Inspection on 10/06/05 for Frenchay Park Nursing Home

This inspection was carried out on 10th June 2005.

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

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

Other inspections for this house

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 10/02/06

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 Andrew Pollard Unannounced 10 June 2005 09:30 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Frenchay Park Nursing Home D56_34485_FrenchayPark_225407_100605_Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Frenchay Park Nursing Home Address 140 Frenchay Park Road Frenchay Bristol BS16 1HB 0117 9659957 0117 399300 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Ms June Marilyn Phillips Mrs Leanne Williams Care home with nursing 30 Category(ies) of OP Old age (30) registration, with number of places Frenchay Park Nursing Home D56_34485_FrenchayPark_225407_100605_Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 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 3 November 2004 Unannounced 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 D56_34485_FrenchayPark_225407_100605_Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The following methods of evidence gathering has been used In the production of this report; observation, discussion with residents and staff, tour of the home and sampling policies, records, care plans, meals. On the day of inspection the home had occupancy of 29. There were 17 requirements and 4 recommendations made during the previous inspection. Compliance has been achieved or is in hand for all those matters. General feedback was given to the manager on the day of inspection. All of the residents and visitors the inspector spoke with during the inspection commented positively on all aspects of the home. A selection of the verbal comments received state ‘I am happy here, ‘the staff are kind’ and ‘the food is good’. Staff/ resident interactions were seen to be friendly and supportive. Comments indicated staff were courteous and respectful. What the service does well: What has improved since the last inspection? There were 17 requirements and 4 recommendations made during the previous inspection. Compliance has been achieved or is in hand for all those matters. The service user guide and statement of purpose have been amended. Frenchay Park Nursing Home D56_34485_FrenchayPark_225407_100605_Stage4.doc Version 1.30 Page 6 Residents are consulted and involved where able in provision of leisure activities. Training has taken place and there is greater awareness of POVA issues. Fire safety training and drill are taking place more regularly. New locks are being fitted to bathroom doors. New vanity units are being fitted in bedrooms. 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 Park Nursing Home D56_34485_FrenchayPark_225407_100605_Stage4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Frenchay Park Nursing Home D56_34485_FrenchayPark_225407_100605_Stage4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3, 4, 5 People have the information they need prior to admission to the home. Prospective residents have full assessments of their needs carried out. The letter confirming the homes ability to meet requires further detail. People are introduced to the home and staff/residents where practical. EVIDENCE: Frenchay Park Nursing Home D56_34485_FrenchayPark_225407_100605_Stage4.doc Version 1.30 Page 9 The service user guide and statement of purpose provide clear and detailed information for potential residents. The case files of the last residents admitted into the home were seen. All had completed pre-admission assessment documents as well as completed social service assessments. The assessments seen contained quite detailed written information, facilitating a judgement of whether the home can meet the service user needs or not. The manager writes to prospective residents and/or their relatives to inform them that they can be accommodated however, it must also state that following assessment the home can accommodate their assessed needs. The home’s ability to meet the needs of the residents relies on the individual and collective skills of the staff group. The home employs staff with a range of skills, experience and competencies to meet the needs of the resident group. Where possible people are encouraged to visit the home and have a meal along with a family member or social worker. Daytime or overnight stays can be accommodated. The home offers respite care subject to bed availability, Emergency admissions are taken subject to bed availability and all assessment documentation being made available to the home prior to admission. Frenchay Park Nursing Home D56_34485_FrenchayPark_225407_100605_Stage4.doc Version 1.30 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 standard(s) 7, 8, 9 Assessments are clear and detailed. The care plans identify needs and give clear directions to staff. Residents or their advocates are consulted with about care matters. Medication management and record keeping are to a good standard. Aapropriate arrangements are in place to meet peoples health care needs. EVIDENCE: The home had documentation for assessing, planning and evaluating care. Needs were assessed using a model based on the Activities of Daily Living (ADL). The documentation itself is comprehensive; it comprises individual files and uses a holistic approach to care planning. All residents have a short biography. There is resident/relative involvement in the completion of these profiles and consenting signatures to care plans and reviews. Where possible residents and or relatives take part in reassessments. Waterlow, sterling index moving and handling, nutritional and generic risk assessments