Inspection on 10/02/06 for Frenchay Park Nursing Home

This inspection was carried out on 10th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Frenchay Park Nursing Home 24/02/09

Frenchay Park Nursing Home 13/06/08

Frenchay Park Nursing Home 14/08/07

Frenchay Park Nursing Home 27/02/07

Frenchay Park Nursing Home 13/07/06

Frenchay Park Nursing Home 10/06/05

Frenchay Park Nursing Home 03/11/04

Frenchay Park Nursing Home 11/05/04

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

CARE HOMES FOR OLDER PEOPLE Frenchay Park Nursing Home 140 Frenchay Park Road Frenchay Bristol BS16 1HB Lead Inspector Sam Fox Unannounced Inspection 09:30 10 & 15 February 2006 th th 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 Frenchay Park Nursing Home DS0000034485.V277994.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. Frenchay Park Nursing Home DS0000034485.V277994.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Frenchay Park Nursing Home Address 140 Frenchay Park Road Frenchay Bristol BS16 1HB 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) 0117 9659957 0117 399300 Ms June Marilyn Phillips Mr Gordon Norman Brooking, Mr Derek Marsh Mrs Leanne Williams Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Frenchay Park Nursing Home DS0000034485.V277994.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Staffing notice dated 25/02/2002 applies. Manager must be a RN on parts 1 or 12 of the NMC register Date of last inspection 10th June 2005 Brief Description of the Service: Frenchay Park is registered as a Care Home for a maximum of 30 residents requiring nursing care. The Home is situated in an urban position, and sits on the main Frenchay Park Road. It is a short journey away from the Fishponds High Street. It is within easy access to local community facilities and is less than 4 miles to Bristol city centre. It can be accessed by car or bus, being on a main bus route. The home is a converted older property offering single and shared bedrooms on two floors. There are two lounges and a separate dining room. There is a passenger lift providing access to all service user areas. All parts of the home are accessible to the able-bodied as well as wheelchair users. Frenchay Park Nursing Home DS0000034485.V277994.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s second unannounced inspection this year. It took place over two days totalling eight hours. The purpose was to check on residents’ welfare and ensure that they were in a safe environment. In addition to this staff training and recruitment procedures were examined. Evidence was gathered through discussion with residents and the manager and consultation with seven members of staff. Key records were also inspected to provide further evidence of work practice. Not all standards were assessed during this visit and as such this report should be read in conjunction with others so a fuller picture of the home can be gained. What the service does well: What has improved since the last inspection? What they could do better: All residents should be issued with a contract so they have a full awareness of the terms and conditions of living at the home. Frenchay Park Nursing Home DS0000034485.V277994.R01.S.doc Version 5.1 Page 6 In order to further promote the health and safety of residents, risk assessments for the use of bed rails need to be further developed, along with a workplace fire risk assessment. In addition to this the flooring in the kitchen has been identified by the environmental health officer as in need of replacing. Care plans need to be more detailed, at the moment they do not reflect actual good work practice that takes place on a daily basis. This would enable the home to further evidence that they are providing an individualised service. Fluid and food intake charts need to be more consistently filled out to further ensure residents’ specific health care needs are being met. The home should begin a planned programme of introducing bedroom door locks – this would enable residents to maintain their privacy and keep their personal possessions secure. Staff would benefit from receiving more consistent formal supervision. 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 Park Nursing Home DS0000034485.V277994.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 Frenchay Park Nursing Home DS0000034485.V277994.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): 2,3,4,5, There is an effective admissions procedure in place so residents can be reassured that staff will have the skills and resources to meet their needs. Contracts need to be issued to all residents so they are fully aware of any house rules. EVIDENCE: It was noted that some residents have a contract, which states the terms and conditions of living within the home. This includes the room to be occupied, fees, information about the data protection act and some of the facilities to be provided. This meets with requirements of the legislation. It was noted, however, that not all residents had a contract – the manager should ensure that they each receive an updated version of these. Frenchay Park Nursing Home DS0000034485.V277994.R01.S.doc Version 5.1 Page 9 Personal files provided evidence that the manager carries out a full assessment prior to new residents moving to the home. This is important as it enables them to check that they have the resources and skills to meet their needs. In addition to this there were reports and assessments from outside professionals, including social workers. Obtaining these reports enables the home to gain a fuller picture of the individual. The manager now sends letters to prospective new residents confirming that they can meet their needs. This meets with a requirement made at the last inspection. The manager and staff confirmed that residents do have the right to trial visits, many of them, however, often get their family or representatives to look around for them. Frenchay Park Nursing Home DS0000034485.V277994.