooms, 2 communal toilet facilities and 5 bedrooms with the permission of the residents. The areas assessed were clean and well maintained, with personalised bedrooms. There is a designated lounge area for persons wishing to smoke and another non-smoking lounge both had TV’s with restrictions on viewing. The kitchen and dining area appeared adequate for the current group. The kitchen was clean and well organised with food stored appropriately. The counselling room is separate from the lounges and dining area allowing some privacy. There was a smaller room used for 1:1 sessions. Frenchay Mews DS0000008124.V271592.R01.S.doc Version 5.0 Page 17 The laundry area is adequate with two domestic washing machines and an industrial tumble dryer since the last inspection. The manager told the inspector that industrial washing machines were being considered. There appears to be sufficient toilets and bathrooms to meet the needs of the number of people accommodated. Residents did not raise any concerns with regard to this provision. Frenchay Mews continues to be refurbished. The décor and furnishings at the home were of a good quality. Frenchay Mews DS0000008124.V271592.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 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; 32; 33; 35, and 36. The skill mix of staff at the home was good and staffing levels suit the needs of the residents. Staff morale was good and staff were supported and competent to do the job they had been employed for. EVIDENCE: There had not been any new staff employed since the last inspection. Residents praised the staff team. All counselling staff had relevant qualifications and experience in the field of addiction. Residents were very positive about the counsellors and felt they were competent. The home is staffed 12 hours per day by two counsellors and the registered manager, supported also by the administrator. During the evening and at weekends there are accredited support workers on duty with a counsellor always on call. Since the last inspection a duty rota is recorded. Frenchay Mews DS0000008124.V271592.R01.S.doc Version 5.0 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39; 40, 41, 42 and 43. The manager continues to effectively manage the home and the management style provides an open and inclusive environment for residents and staff. The home was taking appropriate steps, to ensure the health and safety of residents, staff and visitors. EVIDENCE: The manager has almost completed a Level 3 NVQ in care. She is an experienced and competent counsellor who has been working in this field for many years. Residents spoke highly of the management of the home. The discharge processes and rules were discussed. Residents felt that the programme was intense and rigorous and that the home was managed appropriately and in a way that safeguarded the interests and welfare of the group. Frenchay Mews DS0000008124.V271592.R01.S.doc Version 5.0 Page 20 The Providers visit the home and make reports under Regulation 26. As part of their quality assurance the home asks residents to complete questionnaires before they leave to gain their views on the conduct and usefulness of the service provided. The fire log indicated regular periodic checks and tests are undertaken. Fire fighting equipment was checked weekly alongside the fire alarms. The fire alarms and annual fire check of the home and equipment was completed in October 2005. Emergency lighting was checked monthly. Staff had received appropriate fire awareness training and as recommended at the last inspection the names of the staff who have received training had been recorded. Access to records is controlled and there is policy guidance with regard to confidentiality and disclosure. A current Employers Liability Insurance certificate was displayed – expiry date of 23/12/06. The gas service was last on 25/07/05. Portable Appliance Testing (PAT) was last done on 14/01/06. The passenger lift was last serviced on 19/01/06. Electrical wiring was checked on 04/01/06. Frenchay Mews DS0000008124.V271592.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 4 4 3 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 X X 3 LIFESTYLES Standard No Score 11 3 12 X 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 X 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Frenchay Mews Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 3 DS0000008124.V271592.R01.S.doc Version 5.0 Page 22 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. 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. Refer to Standard Good Practice Recommendations Frenchay Mews DS0000008124.V271592.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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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