Inspection on 15/11/05 for Frethey House

This inspection was carried out on 15th November 2005.

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

Frethey House 09/09/08

Frethey House 06/09/06

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

CARE HOMES FOR OLDER PEOPLE Frethey House Frethey Lane Bishops Hull Taunton Somerset TA4 1AB Lead Inspector Caroline Baker Announced Inspection 15th November 2005 09:00 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 Frethey House DS0000064474.V253028.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Frethey House DS0000064474.V253028.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Frethey House Address Frethey Lane Bishops Hull Taunton Somerset TA4 1AB 01404 861785 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) Affirmative Care Ltd Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Frethey House DS0000064474.V253028.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Communal space must be increased to at least 4.1 sq metres of space per service user to include a dining areas within two years of registration. Elderly persons of either sex, not less than 60 years, who require nursing care. Up to three places for persons receiving personal care only. Date of last inspection NA Brief Description of the Service: Frethey House is situated on the edge of the village of Bishops Hull on the outskirts of Taunton. The home is registered with the Commission for social Care Inspection (CSCI) for 30 people not less than 60 years of age, who require general nursing care, and up to 3 places for people receiving personal care only. Affirmative Care Ltd has owned the home since July 2005, the Registered Individual being Amanda Willmott. The Registered Manager recently retired and the manager designate is Susan Hull who is awaiting registration with the CSCI. Frethey House has a dining room and lounge on the ground floor and a small lounge on the first floor. The home has 30 single bedrooms at present all with en-suite facilities. Plans are to extend the home to provide extra communal space and living accommodation. The home has four communal assisted baths, one shower facility and 2 communal toilets. Car parking facilities are good. Frethey House DS0000064474.V253028.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first inspection under the Care Standards Act 2000 since Affirmative Care Ltd purchased the home in July 2005 Mrs Amanda Willmott is the registered individual (RI) and Susan Hull is the manager designate since the registered manager retired at the end of October 2005. This inspection took place over one day (8 hours) and was conducted by Caroline Baker. Twenty-eight service users were residing at the home. Staffing levels were adequate on the day of inspection. An assessment of the premises took place where a selection of bedrooms and communal areas were seen. At least ten service users were spoken with. Many staff on duty during the morning were consulted. Two relatives were spoken to. The RI and manager were available throughout the inspection. Throughout the day the inspector was able to observe interactions between staff and service users. Records relating to the care of the service users, staff and health and safety were examined. The inspector would like to thank service users and staff for their time and help during the inspection. What the service does well: Frethey House provides a well maintained, secure and comfortable environment, which is furnished and decorated to a high standard. It meets the needs of the current client group. Service users were observed using all communal areas and appeared comfortable and relaxed in their environment. Service users spoken to stated that they liked their bedrooms and were happy and felt safe at the home. Service users were well attired and looked well cared for on the day of inspection. Service users praised the food. A good choice of wholesome food was given. Service users praised the staff. Some comments received from service users were “ the staff are always kind and caring” and “the food is excellent”. Frethey House DS0000064474.V253028.R01.S.doc Version 5.0 Page 6 Relatives spoken to indicated their satisfaction at the provision of care at the home and the helpfulness of the staff. Comments received through comment cards from relatives included: “The aspects could be improved by a more proactive attitude and a better understanding of what relatives need to know in order to feel ‘comfortable’ I have raised these aspects with the new management and they are currently being positively addressed” and “The home is always clean; the staff are very helpful and caring”. Many more comments were received and fed back to the provider and manager. Staffing numbers and the skill mix of staff were sufficient to meet the dependency needs of current service users on the day of inspection. Staff spoken with indicated that they felt well supported and happy working at the home. Staff training was well documented and the provision of training for staff was good. The new provider who had already made improvements in light of comments received from service users staff and relatives had taken quality Assurance seriously. 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. Frethey House DS0000064474.V253028.R01.S.doc Version 5.0 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 Frethey House DS0000064474.V253028.R01.S.doc Version 5.0 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): 1; 2; 3; 4 and 5. NMS 6 is not applicable to this service. Service users are provided with the information they need to enable them to make an informed choice about moving to the home. Terms and Conditions of stay are issued to service users. The home was able to demonstrate that service users are fully assessed prior to admission to ensure their needs can be met. The home would be able to introduce prospective service users to the home prior to admission. Staff individually and collectively have the skills to deliver the care. EVIDENCE: The home has developed a statement of purpose and service user guide in line with National Minimum Standards (NMS), which is placed in all service users rooms. It is also displayed at the home for visitors to peruse. This was evident on assessment of the premises. Frethey House