Inspection on 06/02/07 for Frenchay Mews

This inspection was carried out on 6th February 2007.

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 26/01/06

Frenchay Mews 30/09/05

Frenchay Mews 01/02/05

Frenchay Mews 17/08/04

Frenchay Mews 24/02/04

Similar services:

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 Nicola Hill Unannounced Inspection 6 February 2007 13:30 th Frenchay Mews DS0000008124.V321391.R01.S.doc Version 5.2 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.V321391.R01.S.doc Version 5.2 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.V321391.R01.S.doc Version 5.2 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.V321391.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Manager should commence NVQ4 Care Management training in 2003 and complete this before 2007. 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 accommodation. Communal space is adequate. Toilet and bathing facilities are adequate. Weekly fees for the home are £455. Frenchay Mews DS0000008124.V321391.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced key inspection at Frenchay Mews took place with the manager, Ann Matthews, over a period of four hours. At the time of the inspection there were 11 people in residence, and several prospective service users on the waiting list. The majority of the residents were spoken with, and the registered manager was available during the visit. The inspector gathered evidence for the report from residents, staff, and documentation held at the home. The home has been assessed as providing a good level of service. What the service does well: Frenchay Mews provides a robust treatment programme for those addicted to drugs or alcohol. The service provision meets the criteria identified in research by the National Treatment Agency (NTA) to promote retention of service users in treatment, in that it is a small home with a good staff/service user ratio. The accommodation, whilst communal, is of reasonable quality and there are a variety of facilities available. The residents identified that the programme was based on trust and appreciated being treated as responsible individuals. The ethos of the home was described as person centered, and the support from the staff was seen to be respectful and tailored towards the individual. The residents have regular house meetings to raise any concerns and speak directly to staff or other residents in order to find a resolution to issues. The residents stated that programme allowed flexibility with very clear boundaries. The group therapy approach was seen to support the continuation of the key themes of the programme in the absence of formal groups. The comments from the residents were very positive, and several were able to compare Frenchay Mews favourably with other treatment centres. The home has a good reputation locally and nationally, and can deal effectively with people with multiple addictions. Frenchay Mews DS0000008124.V321391.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Frenchay Mews DS0000008124.V321391.R01.S.doc Version 5.2 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.V321391.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2,4 Quality in this outcome area is good. Skilled and experienced member of staff always undertakes preadmission assessments. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All the residents have an assessment undertaken prior to admission, which covers all aspects of their life including any mental health issues. It is from this information that a decision is made to offer a place on the programme. The residents currently in Frenchay Mews told the inspector that they had a choice of home to go to, however Frenchay Mews was chosen either because of the personal recommendation or advice from care managers. The inspector discussed with the residents their experience of the assessment process. The majority of residents had visited prior to admission and had been able to meet the staff and residents, which helped them to decide about entering the programme. Some of the residents had been to other rehabilitation units, residential and community, and so had their own experiences to assist with decision-making. None of the residents spoke about the information in the statement of purpose/brochure, however all of them were made aware of the services and expectations of the programme prior to admission. In addition to the preadmission assessment, all files reviewed had a care plan from the placing authority, which included an agreement for treatment. Frenchay Mews DS0000008124.V321391.R01.S.doc Version 5.2 Page 9 Frenchay Mews DS0000008124.V321391.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each resident has a care plan, which is developed following person centered planning principles; the quality of the care plans could be improved. EVIDENCE: All of the residents have an individual care file including risk assessments and discharge planning. The residents had their individual needs reflected on the care plans, and there was evidence that plans were reviewed and evaluated on a regular basis. Some of the care plans were poorly written, and difficult to read. This was brought to the attention of the manager, and information about the National Treatment Agency service specification for care plans has been provided to the home. The home also records outcomes of counselling sessions and any visits to other agencies such as GP, probation officer. The care documentation at the home can be used to track a residents progress from the initial referral with the presenting care needs to working through the programme, and the after care required on discharge e.g. housing. Frenchay Mews DS0000008124.V321391.R01.S.doc Version 5.2 Page 11 The discharge planning documentation is good and includes