Inspection on 09/08/06 for Frensham House

This inspection was carried out on 9th August 2006.

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

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

Other inspections for this house

Frensham House 14/11/07

Frensham House 15/11/05

Frensham House 26/10/04

Frensham House 25/05/04

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

CARE HOMES FOR OLDER PEOPLE Frensham House 125 New Road Brixham Devon TQ5 8BY Lead Inspector Stella Lindsay Key Inspection (unannounced) 9th August 2006 9:45 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 Frensham House DS0000018354.V289005.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. Frensham House DS0000018354.V289005.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Frensham House Address 125 New Road Brixham Devon TQ5 8BY 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) 01803 857476 01803 858976 frensham@stone_haven.co.uk Stonehaven (Healthcare) Ltd Nicholas Paul Ross Care Home 14 Category(ies) of Dementia - over 65 years of age (14), Old age, registration, with number not falling within any other category (14), of places Physical disability over 65 years of age (14) Frensham House DS0000018354.V289005.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th March 2006 Brief Description of the Service: Frensham House provides care for up to fourteen persons over the age of 65. The service is designed for residents who have some form of dementia or other mental health problem. It is a detached house on the main road leading to the harbour and town centre of Brixham. Residents are accommodated on two floors. A stair lift serves the main part of the staircase, but residents need to be able to manage five steps if their bedroom is on the first floor. There are eight single and three double bedrooms. Four of the single bedrooms are situated on the ground floor of the home. None of the bedrooms have an en suite toilet. There are five toilets, and two baths, one of which is fitted with a hoist. The home has a comfortable lounge beside the kitchen, and a small sun lounge at the front of the building; meals are taken in a separate dining room. A sheltered sunny garden is at the front of the home, with chairs and tables provided for residents. To the rear of the building there are three off road parking spaces. The easiest access to the home is from the rear, where there are six steps to reach the path to the front door. Fees range from £300 - £410 per week. Frensham House DS0000018354.V289005.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced, and took place over two days in August 2006. It involved a tour of the premises, and examination of care records, staff files, health and safety records and the medication system. The inspector met with the Registered Manager, the consultant to Stonehaven, 12 residents, three relatives, and four staff on duty. Additional and supportive information was received via questionnaires from staff members, health & social service workers and relatives, and pre-inspection documentation provided by the Registered Manager. What the service does well: What has improved since the last inspection? Residents have previously had care plans, but since they were last inspected, not only has a new format been introduced to ensure that health problems are recognised promptly, but also life histories of residents, with photos and press cuttings supplied by families. These are fascinating, and as well as providing interest while they were being compiled, they now provide the basis for more stimulating conversations between staff and residents, and visitors, and knowledge about previous skills and interests. Staffing levels had been improved, and an extra member of staff is now employed from 8 – 11am for cleaning duties, and an extra person every afternoon, to enable social activities to take place and maintain safety of the residents. Training has improved, with specialist knowledge about meeting the needs of people with dementia being gained by the Manager and staff team. Much work has gone into improvements of the building. Security within the house has been completely revised, with infrared beams installed at the top and bottom of the stairs to alert staff when a resident goes that way, and a keypad and fire door fitted to the kitchen. Frensham House DS0000018354.V289005.R01.S.doc Version 5.1 Page 6 Redecoration was being carried out, following the Manager’s research into best practice, to find elements in the environment that will help the residents see clearly, and keep safe and well orientated. This included the colour schemes of the lounge and dining rooms, the colours of window frames, and doors including toilet doors. The corridors had also been painted and new lights fitted, and were looking bright. New plain carpets had been ordered, as some residents were put at risk by misunderstanding patterns on the carpets, and stooping to pick them up. The kitchen had been refitted since the last inspection. New flooring has been laid, the ceiling redecorated and the walls tiled, and stainless steel tables and shelving have been fitted and a new 8 ring electric and gas cooker installed. A dishwasher had also been provided, to ensure disinfecting temperatures could be used to clean cutlery and crockery, and to free up staff time following meals. What they could do better: Frensham House is built on a hillside, with many steps from the front door down to the main road, and six steps up to the parking area at the back. This means that some