DS0000064474.V253028.R01.S.doc Version 5.0 Page 9 On sampling four individual care plans evidence was seen that a thorough preadmission assessment is completed for each prospective service user to ensure the home can meet their individual needs. Service users consulted and able confirmed being met prior to admission by a representative of the home. Service users are able to visit the home at any time prior to admission. Evidence was seen of enquirers completed questionnaires. The inspector saw evidence that contracts of the homes terms and conditions were given to service users. From the sample of service user plans inspected it was confirmed that specialist practitioners advise on some aspects of care in the home. It could also be seen from the samples of care plans assessed, that service users are being admitted according to the home’s admission criteria. Duty rotas examined confirmed that the home had a Registered Nurse on duty 24 hours per day supported by care staff. Frethey House DS0000064474.V253028.R01.S.doc Version 5.0 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 and 11. Each service user had an individual plan of care. The home’s care planning system demonstrated that care plans were kept under review however there was need for improvement. Service users have access to health care professionals expertise to meet their individual needs. Service users were generally protected by the homes procedures in regard to the receipt, administration, recording and disposal of medications – minor shortfalls were noted. Service users were generally treated with kindness and respect and those who were very ill looked well cared for and comfortable. EVIDENCE: The inspector assessed four individual care plans and met with the service users as part of the case tracking process. Overall the systems were well documented. Personal care had not always been recorded. One social record was incomplete. Nutritional risk assessments (MUST tools) had not been completed. Wound care plans were confusing as to the ‘type of wound’ and to Frethey House DS0000064474.V253028.R01.S.doc Version 5.0 Page 11 when the wound should be assessed. Some care needs recorded in the daily record had not been developed into a care need plan. Care planning was discussed with the management who agreed there were gaps and had already acknowledged the problems. This was being addressed by removing care plans from each individual service users room where they had been stored to a central secure area where the manager and trained staff could audit them and review them to ensure they were up to date and reflected all care needs. Evidence was seen that individual service users had been seen by and had access to a chiropodist, optician, dentist, and GP. Pressure relieving equipment was being used appropriately. Medication systems were examined to include records of receipt, administration, recording and disposal. Minor discrepancies were noted and discussed with the management in regard to recording. Overall good practice was maintained. Care plans reflected preferred names. Service users can lock their bedroom doors from the inside if they wish for extra privacy, and staff would be able to access the rooms from outside in an emergency. Staff were seen and heard to knock on doors before entering service users rooms. Service users spoken to and able confirmed that this always happened. Service users spoken to indicated that the staff always treated them with respect. They indicated that they felt well cared for, liked living at the home, that the staff treated them well and that their privacy was respected. Comment cards received indicated the same. Whilst in the lounge area the inspector observed staff assisting service users into wheelchairs ready for lunch. It was concerning that some of the staff did not speak to the service users they moved, and transferred them by lifting them under their arms despite already putting a transfer belt on the service users. This was brought to the attention of a senior carer on duty, who immediately spoke to the staff, and discussed with the management who agreed to address the issues raised. Policies were in place in regard to death and dying. It was evident when meeting with very poorly service users nursed in bed that a high standard of care was being delivered and systems were in place to ensure hydration and pain control. Frethey House DS0000064474.V253028.R01.S.doc Version 5.0 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; 14; and 15 Service users benefit from a range of activities to suit their individual choices and needs. The home is open to visitors at any time and encourages service users to access the local community. Service users individual choices and needs dictate the routine of the home. Service users are offered a choice of nutritious well-balanced and varied menus promoting their health and well-being. EVIDENCE: The inspector spoke at length with the recently employed activities coordinator and examined activities records. It was evident that a lot of thought had been put in to activity provision at the home. Activities such as flexercise, art and crafts, reading, aromatherapy, music, manicures, board games and trips out are provided. Service users consulted indicated that they thought the activity provision had improved and was adequate. Evidence of 1:1 activities was recorded in individual care records sampled. The homes visitors record evidence many visitors to the home. Relatives were seen visiting on the day of inspection and spoke highly of the care provision. Frethey House DS0000064474.V253028.R01.S.doc Version 5.0 Page 13 Service users consulted and able were happy at the home and felt they were given a choice of daily living of when to get up and go to bed. Evidence was seen of service users in their own rooms knitting or reading or watching TV. Service users were addressed by their preferred names they informed the inspector. Comment cards received from service users indicated the majority enjoyed the food provided. Service users consulted spoke highly of the food provision. One service user told the inspector that the menus had improved and the delivery of food on trays was to a higher standard with the use of tray cloths and serviettes. Relatives spoken to told the inspector that