strategies for safeguarding the health and welfare of service users after discharge. The risk assessment part of the care plan assessment demonstrates good practise and reflection of National Treatment Agency guidance as it identifies potential risks and possible triggers that may cause relapse or disciplinary discharge. This had been completed for the majority of residents; the inspector discussed with the manager the identification of triggers for relapse/early discharge. These were not on the initial risk assessments as she felt that until the resident had been in treatment for a short time there was insufficient information available to be able to document these details. The manager suggested that the risk assessment be reviewed with residents at the four-week stage and included on the documentation. Individual choice and decision making is subject to the limitations of the programme, however, all the residents stated they were treated as individuals and supported as such. The residents stated that having a person centered approach to the programme and being entrusted to follow guidance relating to the restrictions on personal freedom, helped them to develop their own selfreliance and make informed choices. This ethos was stated to be strength of Frenchay Mews by residents who, had been through rehabilitation units, which had stricter house rules with less freedom, but where residents felt that they had been programmed through the rehabilitation programme. Frenchay Mews DS0000008124.V321391.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a strong commitment to enabling residents to develop their skills and supporting them to identify their goals and work to achieve them. EVIDENCE: The evidence for this section was obtained through conversations with the residents currently at Frenchay Mews. The resident group at Frenchay Mews discussed the way the home operates a programme of group therapy and group support so that the residents learn to deal with issues that arise for them and to support others. This was seen as a strength and that it gives them confidence to share issues and develop networks. The group support also ensures that people cannot isolate themselves when there are no planned therapy groups, and that untoward behaviour is challenged. The issue of challenging each other was stated to be strange at first, and could be construed as a personal attack. However as residents reflected on the reasons and themes of the challenges, the benefits of being open and honest could be appreciated. Frenchay Mews DS0000008124.V321391.R01.S.doc Version 5.2 Page 13 The programme was stated to be enabling them to learn about themselves, especially through doing their life story, and receiving feedback from their peers. The residents felt that on their arrival to the home they felt quite comfortable, and benefited from having a peer group often more advanced in the programme than themselves was very positive. Within the group there was recognition of responsibility toward others, and one resident commented that they felt safe within the group and that what was discussed in sessions was confidential. The residents agreed that Frenchay Mews provided a safe and supportive environment. Residents take responsibility for the day to day running of the household and all have allocated tasks. The resident are all involved in meal planning and preparation. This allows residents to develop domestic and personal care skills. Frenchay Mews DS0000008124.V321391.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Where possible residents are supported and held to be independent and are responsible for their own health-care needs. EVIDENCE: All the residents require support through the programme, which is provided through counselling on a one-to-one basis and through group therapy. The house rules dictate that residents are well groomed and wear clean clothing in order to develop their personal-care skills and their sense of respect of themselves and towards their peers. Residents identified this as a good thing, as were the therapeutic duties, which developed the sense of community at the home. All service users are supported to achieve optimum health and well being and are assessed on admission by the GP’s who support the home. Some of the residents have health care needs which require external appointments such as hospital treatment, these needs are assessed on admission and local services accessed when necessary. Frenchay Mews DS0000008124.V321391.R01.S.doc Version 5.2 Page 15 Medication at the home is minimal, with only three residents taking regular medication. The inspector was able to review the system and records, which were all accurate at the time. Residents are supported in the latter stages of the programme to take more responsibility for themselves and this may include self medication for minor ailments. Frenchay Mews DS0000008124.V321391.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an open culture, which enables residents to express their views, and concerns in a safe and none blame environment. EVIDENCE: Frenchay Mews ensures that all residents receive a copy of the complaint procedure. There have been no complaints recorded since February 2006; the inspector was able to read the complaint and the action taken. The manager and staff regularly attend training including adult protection awareness. The residents were able to confirm that the systems at the home support them when raising issues; none of the residents who spoke with the inspector expressed any dissatisfaction or concerns about the home. Frenchay Mews DS0000008124.V321391.