residents are unable to leave the premises. The proprietors must put into action their plans for a ramp that will relieve this problem. The stair lift goes up the main straight part of the staircase, but does not reach the first floor landing. Frail people are accommodated on the first floor. The proprietors should improve this facility so that people can get safely from their bedroom to the communal rooms. The proprietors have agreed that they will meet these two requirements by 31st March 2007. The home’s statement of purpose was prepared by Stonehaven and describes their services in general, but does not accurately reflect the service on offer at Frensham House. Health records were kept on behalf of each resident, but not all had the benefit of a diagnosis of their condition. This should be obtained where possible, to give the staff guidance as to the likely development of the person’s condition. A greater variety in the fresh vegetables provided and in home baking should be promoted, for the pleasure and interest of the residents as well as good nutrition. One of the two baths has no hoist, and is not used by any residents. It should be replaced by a walk-in shower to provide choice in bathing facilities for the residents, particularly as some are nervous about using the hoist, and some refuse baths. Professional advice should be taken as to a suitable and hygienic method of cleaning commode pots, separate from residents’ bathing facilities. Frensham House DS0000018354.V289005.R01.S.doc Version 5.1 Page 7 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. Frensham House DS0000018354.V289005.R01.S.doc Version 5.1 Page 8 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 Frensham House DS0000018354.V289005.R01.S.doc Version 5.1 Page 9 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): 1,3 Quality in this outcome area is good, with information available to help people make their choice, and careful assessment by the Manager to avoid inappropriate admissions. EVIDENCE: Stonehaven have produced a Statement of Purpose and Service Users’ Guide, which should be revised to reflect the service offered at this particular home. Frensham House News Letters are produced every two months, and these are very informative, and include colour photos. They cover social activities, any changes to the building, as well as staff training and any current vacancies. Relatives said that they chose the home for their parent, after visiting, finding the atmosphere agreeable, the staff welcoming and the Manager reassuring. Residents’ files were examined, and all recent admissions had been agreed on the basis of a full assessment of their care needs by the Manager. Intermediate care is not provided at Frensham House. Frensham House DS0000018354.V289005.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): 7,8,9,10 Quality in this outcome area is good, with much attention paid to individuals’ personal, health, and social care needs, and with good clear recording. EVIDENCE: All residents had a care plan, based on a careful assessment of the person’s needs as observed by the staff team. The home’s format includes many sections to ensure that no physical or mental health problems are missed, and the Manager writes a summary, to ensure that staff can quickly find out what the resident needs every day and night. Since the Manager attended a conference in June about good practice for dementia care, life histories had been compiled for all residents. Families have supplied photos - and in some cases press cuttings - and fascinating albums had been created. These are to help the staff to have stimulating conversations with residents, and give ideas for continuing social interests. Good clear records are kept with regard to the residents’ health care. Separate sheets are kept to record District Nurse treatment, hospital visits, and a chart showing treatment by Dentists, Optician, Chiropodist, weight, and admission & discharge from hospital. Frensham House DS0000018354.V289005.R01.S.doc Version 5.1 Page 11 Not all residents had a clear diagnosis of their mental health problem. It was advised that this be requested in all cases, so that the team may be aware of likely future developments. This is in spite of the fact that a GP visit is requested within two weeks of a person being admitted, for a health check and review of their medication. Daily records are made on a Cardex, with health issues highlighted. A Night record sheet is kept, showing for each individual on hourly checks whether they were awake or asleep, and what time they went to bed or got up. When residents are ill, charts are kept to record fluid and food taken. Risk assessments had been written, including many control measures by which staff can reduce the risks encountered. Risk assessments were seen on file for the use of bed guards (cot sides). The Occupational Therapist and District Nurse had been consulted and had provided the equipment, and a letter of agreement had been prepared ready to send to relatives. Five health & social service professionals returned feedback cards to the Commission for Social Care Inspection. All found that staff at Frensham House demonstrate a clear understanding of the care needs of the residents, and that any specialist advice given was incorporated into the care plans. There were additional comments about the good communication between the home and social workers being good, that clients’ needs are addressed with respect for individual needs, and in particular the Manager is always very