the food provision was much improved and that cakes, biscuits and fruit are offered for afternoon tea. The inspector observed the lunchtime meal being eaten. The tables were laid nicely and there was a choice of a cheeseboard, fresh fruit and a dessert after the main course. Many service users in the dining room had not finished their main meal and told the inspector it was very tasty but too much. It was concerning to see the dining room unsupervised whilst staff went to the kitchen to get desserts and some service users had not finished their meals and needed assistance. This was brought to the attention of the Nurse in Charge and the management who agreed that this was not acceptable and that it would be addressed. The home is in the process of changing the routine of delivery of food from the kitchen to the dining room and a hot trolley will be used and served from in the dining room, which will prevent the dining room from being unsupervised at any time. The kitchen was well equipped clean and organised. More kitchen staff had been employed. Frethey House DS0000064474.V253028.R01.S.doc Version 5.0 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; 17; and 18. A complaints procedure is made available to service users to allow them to raise any concerns. All service users were registered to vote in local elections. Systems in place to reduce the risk of harm or abuse to service users were robust. EVIDENCE: A complaints register is maintained and the inspector was advised that the home had received three complaints since July 2005. Evidence was seen that the complaints had been appropriately investigated and acted upon in line with the homes complaints procedure. No complaints or concerns have been received by the CSCI regarding the home. Service users consulted knew who to talk to should they have any concerns and the complaints procedure forms part of the service user guide, which is available in each bedroom. Comment cards received all indicated that service users knew who to raise any concerns with. The POVA list is now operational. Systems in place were robust see NMS 29. Frethey House DS0000064474.V253028.R01.S.doc Version 5.0 Page 15 Staff spoken to at inspection were aware of the steps to take should they suspect any form of abuse. Policies and procedures were in place and brought to the attention of staff during induction. The management have also purchased a video training package on the protection of vulnerable adults, which will form part of the on-going training for staff. Comment cards received and those service users spoken to all indicated that they felt safe at the home. Frethey House DS0000064474.V253028.R01.S.doc Version 5.0 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; 20; 2; 22; 23; 24; 25; and 26 Service users live in a homely, clean environment where they can enjoy the privacy of their own bedrooms or socialise in communal areas. EVIDENCE: The environment was well maintained and complied with the local fire and environmental health department. The home is set in a quiet but central position in Bishops Hull. It is a large house set on two floors. There is a passenger lift to all floors. There are well-maintained, very pleasant grounds and gardens around the home and these are accessible by wheelchair. On assessment of at least eight of the thirty bedrooms it was noted that they were furnished and decorated to a high standard. They were personal to the individual service user, homely and clean. Service users and relatives spoken to at the inspection were pleased with their rooms. Frethey House DS0000064474.V253028.R01.S.doc Version 5.0 Page 17 The main lounge and dining areas were homely and clean and the present providers are planning to extend communal space as part of the new extension planned to commence in January 2006. One further quiet room on the first floor can seat six comfortably. The first floor assisted bathroom has a parker type assisted bath. There is an assisted shower facility in a further bathroom. There are ample communal toilets. En suite facilities are available in the bedrooms. The home is accessible for people with all levels of mobility. There are handrails around all ground floor corridors and communal facilities to assist service users to maintain their independence. There is a passenger lift to all floors, and this is able to accommodate wheelchairs. There is a call bell system throughout the home. Infection control systems were in place to include the provision of aprons and gloves and hand washing facilities for staff. Domestic cover was adequate and this was evident by the cleanliness of the home at this inspection. The laundry facilities were adequate for the number of service users. There were sluicing facilities available. Frethey House DS0000064474.V253028.R01.S.doc Version 5.0 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; and 30. The home’s recruitment procedures for staff were robust and protected service users from the risk of abuse. The numbers and skill mix of staff were appropriate to meet the needs of current service users. Staff morale was good. Recorded evidence of induction and on-going training was good. EVIDENCE: Duty rotas were recorded and reflected the staff on duty at the time of the inspection. Copies were sent to the inspector as part of the inspection process. Service users and staff spoken to at inspection commented on how they felt the home was adequately staffed. At the time of this inspection 28 service users were residing at the home. The home appeared adequately staffed at the time of the inspection. Four staff recruitment files were examined and contents evidenced very good practice in regard to pre-employment checks for the protection of vulnerable adults. Frethey House DS0000064474.V253028.R01.S.doc Version 5.0 Page 19 81 of staff had gained an NVQ in care, which exceeds this standard. Staff spoken to confirmed the training they had received. One member of staff had been promoted to training officer for the care staff and was being trained to have the skills she will need including supervision training. Registered Nurses were on duty 24 hours a day evidencing that staff individually and collectively had the skills to deliver the care for the needs of the current service users. The inspector was informed