Inspection on 06/09/06 for Frethey House

This inspection was carried out on 6th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 15/11/05

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 Kathy McCluskey Key Unannounced Inspection 6th September 2006 09:30 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.V304259.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V304259.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Frethey House Address Frethey Lane Bishops Hull Taunton Somerset TA4 1AB 01823 253071 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 Susan Hull Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Frethey House DS0000064474.V304259.R01.S.doc Version 5.2 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 15th November 2005 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 included in the maximum numbers of 30, 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. Since the last inspection the CSCI have approved an application for Susan Hull to be the registered manager. The home has 30 single bedrooms at present all with en-suite facilities. A rolling programme of refurbishment is well underway with many bedrooms already upgraded. Work is underway 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. The home has been awarded the ‘Quality Rating’ by Social Services. Social Services currently have a contract with the home for 16 of the home’s beds. Frethey House DS0000064474.V304259.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Key inspection was carried out in line with the CSCI framework ‘Inspecting for Better Lives 2’. This unannounced key inspection was conducted over one day (8hrs) by CSCI Regulation Inspector Kathy McCluskey. The registered manager Sue Hull and registered providers Mr and Mrs Wilmott were available throughout the inspection. At the time of the inspection 24 service users were living at the home and eight were spoken with in depth. The inspector also met with a number of staff. A tour of the premises was carried out where communal areas and the majority of bedrooms were seen. Records were examined relating to service users, staff, medicines and health and safety. The inspector would like to thank service users, staff, the registered manager and providers for their time and cooperation with the inspection process. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. As part of this key inspection CSCI comment cards were sent to service users, relatives/visitors, GP’s and other professionals. Comments received about the home were positive. Service users stated that they felt well cared for and were treated well by staff. Service users also stated that they felt safe at the home. Comments received from relatives/visitors were also positive. All indicated that they were satisfied with the overall care provided and that they were kept well informed of important matters. Some comments included: ‘the quality of care is second to none’, ‘we are always made to feel very welcome and part of the home’, ‘there is an ongoing process of improving care and standards which is reflected in the small details always apparent’ and ‘the staff do a wonderful job’ Six comment cards were received from Health and Social Care professionals and again, comments were positive. All stated that the home communicated clearly and worked in partnership with them and that they were satisfied with Frethey House DS0000064474.V304259.R01.S.doc Version 5.2 Page 6 the overall care provided to service users. Other comments included; ‘the care at this home is of a good standard’, ‘I find the carers very caring’. Three comment cards were received from GP’s and responses were positive. All indicated that the home communicated well and worked in partnership with them, that medication was appropriately managed and that they were satisfied with the overall care provided to service users. Other comments included; ‘a caring and responsive home’. What the service does well: Frethey House ensures that no service user moves to the home unless their needs have been fully assessed. Because the home wants to be sure that the needs of a prospective service user can be fully met, emergency admissions are avoided. This is felt to be positive. The home also ensures that prospective service users have all the information they need to enable them to make an informed choice about moving to the home. Service users spoken with during the inspection were very positive about the way in which the manager and staff ensured that their move to the home was managed in a caring and sensitive manner. Those spoken with confirmed that they had been given lots of information prior to moving to Frethey House and that they had been able to make an informed choice. The home also goes to great lengths to ensure that relatives/representatives have the support they need. Frethey House is set in a peaceful location on the edge of a village. The centre of Taunton is only a few miles away. The home provides a very comfortable and homely environment. Service users are accommodated in single bedrooms with en-suite toilet facilities. The home takes appropriate steps to ensure the health and safety of service users, staff and visitors. The home has appropriate aids and adaptations to meet the needs of service users. The home maintains care plans for each service user, which clearly reflect individual’s needs. The home promotes a ‘person centred’ approach to care and care plans reflect the preferences of service users and their input. Frethey House DS0000064474.V304259.R01.S.doc Version 5.2 Page 7 Service users spoken with were very positive about the care they received. All stated that they felt their needs were met and that staff respected their privacy and dignity. All stated that they felt safe at the home and commented on the kindness of the staff. One comment received from a GP was that Frethey House was ‘a caring and responsive home.’ On a CSCI comment card, a relative stated that ‘the quality of care is second to none’. The home ensures that the health and social needs of service users are met. The home has good links with healthcare professionals. An activities co-ordinator is employed and a varied programme of activities is available which includes group and one to one sessions and trips out. A hairdresser visits the home weekly. Many service users were enjoying this facility on the day of the inspection. The routines at the home are dictated by service users. Service users spoken with informed the inspector that they chose how and where to spend their day, what time they got up in the morning and what time they went to bed. The views of service users are sought through regular meetings. The home have also recently set up a committee group which is made up of service users and relatives. This group meet regularly with the management team. Service users and relatives indicated that any issues are acted upon promptly. Staff at the home collectively have the skills and knowledge to ensure that the assessed needs of service users are met. Regular training is available and encouraged. 80 of the care staff team have achieved a minimum of an NVQ level 2 in care. Staff spoken with were very positive about the training and support they received. The home is effectively managed. The registered manager promotes an open and inclusive style of management and is committed to providing high standards of care. The registered providers are also very much part of life at the home and are also committed to raising standards at Frethey House. One service user spoken with described life at the home as ‘like living in a 5 star hotel.’ A comment received from a relative was ‘there is an on-going process of improving care and standards which is reflected in the small details apparent’ Since taking over the home a year ago, the registered providers have introduced a major programme of refurbishment. Many bedrooms have benefited from redecoration, new furniture, new carpets and curtains. En-suite facilities have also been upgraded and redecorated. Major building work is well underway and this will provide increased communal facilities for service users, additional bedrooms and improvements to existing facilities. Service users spoken with did not express concerns about the building work and were looking forward to their new facilities. The registered manager and providers have taken steps to ensure that any disruption to service users and staff is minimised. The management team have also ensured that everybody has been kept fully informed. Frethey House DS0000064474.V304259.R01.S.doc Version 5.2 Page 8 One comment received from a relative/visitor was, ‘throughout the building works facilities have been restricted but the staff have maintained a high level of care and good humour throughout’. The home provides a wholesome and varied menu. Special diets are catered for and choices are always available. Service users spoken with were very positive about meals at the home. 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.V304259.R01.S.doc Version 5.2 Page 9 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.V304259.R01.S.doc Version 5.2 Page 10 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. Standard 6 is not applicable as the home is not registered to provide intermediate care. The quality for this outcome group is excellent. The home ensures that prospective service users have the information they need to make an informed decision about moving to the home. The home’s arrangements for ensuring that the assessed needs of prospective service users can be met are very good. Staff have the skills to ensure that the assessed needs of service users can be met. 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, this also includes a copy of the home’s last CSCI inspection report. These documents are also displayed at the home for visitors to peruse. Both Frethey House DS0000064474.V304259.R01.S.doc Version 5.2 Page 11 documents are made available to prospective service users and/or their representatives. Information made available to the inspector indicated that the homes current fee range is between £485 and £775 per week. Extra charges met by service users are; Dry cleaning, hairdressing, chiropody, dentist, private telephone installation and calls, newspapers and magazines, escort services to external appointments, some activities/outings outside of the home, personal toiletries, insurance of personal items, some medical products, personal shopping service, aromatherapist. The inspector spoke with two service users who had recently moved to the home and both were very positive regarding the information they had received before they had made a decision to live at the home. Service users confirmed that they had been provided with a contract/statement of terms and conditions. The registered manager is committed to ensuring that service users only move to the home if they are sure that the individuals needs can be fully met. The registered manager visits prospective service users in their home or hospital and conducts a full assessment. This was also confirmed by the two most recent service users. Evidence of pre-admission assessments were seen in care records examined. The registered manager also obtains assessments from other professionals where available. Where appropriate, prospective service users and their representatives are invited to visit the home to ensure that they are happy with the facilities/services available. Because the home is committed to ensuring that it can fully meet the assessed needs of prospective service users, emergency admissions are avoided. Admission will only be offered if a full assessment has been carried out. This is felt to be positive. Although Social Services currently have a contract with the home for 16 beds, it is the registered manager who is responsible for ensuring that service users are only offered admission if the home can meet the individuals needs. The first month of admission is considered a trial period. This is to ensure that all parties are satisfied that the home is able to meet the individuals assessed needs. This was confirmed by the two most recent admissions to the home. Service users spoken with were very positive about the care they received at Frethey House and stated that they felt their needs were fully met. Service users were positive about the staff stating that they were kind and very caring. Frethey House DS0000064474.V304259.R01.S.doc Version 5.2 Page 12 The home has sufficient specialist equipment