are completed as needed. In general the documentation was comprehensive and completed to a good standard. Frenchay Park Nursing Home D56_34485_FrenchayPark_225407_100605_Stage4.doc Version 1.30 Page 11 Residents are normally registered with local GP’s. Arrangements are made for people to see a chiropodist, dentist and optician, or a home visit is arranged. Specialist services are accessed by GP referral. The manager evaluates equipment needs to ensure the home is able to meet the changing health needs of the residents. The home does not have a portable suction machine. The home has a satisfactory medication policy. No residents are able to self-medicate at present. The receipt, storage, disposal, controlled drugs and administration records were up to date and in order. A local pharmacist carries out regular advisory and training visits. Several Registered Nurses (RN’s) staff have completed medication management training. Frenchay Park Nursing Home D56_34485_FrenchayPark_225407_100605_Stage4.doc Version 1.30 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 standard(s) 12, 13, 15 It was evident from the range of social activities taking place that the staff are striving to enhance resident’s quality of life. Resident’s families are involved and informed of issues related to their relatives. From speaking to residents and reviewing records it was evident that the food provided is to peoples liking and offers a healthy diet. EVIDENCE: All residents had social activity assessments and records. The manager had organised a general activities rota. There was recent evidence of consultation with regard to the range of activities offered. There was a residents meeting in April who was well attended and residents have asked to do some baking and craft work, which is being arranged. There was evidence of consultation re the re-decoration of the communal areas recorded in the minutes of the residents meeting. People can meet visitors in their own rooms or the communal lounges / dining area. The activity records list attendance and general feedback from those taking part. The manager also arranges for several external entertainers to attend the home monthly, including gentle activities to music, a visiting clothes show, various musicians, sing along and quizzes. Frenchay Park Nursing Home D56_34485_FrenchayPark_225407_100605_Stage4.doc Version 1.30 Page 13 Recent outings have been to Slimbridge and Weston. The company has two disabled accessible minibuses. A local clergyman offers an act of worship weekly. The cook has previously carried out a survey of resident likes and dislikes and plans a weekly menu. Daily three choices of food are offered and alternatives are always available. Choice of evening meals and supper are offered. The menu was varied and provided a balanced diet. None of the residents have special cultural dietary needs. Frenchay Park Nursing Home D56_34485_FrenchayPark_225407_100605_Stage4.doc Version 1.30 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 standard(s) 16, 18 The complaint and POVA policies are clear and detailed. The staff are aware of the complaints and POVA policies and are trained in putting them into practice to protect residents from abuse. The full (revised) Bristol No Secrets policy is not yet available in the home. EVIDENCE: The complaints policy was on display clearly written and is available in the service user guide. A complaints log is maintained. No formal complaints had been made since the last inspection. One member of staff was dismissed following feedback from residents to the manager. This person has been reported for inclusion on the list of unfit persons. The home has written procedures for adult protection, whistle blowing, management of aggression, abuse, bullying and management of resident’s money/valuables. The DOH ‘No Secrets’ document was available, but not the Local Authority version as they are currently not available a copy is on order. The manager has the relevant POVA contact numbers. There is a necessity for all staff to attend appropriate external adult protection training and this is being arranged with Social Services. The manager has attended an alerter’s level course. All staff have been given copies of the GSCC code of practice and an abridged version of Bristol No Secrets policies. The documents have been discussed at team meetings and during induction. Frenchay Park Nursing Home D56_34485_FrenchayPark_225407_100605_Stage4.doc Version 1.30 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 standard(s) 19, 22, 24, 26 The house is a clean, comfortable and safe environment for the current residents. The bedrooms and communal rooms and facilities are suitable for their purpose and meet the resident’s needs. Residents have any specialist equipment they presently require to maintain and promote their independence. EVIDENCE: Frenchay Park Nursing Home D56_34485_FrenchayPark_225407_100605_Stage4.doc Version 1.30 Page 16 The home is an older property converted and adapted to care for elderly people. There is a passenger lift, which provides level access to the two floors. The home had no unpleasant odours and was generally well presented. The standard of cleanliness was good. The home is a smoke-free environment. There are two lounge areas both incorporate a dining area. These were found to be comfortably furnished and homely in appearance. All lounge areas had daily provision of fresh fruit and drinks. The home has an adequate ratio of toilets and bathrooms to the number of beds. Some of the bathrooms are fully disabled accessible. New locks are being fitted to bathroom and toilet doors. Environmental adaptations and equipment meet the needs of the current residents. There is a lift to all floors, bath hoists, stand aids and toilet