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The layout and design of the home house or small clusters of residents to live together in a non-institutional environment. EVIDENCE: The inspector toured the home with the manager. The home is in a good state of repair with adequate funds allocated for maintenance, refurbishment of areas in the home is planned a rolling programme. The grounds are small but there is access to outside space, the house was clean with no unpleasant odours. The accommodation for the residents is comfortable and efforts have been made to ensure that bed linen matches and that each resident has sufficient space. There is a mix of shared and single rooms, but all were very clean. The residents work together and complete household tasks as part of the therapeutic duties. Frenchay Mews DS0000008124.V321391.R01.S.doc Version 5.2 Page 18 The communal accommodation has natural light; the residents are able to smoke in the lounge, however there is an outside venting extractor in the room to remove the smoke. The residents can also access a non-smoking lounge, and a study area to complete written work. The residents stated they were to be satisfied with the physical environment of the home, stating that they had everything they needed to be comfortable. Frenchay Mews DS0000008124.V321391.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service report that staff working with them are very skilled in the role and are able to meet their needs. EVIDENCE: The home is staffed on a 24-hour basis; out of hours staffing is by support workers, whilst counsellors are on call. The manager stated she was aware that training had not been formalised for this year. The statutory training for staff was up-to-date. There are specialist skills training linked to the DANOS recommendations for support staff working in drug and alcohol rehabilitation available for support staff to access. The counselling staff were stated to be skilled at their job by the residents, and ran the programme in such a way that residents could not coast through the stages of the programme. The residents praised the support workers at the home for their skills of and understanding approach. They work on their own, but have the opportunity for supportive supervision. The inspector saw that the support workers currently also received informal supervision during handovers and debrief at the start and finish of shifts. The individual staff records indicated that although support workers receive individual supervision, and the counsellors Frenchay Mews DS0000008124.V321391.R01.S.doc Version 5.2 Page 20 receive individual professional supervision, there was no evidence of individual managerial supervision for the counselling team. The manager must introduce formal supervision/appraisal in order to identify individual training needs for the counselling staff through a mixture of group and individual supervision, both of which must be recorded. Frenchay Mews DS0000008124.V321391.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is person centered in her approach and leads a well-trained staff team. EVIDENCE: The manager has completed NVQ 3, but has not yet started the NVQ 4 qualification. The completion of NVQ 4 by 2007 was a condition of registration for the manager. The inspector and manager discussed the appropriateness of the training as rehabilitation units should have managers with qualifications linked to job role. The other issue that arose was the absence of the operations manager on maternity leave. The responsibilities taken on by the operations manager are not part of the role of the registered manager at Frenchay Mews. The manager must discuss with the registered providers how all the managerial duties will be fulfilled. Frenchay Mews DS0000008124.V321391.R01.S.doc Version 5.2 Page 22 The quality assurance carried out at the home includes collation of information relating to retention rates, service user satisfaction and completion rates. The home also holds an annual summer reunion, which is well attended and gives an indicator to the success of the programme. The homes policies and procedures are reviewed on an annual basis and reflect current legislation and good practice guidance for rehabilitation programmes. The staff maintains the records at the home; residents are aware that they have the right to see all records held on them. The fire alarm system testing had been implemented appropriately, with regular testing of equipment. The fire safety risk assessment was not available at the manager was advised that this assessment be completed as a matter of urgency. The inspector reviewed the accident records for residents/staff, which indicated 12 minor incidents, which were not predictable and therefore not preventable. Whilst touring the building there were no areas of concern about the health and safety implementation, the home use the Food Standards Agency record file for food preparation and storage; the staff had completed statutory training. Frenchay Mews DS0000008124.V321391.R01.S.doc Version 5.2 Page 23 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 Standard No Score 1 X 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND SHEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Frenchay Mews DS0000008124.V321391.R01.S.doc Version 5.2 Page 24 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. 1. 2. 3. Refer to Standard YA6 YA37 YA36 Good Practice Recommendations The National Treatment Agency service specification for care plans could be implemented at the home. The organisation should clarify management responsibilities in the continued absence of the operations manager. The manager must record any supervision sessions held with the counselling team. Frenchay Mews DS0000008124.V321391.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Frenchay Mews DS0000008124.V321391.R01.S.doc Version 5.2 Page 26 - 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. 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