to meet the needs of service users and the home has been suitably adapted. Frethey House DS0000064474.V304259.R01.S.doc Version 5.2 Page 13 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 The quality for this outcome group is excellent. The home takes appropriate steps to ensure that the assessed needs of service users are met. The rights and wishes of service users are respected and the home promotes a person centred approach to care. The home’s arrangements for the management and administration of medication is good. Service users are treated with respect and their right to privacy is upheld. The wishes of service users during their final days and following death are respected. Staff ensure that service users and their families are treated in a sensitive and respectful manner. EVIDENCE: Three service user care plans were examined in detail. All contained the information needed to ensure that the heath and social needs of the individuals are met. It was positive to note that the home makes all attempts to obtain Frethey House DS0000064474.V304259.R01.S.doc Version 5.2 Page 14 information about the individual’s social history. Evidence of this was seen in the care plans examined. Care plans were well maintained and had been reviewed monthly. Assessments had been completed relating to the prevention of pressure sores, reducing the risk of falls, moving and handling needs and nutrition. Any specialised equipment in use was identified. Care plans were person centred, contained detailed information on the assessed needs of the individual and clear instructions for staff on how needs should be met. Care plans demonstrated input from the service user and identified any preferences they had. Staff record informative entries during the day and night relating to the health and well being of the service user. Nine CSCI comment cards were received from service users and all indicated that they felt well cared for. Service users spoken with during the inspection were very positive about the care they received and commented on the kindness of staff. During the inspection, staff were observed interacting with service users in a kind and respectful manner. The home takes appropriate steps to ensure that the healthcare needs of service users are met. All service users are registered with a GP and have access to other healthcare professionals. Evidence of this was seen in the care plans examined. The home has recently arranged for a GP to hold a clinic at the home on a monthly basis. CSCI comment cards were received from 3 GP’s and 6 health and social care professionals. Comments were positive and all indicated that the home provided a good standard of care and liaised closely with them. The home monitors service users weights on a monthly basis to ensure that prompt action can be taken to address any concerns. Staff follow the correct procedures for the management and administration of service users medication. Medicines are only administered by the registered nurse on duty and the inspector was able to see evidence that they had received recent ‘update’ training. The home uses the monitored dosage system for medicines (MDS) with preprinted medication administration records (MAR). MAR charts were examined and were found to be appropriately completed. All medicines were seen to be securely stored. Oxygen was appropriately stored and warning signage was in place. Frethey House DS0000064474.V304259.R01.S.doc Version 5.2 Page 15 The home’s procedures relating to controlled drugs and for the receipt and destruction of medicines were good. Daily temperatures are recorded for the drugs fridge and for the room storing the medicines to ensure that temperatures remain within acceptable ranges. Service users informed the inspector that they were treated with respect by staff and that their privacy was respected. Service users stated that personal care needs were met by staff in a kind and sensitive way. During the inspection, the inspector noted that staff were very professional and caring in their approach. Where service users required assistance with a task, the inspector heard staff explaining to service users how they would assist them. The rights and wishes of service users were respected. The inspector was able to see evidence that the home takes steps to ensure that the wishes of service users during their final days and following death are respected. Individual’s are supported to document/communicate their wishes so that this can be placed within their care plan. A selection of cards were seen from the relatives of some service users who had spent their final days at the home. Comments were very positive about the very sensitive care and attention given to their relative and of the support given to the family during and following the death of their loved one. Frethey House DS0000064474.V304259.R01.S.doc Version 5.2 Page 16 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 The quality in this outcome group is excellent. The home provides service users with a varied programme of activities and takes steps to ensure that the wishes and preferences of service users are met. Service users are given the opportunities and support to exercise choice and control over their lives. Visitors are made very welcome at the home. Service users are offered a choice of nutritious well-balanced and varied menus promoting their health and well-being. EVIDENCE: During the inspection, the atmosphere in the home was very calm and relaxed. Service users who were able, were observed moving freely around the home. Service users spoken with informed the inspector that they choose how and where to spend their day. Some service users are dependant upon staff to move/mobilise and staff were heard offering those service users choices throughout the day. Frethey House DS0000064474.V304259.R01.S.doc Version 5.2 Page 17 The home employs an activities co-ordinator and a wide range of activities are available to service users. The activities co-ordinator informed the inspector that she ensures that ‘nobody is forgotten’. She acknowledged that group activities are not appropriate for everybody so one to one sessions are also offered. The activities co-ordinator takes steps to ensure that service users are fully involved