helpful, and communicates well with regard to any issues arising. District Nurses had provided a hospital bed and an air mattress for a resident who had become bedridden. A hoist was in daily use, with different slings for each resident. One resident attends the diabetes clinic every six weeks. The optician and chiropodist were both booked and due to visit within a fortnight of this inspection. The home has a policy and procedure for the administration, storage and recording of medication, and staff were seen to be working in accordance with it. There was a list of competent staff, who had received training from the pharmacy, and their initial which they use when signing the record. A competent staff member was seen to giving the medication individually at the end of lunch, and signing the Medication Administration Record at the same time. No gaps were seen in the record. Any drugs needing to be returned to the pharmacy were recorded, and signed for on behalf of the pharmacy by their driver. There was a suitable storage facility for Controlled Drugs, but the Manager stated that none were in use at this time. A District Nurse visits daily to administer insulin. The Manager had written a list of medication, including dosage and the reason for it, on behalf of each resident. This was for the advice of his staff, and to accompany the resident if they had to be admitted to hospital. This is good practice. Staff were seen to treat residents with dignity and respect. Screens are available for privacy in double rooms. A visiting relative said that staff are Frensham House DS0000018354.V289005.R01.S.doc Version 5.1 Page 12 very helpful in taking the handset of the office phone to residents’ rooms so they can receive a phone call in private, and of advising families on the best time to phone. Relatives were pleased to say that they no longer had to worry about their parent, since their admission to Frensham House. Frensham House DS0000018354.V289005.R01.S.doc Version 5.1 Page 13 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): 12,13,14,15 Quality in this outcome area is good, with staff giving individual attention to residents, and much effort made to find and provide social stimulation appropriate for each person. Further progress is needed in the quality of meals provided. EVIDENCE: Staffing during the afternoons has been increased in order that social activities are possible. Materials have been purchased, and information about residents’ interests gathered from families. Staff stated that photos have been very useful in stimulating discussion amongst residents. The weather was warm during this inspection, and residents were seen to be enjoying the garden both morning and afternoon, with staff and with their visitors. Staff lead singing with residents in the lounge, and were seen to be talking with residents, both morning and afternoon. A music workshop with a visiting leader is a regular occurrence, and there was great excitement when ‘Elvis Presley’ visited Frensham House in July. Relatives confirmed that staff make them welcome when they visit, and bring tea and cake in the afternoons. A garden fete was held at the end of July, with a lot of effort from staff, and relatives contributing as well. The Salvation Army have visited, and residents have enjoyed their sing-a-longs, with hymns and prayers. The team have been planning to take residents on a trip out to the zoo or a cream tea at a local beauty spot, but this had not yet happened. Frensham House DS0000018354.V289005.R01.S.doc Version 5.1 Page 14 Some residents are unable to leave the premises, because they cannot manage the steps. Links with the community cannot be considered good until this is remedied. The meal served during the inspection was substantial and tasty, but incorporated no fresh vegetables. Shepherds pie had been made with frozen mixed vegetables, and frozen carrots were served as a vegetable. Fresh fruit, and salad and milk were available, but cakes, puddings and vegetables were frozen. Care staff take turns to cook, and though there is no question of their general ability, a trained cook may have more focus on interesting menus and presentation. The proprietor provides a restricted list from which regular orders are made. The staff are allowed to buy fresh food from the local shop. Encouragement should be given to provide more variety, as the residents’ entire nutrition is taken within the home. Also, the baking of cakes within the home would provide interest and good smells for the residents. Alternatives are offered, and a record kept of residents’ menu choices. Frensham House DS0000018354.V289005.R01.S.doc Version 5.1 Page 15 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 Quality in this outcome area is good. Residents and their relatives were confident that any concerns they raised would be dealt with to their satisfaction and had confidence in the Manager. Carers were clear about the adult protection procedures in the home. EVIDENCE: The complaints procedure of the home is included in the material given to a new resident and is also readily available in the home. No formal complaints had been made to the home or to the Commission for Social Care Inspection. Residents and their relatives were confident that any concerns they raised would be dealt with to their satisfaction and had confidence in the Manager. The home’s policy on the Protection of Vulnerable Adults was clear. Staff had received training in June, and knew what should be done if they had any suspicion of abuse. Staff