frames etc. There are grab rails around the home and a new call bell system in each bathroom, bedroom and lounges. Most rooms were well presented, offering appropriate furnishings and fittings. New vanity units have recently been delivered for all bedrooms. Not all bedroom doors were lockable; but locks could be provided on request. Individuals have personalised rooms with photographs, plants, and furniture. The majority of the radiators in the home had been fitted with new guards. The laundry has an industrial washing machine and tumble dryer with appropriate specified programmes. The laundry room is exceptionally small and has no space for sorting or storing the laundry. One sluice area contains a disinfector. Frenchay Park Nursing Home D56_34485_FrenchayPark_225407_100605_Stage4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 The home is adequately staffed with appropriately trained and experienced staff. The recruitment procedures and records are in good order. Proper training arrangements are in place for care staff. Clinical updating for RN’s needs to be maintained. EVIDENCE: The home is working in accord with the overall number of hours required of the staffing notice although the shift times vary from the notice. The manager is working 18 hours supernumerary each week. There has been occasional use of bank and agency staff. There are no administrative personnel on site. Laundry and domestic staff work 6 days per week. There are 2 cooks and kitchen assistants providing all meals. The home operates an equal opportunities employment policy. The employment records were generally in good order. All staff had CRB/POVA disclosures. As yet there is no log for an inspector to sign off the disclosures, the manager is to create such so this can be done at the next inspection. Registered Nursing staff have had their qualifications validated in writing. Application forms, interview notes and health declarations were retained on file along with references from the previous employer. One person’s references had been requested from private addresses rather than a work place. Staff were issued with Job descriptions and written terms and conditions. The GSCC code of practice has been issued to all staff. Frenchay Park Nursing Home D56_34485_FrenchayPark_225407_100605_Stage4.doc Version 1.30 Page 18 The training and induction records were generally up to date in the mandatory training requirements of load handling; food hygiene, health & safety, fire safety, POVA and first aid. A comprehensive induction format is in use for new staff with separate versions for RN’s and care staff. The booklet acts as a prompt for the trainer to discuss issues, systems and policies with new staff, who then signed to confirm the information has been given. R/N training records viewed evidence of relevant prep updates for most staff although it was acknowledged that they are not fully up to date. Five staff have NVQ level 2, one has level 3 and five staff are on programmes. An overview of the staff training records evidenced a broad spectrum of skills relevant in meeting the needs of the residents. Frenchay Park Nursing Home D56_34485_FrenchayPark_225407_100605_Stage4.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35,38 There are appropriate arrangements in place to service and repair plant and equipment. The home has good Health and Safety arrangements. Resident’s money is secure and properly accounted for. EVIDENCE: The majority of people have requested that their personal allowance is looked after by the home. Each person has his or her own ledger sheet and cash is individualised. If residents are unable to sign for their money, then two staff members sign to say they both agree with the amount returned or received for safe keeping. Receipts are kept for all purchases. Each bedroom has a lockable drawer. Frenchay Park Nursing Home D56_34485_FrenchayPark_225407_100605_Stage4.doc Version 1.30 Page 20 The manager has delegated responsibility for health and safety matters. A monthly audit of health and safety records takes place. The home has an appropriate infection control and policies and procedures were in place. COSHH products were properly stored information was displayed. Water temperatures are being monitored and recorded monthly. The fire logbook was up to date and in order. Training and fire drills are taking place. All records relating to the inspection servicing and maintenance of hoists, the lift, fire alarm, and gas supply were up to date and in order. Annual PAT testing had been completed. A copy of the service record of the 5 yearly electrical safety check had been forward to the CSCI. All windows above ground floor level were restricted. The kitchen area, this was clean, tidy and well organised. The EHO visited recently and some minor works were required which have now been completed. The Regulation 26 reports were properly completed each month. Frenchay Park Nursing Home D56_34485_FrenchayPark_225407_100605_Stage4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 2 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x 3 x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x 3 x x 3 Frenchay Park Nursing Home D56_34485_FrenchayPark_225407_100605_Stage4.doc Version 1.30 Page 22 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 4 Regulation 14 Requirement Send a letter to prospective residents confirming their assessed needs can be met. Timescale for action From 10/06/05 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 8 29 29 Good Practice Recommendations Provide portable suction equipment Create a log for CRB records to be signed off by an inspector prior to their confidential disposal. Seek references from workplace addresses. 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