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,10, Care plans need to be expanded so that residents can be more re-assured that they will receive an individualised service. Residents can expect to have their health care needs met. In order to further promote their well being, however, risk assessments should be filled out for the use of bed rails and food intake charts more consistently maintained. EVIDENCE: Three care files were looked at in detail during this visit. They contained assessments on activities for daily living, including mobility, personal hygiene and continence. In addition to the above each resident has a set of care plans. These were found to be limited in detail and need to be expanded. They do not reflect the actual support that staff give on a day-to-day basis. The home must also try and ensure they are signed, as agreed to, by either the residents or their representative. Frenchay Park Nursing Home DS0000034485.V277994.R01.S.doc Version 5.1 Page 11 Care plans are reviewed on a monthly basis. This meets with good practice guidance. It was observed that the home was recording the food and fluid intake for one resident with eating difficulties. This was not being filled out consistently and staff must ensure that they record such information accurately. It was noted that there were a number of specialists mattresses designed to reduce the risk of pressure sores developing and the home appears to be well resourced in this respect. The manager said that the home were short of wheelchairs which she was trying to rectify. Each personal file contained a nutritional assessment, all of those seen were at low risk and therefore did not warrant an additional care plan. In addition to this there were waterlow risk assessments, which indicate the risk of developing pressure sores. Some residents use bed rails. The manager was advised that there needs to be separate risk assessments for the use of these. They should include confirmation that they are safe to use, that help can be summoned if the resident wants to get out of bed and consent. It was noted that one resident refused to use bed rails and that her wishes were taken onto account in this respect. This is good practice, the home, however, must ensure that they have agreement forms in relation to this. Records showed that residents are supported to see their GPs and health care specialists. All residents consulted with spoke positively about the staff team and what they did for them. Staff displayed a good understanding of individual needs and the importance of respecting rights to privacy and dignity. One resident shares a room and screening is provided to ensure their privacy is not compromised. Care plans included residents wishes in the event of their death. This standard was not looked at fully and will be a focus of the next visit. Frenchay Park Nursing Home DS0000034485.V277994.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15 Residents are supported to maintain links with their family and friends. Records need to be more detailed to evidence residents are being enabled to dictate their own daily routines. EVIDENCE: There was information about residents past histories on file, although the detail in these varied considerably. In addition to this they contained information about daily routines. These were not detailed enough to give a good picture of individual preferred routines and examples of how these could be improved were discussed with the manager. It is particularly important that these are completed for people with dementia who may not be able to directly say what they would prefer. It was observed that those residents who wished to stay in bed were left to do so and staff said that residents are also able to go to bed when they wish. There are some formal activities planned for the forthcoming months and these were listed on the home’s notice board. Frenchay Park Nursing Home DS0000034485.V277994.R01.S.doc Version 5.1 Page 13 One relative was spoken with at the time of this visit. He said he could visit at any time and was pleased with the care and attention that was given to his relative. Staff confirmed that family and friends could visit ant any time, they said they liked to build up positive relationships with them so they could feel confident in the home. Records of menus and observation indicated that residents benefit from a wide variety of nutritious meals and that they are offered a daily alternative. The chef said that he had got to know the residents and was aware of their preferences. The home has received a visit from the environmental health officer who noted that flooring in the kitchen needs replacing as it has ingrained rust and in some parts is poorly fitted. Frenchay Park Nursing Home DS0000034485.V277994.R01.S.doc Version 5.1 Page 14 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 Residents can be confident that their concerns will be listened to. There are procedures in place to protect vulnerable adults from abuse. EVIDENCE: The home has a complaints procedure, which is clearly displayed and forms part of the residents’ guide. A complaint has been made by a relative, this has been resolved and all action fully recorded in a logbook. The home has a whistle blowing policy through which staff are encouraged to report bad practice. This has recently been used in the home. Issues in relation to this have been investigated by the area manager and action has been taken as a result of this. All staff consulted with displayed a good understanding of issues in relation to abuse and they have all received training. Records provided further evidence of this. The home has a protection of vulnerable adults policy which includes key people who should be contacted in the event of suspected abuse. Frenchay Park Nursing Home DS0000034485.V277994.R01.S.doc Version 5.1 Page 15 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): 19,20,21,23,24,26 Residents’ benefit from living in a homely, well-maintained and clean environment. Staff would benefit from having more room to do the laundry. EVIDENCE: The home is an older property converted and adapted to care for elderly people. There is a passenger lift – this, however, was out of order at the time of the visit and had been so for nearly a week. A number of residents on the top floor were frustrated about this as it meant they were unable to go downstairs. The manager explained that they were waiting for a spare part