sign a document to say that they understand they must not accept gifts from residents. Frensham House DS0000018354.V289005.R01.S.doc Version 5.1 Page 16 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): 19,21,22,26 Quality in this outcome area is good. Work was being carried out at the time of this inspection to make the interior a safe and attractive environment for people with dementia, the kitchen had been refurbished, and security within the house had been made safe and suitable. Problems of access remain. EVIDENCE: Frensham House is well located, near to the harbour and central part of Brixham. Parking is possible to the rear of the building. However, the house is built on a hillside, which gives problems for access. The path through the front garden to the main road has a flight of steep steps. Access from the back of the house is easier, but there are still six steps down from the parking area. This means that some residents are unable to leave the premises, which is unacceptable. The proprietors have stated that they will build a ramp that will overcome this problem, by 1st April 2007. There is level access from the lounge to the garden, via the office. Sturdy garden furniture had been provided, and attractive lighting. Frensham House DS0000018354.V289005.R01.S.doc Version 5.1 Page 17 At the time of the inspection, two residents were unwell and staying in their rooms on the first floor. This was appropriate, but they would need to be sufficiently well and strong to manage five steps before they would be able to go downstairs again. Residents who are physically frail are accommodated upstairs, and must be able to get safely from their rooms to the communal areas. The proprietors have stated that they will either install a stair chair that extends to the first floor landing by 1st April 2007, or will be building a shaft lift as part of a future improvement plan. Security around the house had been entirely changed and made safe and suitable, with infrared beams installed at the top and bottom of the stairs to alert staff when a resident goes that way, and a keypad and fire door fitted to the kitchen. Redecoration was being carried out, following the Manager’s research into best practice, to find elements in the environment that will help the residents see clearly, and keep safe and well orientated. This included the colour schemes of the lounge and dining rooms, the colours of window frames, and doors including toilet doors. The corridors had also been painted and new lights fitted, and were looking bright. New plain carpets had been ordered, as some residents were put at risk by misunderstanding patterns on the carpets, and stooping to pick them up. There are two bathrooms, but the powered bath seat had been removed from one, so effectively there is now only one usable bathroom. This does not meet the standard. The removal of the unused bath, and the installation of a walkin shower would be a benefit to the home, providing choice in bathing facilities for the residents. This would be particularly valuable in the case of residents who find it alarming to be lifted in a hoist. Some residents at Frensham House refuse baths. Families are involved in the decisions about whether a resident will share a room. There are no married couples, but people who are more anxious when alone, have been willing to share. The kitchen had been refitted since the last inspection. New flooring has been laid, the ceiling redecorated and the walls tiled, and stainless steel tables and shelving have been fitted and a new 8 ring electric and gas cooker installed. A dishwasher had also been provided, to ensure disinfecting temperatures could be used to clean cutlery and crockery, and to free up staff time following meals. Paper towels in dispensers and liquid soap had been provided in each bedroom, to help avoidance of any cross infection. The Health Protection Unit had provided a training session on good practice in infection control, and further staff training was planned. A soluble (red) bag system was in use for soiled laundry, as people with on-going continence problems must be catered for, while avoiding any risk of cross contamination. There was no dedicated place for commode pots to be cleaned. Frensham House DS0000018354.V289005.R01.S.doc Version 5.1 Page 18 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): 27,28,29,30 Quality in this outcome area is good, as staffing levels and training have been improved, and the recruitment procedure had been carried out rigorously. EVIDENCE: Staffing levels had been increased since last inspected, and were found to be enough to meet the care needs of the current residents. During the mornings, two people are employed as carers, one as cook (8-1pm), and one as cleaner (8-11am). All are members of the care team. The Manager is additional to this, and if he is not on duty, a Senior Carer is detailed to be in charge. During the afternoons, there are two carers as well as the Manager, in order that social activities can take place. At night, there is one Night Senior on duty, and one carer sleeping in. A written rota is kept, which shows each person and the capacity in which they are serving. Progress continues with NVQ achievement. Two more staff are starting NVQ2, and a Senior Carer is engaged in NVQ3 in care. The Manager stated that 5 of the 9 carers are now qualified. The inspector examined the files of the three most recently recruited staff, and found that the recruitment system was sound and that all checks had been made, in