that a new ‘Care Procedures’ was being developed to include training modules in line with Skills for Care. It was evident that induction begins on day one of employment; the induction checklist covers all aspects of the home, and health and safety mandatory training. An on-going rolling programme of training is given and evidence of this was seen in staff files examined. The individual staff sign records of training. Each member of staff is given an Employee Handbook on commencement. Staff spoken to at inspection confirmed that they had received mandatory training during their induction period. Staff appeared relaxed and happy on the day of inspection and told the inspector that they enjoyed working at the home. Service users complimented the staff group. It was noted at inspection that staff dynamics at the home needed addressing. This was discussed at inspection and the manager agreed and acknowledged that routines and who was working together would be monitored. Frethey House DS0000064474.V253028.R01.S.doc Version 5.0 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): 32; 33; 34; 35; 37 and 38. The manager designate with full support of the registered individual was effectively managing the home. 1:1 supervision of staff had not yet been implemented. The provider is financially viable and intends to improve and enhance the environment; staff provision and training, ensuring service users best interests and views are taken into consideration. Service users financial interests were protected by the systems in place. Policies and procedures sampled were up to date and in line with current legislation. The systems in place for ensuring the health and safety of service users and staff were good. Frethey House DS0000064474.V253028.R01.S.doc Version 5.0 Page 21 EVIDENCE: The registered manager had recently resigned at the time of this inspection. Susan Hull who was the deputy manager at the home had successfully been promoted to manager and has applied to be registered with the CSCI. The application is being processed. The provider informed the inspector that the ethos of management at the home was being reviewed to ensure it is being management as a team with administrative support. It was evident having spoken to staff and service users on the day of inspection, that the manager designate communicates a clear sense of direction, and leads the staff in a way that they understand. Service users and visitors were made aware of the inspection by a poster being displayed on the main notice board. Service user surveys had been distributed in July 2005 and returned for auditing. These enable the provider to act on any concerns raised. All were very complimentary of the homes provision of care. A suggestions book and notice board for service users and their representatives had been developed to gain further views, which were reviewed each week at a management meeting. A new telephone system was in place to improve communication within the home. The new providers showed the inspector and gave copies of their accounts to date, which evidenced a large investment in the home already. A current Employers Liability Insurance Certificate was displayed. All policies and procedures seen had been reviewed and updated in October 2005. All other records seen were in line with current legislation. There are plans to extend the home to provide a further ten beds and extra communal space and gardens. Site plans were displayed in the main hallway at the home for service users and visitors to view and comment on. A Newsletter, which is distributed and displayed for service users and visitors, includes any changes planned at the home. Staff are involved in the refurbishment of the home and their views were actively sought. Staff consulted confirmed this. Staff supervision and 1:1supervison was being developed at the home and will be reviewed at the next inspection. Staff meetings had been held at the home on 02/11/05.recorded minutes were seen. A service users meeting took place on 07/07/05 and a further meeting was planned for January 2006. Frethey House DS0000064474.V253028.R01.S.doc Version 5.0 Page 22 The home held monies for up to ten service users at the time of this inspection. Monies checked reconciled with the amounts recorded and receipts were kept for all transactions. All service histories were current. The fire records were examined, the home conducts weekly fire checks. The emergency lighting and fire equipment was last serviced on the 7/02/05. Emergency lighting was tested on a monthly basis. The Electrical Hard Wiring was checked May 2004. Gas servicing was completed on 25/10/05. Records indicated that staff attended regular fire training. There were a total of 39 accidents recorded since the last inspection. Accidents had been audited. COSHH records were maintained. There have been thirteen deaths at the home in the past 12 months. The home has informed the CSCI of any serious incidents. The kitchen was spotlessly clean and well organised and records required by legislation were up to date. Frethey House DS0000064474.V253028.R01.S.doc Version 5.0 Page 23 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 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 N/A 3 3 3 3 N/A 3 3 Frethey House DS0000064474.V253028.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? NA 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 Standard OP7 OP8 Regulation 17(1)[a] 17(1)[a] Sch3 [n] 13(2) 12(3) Requirement Care plans must be completed in regard to personal care delivered and social needs. Nutritional Assessments and Wound care plans must reflect individual service users current care needs. Staff must follow the homes medication policy at all times. Staff must always address service users appropriately before moving and handling them and ensure they use correct techniques. Service users in the dining room needing assistance must not be left unattended at any time. Timescale for action 12/12/05 12/12/05 3 4 OP9 OP10 30/11/05 30/11/05 5 OP15 12(3) 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Frethey House DS0000064474.V253028.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Frethey House DS0000064474.V253028.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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