in choosing what activities are offered and that they are meaningful. The home currently has a poetry group and scrabble group, which is thoroughly enjoyed. Some service users were also keen to show the inspector various things they had made. The home produces an activities calendar for service users along with a monthly newsletter. These are also displayed on the service users notice board. Trips out are provided each month and the home hires a wheelchair accessible minibus for this. Recent trips have included the local flower show, Willow Centre and Garden Centres. One service user is looking forward to their planned trip to a local cricket match. The home has regular fund raising events and all money raised is used to benefit service users. Service users spoken with during the inspection were positive about the activities available at the home. In line with the preferences/wishes of service users, the home welcomes visitors at any reasonable time. Service users choose where to see their visitor and can use the privacy of their bedroom if they wish. No visitors requested to see the inspector during this inspection though six CSCI comment cards were received from relatives/visitors. Comments were very positive. All stated that they were made to feel welcome at any time and could see their relative in private. All indicated that they were kept well informed of important matters. The home holds regular meetings for service users and relatives and also has ‘resident committee’ meetings where a selection of service users and relatives/visitors meet with the management team. Service users were positive about the meals offered at the home. Service users informed the inspector that ‘there is always plenty to eat’, ‘the food is excellent’, ‘the staff always ask you what you would like’. All meals are freshly prepared at the home using fresh produce. A four week menu was made available to the inspector. The menu appeared wholesome and varied. The main meal is enjoyed at lunch time with a lighter hot or cold option at tea time. There are two options for each meal plus omelettes and Frethey House DS0000064474.V304259.R01.S.doc Version 5.2 Page 18 salads are available in addition. This was confirmed by service users and was evident on the day of the inspection. The menu is clearly displayed and service users are also provided with their own copy. Fresh drinks were available in communal areas and all bedrooms viewed. Fresh fruit was also seen to be available. As the home is currently undergoing major building work to improve facilities for service users, the lounge is currently used as the dining area at meal times. Although space is restricted, the inspector was impressed at how this was being managed with very little impact on service users. Lunch was enjoyed in a calm and relaxed atmosphere. The meal looked appetising and was served from a hot trolley by kitchen staff. Soft diets were attractively presented. The inspector observed staff assisting service users in a respectful and unhurried manner. The kitchen was not examined at this inspection but was inspected by Environmental Health on 25th June 2006. No concerns were raised. Work is well underway to improve/extend the current catering facilities. Frethey House DS0000064474.V304259.R01.S.doc Version 5.2 Page 19 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 The quality for this outcome group is excellent. The home has a complaints procedure in place and ensures that appropriate action is taken to address any concerns. The home has appropriate systems in place to reduce the risk of harm or abuse to service users. EVIDENCE: The home has an appropriate complaints procedure in place. All service users spoken with informed the inspector that they did not have any concerns or complaints and stated that they felt confident in raising any concerns if they had any. Six CSCI comment cards were received from relatives/visitors and all stated that they were aware of the home’s complaints procedure. One comment included that ‘concerns are always acted upon promptly.’ Records maintained by the home indicated that 3 complaints had been received since the last inspection (Nov ’05). The inspector was able to see that these had been appropriately investigated and acted upon in line with the home’s complaints procedure. Frethey House DS0000064474.V304259.R01.S.doc Version 5.2 Page 20 No complaints have been raised directly with the CSCI though the inspector was involved in a meeting following concerns raised by and NHS professional. Concerns were fully investigated by the manager and provider and the outcome of the meeting was that the concerns were not upheld and that the home had taken appropriate action. The legal rights of service users are respected. All service users are currently registered to vote. The inspector was informed that there were no service users currently using the services of the advocacy service though the home would support individuals to access this service if required/requested. The home takes appropriate steps to reduce the risk of harm or abuse to service users. Staff are aware of the home’s whistle blowing policy. Frethey House DS0000064474.V304259.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 The quality in this outcome group is good. Service users live in a comfortable and homely environment, which is currently being improved. Service users are accommodated in single bedrooms, which have their own ensuite toilet facilities. Service users are encouraged to personalise their rooms. Sixteen bedrooms have been refurbished/redecorated to a high standard. Service users have access to a range of specialised equipment. The home’s arrangements for reducing the risk of the spread of infection are good. EVIDENCE: Frethey House is a large detached period property set in its’ own grounds. The home is peacefully located in the countryside on the outskirts of the village of Frethey House DS0000064474.V304259.R01.S.doc Version 5.2 Page 22 Bishops Hull. The centre of Taunton is only a few miles away. Bishops Hull is on a bus route and has a post office, small shops, pubs and a church. Accommodation is arranged over two floors and a shaft lift gives access to the first floor. All service users are accommodated in single