order to protect residents from potential harm. Frensham House DS0000018354.V289005.R01.S.doc Version 5.1 Page 19 Induction and foundation training had taken place, with records seen on staff files. Staff had undertaken distance learning in the subjects of COSSH, Control of infection. Also care of people with dementia and challenging behaviour was covered in the distance learning, but as this was at a basic level, and not sufficient for staff at Frensham House, the Manager had arranged with a Community Psychiatric Nurse from the local team to come the following month to talk to the staff about the different mental health problems of the residents, and best practice in dealing with the challenging behaviour that they meet. An outside trainer had been provided by Stonehaven for training sessions on Fire Safety, and the Protection of Vulnerable Adults. Some staff had attended training in foot care, and falls training, at Torbay Hospital. The Manager keeps records showing each staff member’s training record and needs, and the date when up-dates are due. Frensham House DS0000018354.V289005.R01.S.doc Version 5.1 Page 20 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): 31,33,35,36,38 Quality in this outcome area is good, with an effective Manager in post and an improvement in support from the proprietors. Safe systems of work are in place. EVIDENCE: The Manager has achieved the Registered Managers Award. In June he attended the Annual Care Homes & Dementia Conference in order to up-date his knowledge of new ideas on best practice. Following this, designs for the environment, and Life Stories for residents have been introduced. He is intending to attend another conference in the autumn. He attended training on ‘Manager as Coach’ in March of this year. Confidence in his ability to manage the home well and assure good care for the residents were expressed by residents, relatives and health and social service professionals. This inspection found that his energy in introducing good practice, and his ability to motivate the staff, while keeping all systems and records up to date is commendable. Frensham House DS0000018354.V289005.R01.S.doc Version 5.1 Page 21 Weekly audits are maintained to ensure that all safety checks are carried out, and all records are in place. Questionnaires have been given to relatives to gather feedback about their satisfaction with the home’s performance. Occasionally comments have been received. For instance, a request for bird feeders to add interest to the garden was acted upon immediately. Stonehaven have appointed a consultant to carry out the monthly visits on behalf of the company. He will check the home’s performance against the National Minimum Standards, and report to the management accordingly. He stated that he intends to improve the way that feedback is gathered, in order to elicit more meaningful responses. Cash is kept for eight residents, in a small safe. A good format is used to record all transactions, with two signatures and a running total kept. A spot check showed that the recording is accurate. Staff have all signed the policy stating that they do not accept gifts from residents. The Manager carries out appraisals and individual supervision sessions with each member of the care team, with records kept, and these were all up to date in June. Moving and Handling training is provided by a Deputy Manager from another Stonehaven home. The Manager carries out risk assessments and ensures that sufficient staff are available so that when residents at Frensham House need to be hoisted, two staff will be involved, one to work the hoist and one to care for and reassure the resident, which is essential when clients are mentally or physically frail. Staff have attended fire safety training. The fire precaution system was serviced professionally on 08/02/06. First Aid training has been provided, and up dates will be provided as required. Accidents are recorded, and the Manager carries out a monthly review and analysis, so that any patterns become evident, and staff can be made aware of residents’ increased vulnerability. Frensham House DS0000018354.V289005.R01.S.doc Version 5.1 Page 22 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 2 2 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Frensham House DS0000018354.V289005.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP13 Regulation 13(4) 23(2) Requirement The registered provider must provide a ramp to improve access into the home as called for in the occupational therapist’s report. A stair chair which reaches the 1st floor (or a shaft lift) must be installed. Timescale for action 31/03/07 2 OP22 13(4) 23(2) 31/03/07 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 5 Refer to Standard OP1 OP8 OP15 OP21 OP26 Good Practice Recommendations The Statement of Purpose should be revised to accurately represent the service offered at Frensham House. A diagnosis should be requested on behalf of each resident with regard to their mental health, where this has not already been achieved. Variety in fresh vegetables and home baking should be promoted. The unused bath should be replaced by a walk-in shower. A suitable facility for washing commode pots should be provided. DS0000018354.V289005.R01.S.doc Version 5.1 Page 24 Frensham House Frensham House DS0000018354.V289005.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Frensham House DS0000018354.V289005.R01.S.doc Version 5.1 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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