and that it was due to be fixed on the day of the inspection. It was apparent that there were not at fault for the delays. There are two lounge areas, both of which incorporate a dining area. These were found to be comfortably furnished and homely in appearance. Frenchay Park Nursing Home DS0000034485.V277994.R01.S.doc Version 5.1 Page 16 All bedrooms seen at the time of this visit were found to be bright, airy and personalised – some residents have bought in their own furniture to make it more homely. All residents spoken with were satisfied with the quality and quantity of the furniture. There are adequate bathing and toilet facilities to meet the needs of those residents currently accommodated. It was noted that all baths were accessible via a hoist and it is recommended that the home consider upgrading these with more specialist facilities for the disabled. It was noted that no bedroom doors had a door lock – the home should begin a planned programme of installing these. All areas of the home were found to be cleaned to a good standard and there were no unpleasant smells. Laundry facilities, however, are limited and the main laundry room on the ground floor is small. There is no space for sorting or storing the washing. It is recommended that alternative space be sought for this. The washing machine reaches temperatures sufficient to wash soiled laundry and the home has a sluicing facility with a disinfector. The home has a number of polices in place for the control of infection although these were not looked at in detail during this visit. Frenchay Park Nursing Home DS0000034485.V277994.R01.S.doc Version 5.1 Page 17 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): 27,28,29, Residents’ needs are met by a skilled and well-resourced staff team. They are protected by a robust recruitment system. EVIDENCE: The staff rotas indicated that there are sufficient staff on duty to meet the needs of those residents currently accommodated. There are seven care assistants employed in the morning, reducing to three in the afternoon. There is a trained member of staff on duty at all times. Additional staff are employed at peak times. There is a registered nurse and two waking care assistants on duty at night. Opportunity was staken to view three staff files. It was noted that these contained completed application forms, two references and criminal records checks. Recruitment information was found to be well maintained. All staff receive induction training and signed copies of these were viewed on personal files. At this time care staff are also given a copy of the general social care council’s code of conduct. Staff said they felt they were given a lot of opportunity to train and many of them had gained their national vocational qualifications. They said they felt they worked well as a team. Frenchay Park Nursing Home DS0000034485.V277994.R01.S.doc Version 5.1 Page 18 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): 36,38 Staff would gain in confidence if they had more consistent formal supervision. Residents can be assured they are living in a safe environment. EVIDENCE: The manager has introduced a formal supervision system, which provides an important, more formal forum, through which concerns and areas for development can be discussed. It is recommended that these take place at more regular intervals. The fire logbook evidenced that the relevant tests and checks of the system take place at the appropriate intervals. The home employs a maintenance worker who takes responsibility for a number of health and safety checks and carries out regular monitoring. This system appears to be working well within the home. Frenchay Park Nursing Home DS0000034485.V277994.R01.S.doc Version 5.1 Page 19 The manager was informed that she needs to develop a workplace fire risk assessment. Portable electrical equipment was being tested on the second day of the visit. There was an up to date gas safety certificate and the manual handling equipment had been serviced. Hot water outlets are checked at regular intervals, with temperatures recorded. A hand test of hot water evidenced that it is being kept within a safe range. A spot check of training records indicated that there is a rolling programme of statutory health and safety training, including first aid, manual handling and fire. There were general health and safety risk assessments available. These were not looked at in depth during the visit but were noted to cover a wide range of activities. Staff confirmed that they had received statutory training of fire, first aid and manual handling. Frenchay Park Nursing Home DS0000034485.V277994.R01.S.doc Version 5.1 Page 20 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 2 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 x 3 2 x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x x 3 x 3 Frenchay Park Nursing Home DS0000034485.V277994.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. Standard OP2 OP8 OP8 Regulation 5(1)(b) 12(1)(a) 13(4)(c) Requirement Ensure all residents have an up to date contract. Ensure that food and fluid intake records are consistently maintained. Ensure there are detailed, signed, risk assessments available in relation to the use of bed rails. Further develop care plans. Replace flooring in the kitchen Implement planned programme of introducing bedroom door locks Develop a workplace fire assessment. Timescale for action 30/04/06 15/02/06 28/02/06 4. 5. 6. 7. OP7 OP15 OP24 OP38 15 16(2)(j) 12(1)(a), 12(4)(a) 23(4) 30/06/06 30/04/06 30/06/06 30/05/06 Frenchay Park Nursing Home DS0000034485.V277994.R01.S.doc Version 5.1 Page 22 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. 4. Refer to Standard OP21 OP12 OP26 OP36 Good Practice Recommendations Upgrade bathing facilities Improve detail about individual daily routines Find a more appropriate site for the laundry room Formal supervision to take place at more regular intervals Frenchay Park Nursing Home DS0000034485.V277994.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Frenchay Park Nursing Home DS0000034485.V277994.R01.S.doc Version 5.1 Page 24 - 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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