occupancy bedrooms which have en-suite toilet facilities. The home currently has an adequate number of assisted bathing facilities. The home has been suitably adapted to meet the needs of service users. Grab rails are appropriately sited. A nurse call system is installed throughout the home. The home has a good supply of specialist equipment which includes hoists and other moving and handling aids and pressure relieving equipment. Since taking over the home, the providers have replaced beds to ensure that all service users have an appropriate adjustable bed. The current owners, Mr and Mrs Wilmott have owned the home for one year and since taking over, have made many improvements to the environment. As previously mentioned, major building work is nearing completion and will provide additional communal facilities for service users to include a spacious lounge with kitchenette and an additional smaller lounge/library. The existing lounge will become the dining room. The kitchen will be extended and improved facilities will be available for staff. The improvements will also increase storage. There are also plans to provide additional bedrooms. Plans are displayed in the home and the owners and manager have ensured that service users, staff and relatives have been kept fully informed of the developments. The owners and manager are very sensitive to the impact that the building work has on service users and staff and have taken steps to minimise any distress or disruption. Service users spoken with were very positive about the improvements and did not express concerns about noise or disruption. Staff morale appeared very good and no concerns were expressed. One comment received from a relative/visitor was; ‘throughout the building works, although facilities have been restricted, the staff have maintained a high level of care and good humour throughout’. Apart from the major building works, improvements have been made to existing facilities. All bedrooms and en-suites are to be completely refurbished to include redecoration, new furniture, new carpets, curtains and bedding. Sixteen bedrooms have already been completed and work was continuing during the inspection. Bedroom doors are also being fitted with appropriate locks which can be overridden by staff in the case of an emergency. Keys will be available to service users to enable them to lock their rooms if they choose. Frethey House DS0000064474.V304259.R01.S.doc Version 5.2 Page 23 The inspector noticed an old barrel type lock on one bedroom door, which the provider agreed to remove the next day. All windows are in the process of being replaced with double glazed units. The home has large gardens for which there are plans to have professionally landscaped on completion of the building works. Parking facilities are very good. A selection of bedrooms and communal facilities were seen at this inspection. Service users informed the inspector that they liked living at the home and liked their bedrooms. One service user described life at the home as ‘like living in a 5 star hotel’. All areas of the home seen were very clean and free from malodours. The inspector was able to see evidence that service users were encouraged to personalise their bedrooms. All bedrooms are fitted with lockable space for service users to store their possessions. The home takes appropriate steps to reduce the risk of the spread of infection. Notices are displayed for visitors and hand washing facilities are appropriately sited throughout the home. Staff have access to a good supply of protective equipment/clothing. Frethey House DS0000064474.V304259.R01.S.doc Version 5.2 Page 24 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 quality in this outcome group is excellent. The needs of service users are met by a committed staff team who have been appropriately trained. The home ensures that the numbers on staff on duty reflect the needs of service users. The home’s procedures for obtaining references for prospective employees need improving. EVIDENCE: The home benefits from a stable and committed staff team who have been appropriately trained. At the time of this inspection staff morale appeared very good. A four week staff duty rota was made available to the inspector. Suitably qualified registered nurses are on duty 24 hours a day. On the day of the inspection two registered nurses were on duty in addition to the registered manager. During the morning five carers were on duty this changes to between four and five during the afternoon. Nights are covered by a registered nurse and two care staff. Staffing levels appear more than adequate as the home currently only has 24 service users. Frethey House DS0000064474.V304259.R01.S.doc Version 5.2 Page 25 In addition to nursing and care staff, the home employs administrators, activities co-ordinator, kitchen staff, laundry staff, domestics and maintenance staff. The registered manager works in addition to the nursing and care staff on duty. Staff and service users spoken with did not express any concerns about the number of staff on duty. Service users stated that their needs were met and staff said that they felt well supported and that Frethey House ‘was a lovely place to work’. Staff informed the inspector that they offered many training opportunities. Staff training records examined confirmed that staff had received up to date mandatory training. Training has included; moving and handling, first aid, infection control, fire safety, safe management and administration of medicines, nutrition, diabetes, syringe driver management, parkinsons disease, oral health, caring for the dying. 80 of the care staff team have achieved a minimum of an NVQ level 2 in care. The home is in the process of arranging further NVQ’s for staff. On commencing employment, staff undergo a period of induction. Detailed records of induction training were seen in staff recruitment records examined. Three staff recruitment records were examined and procedures were discussed with the providers and registered manager. Although the home generally follows robust recruitment procedures which includes CRB and POVA first checks, it was noted that although two references had been requested, only one written reference had been received for one staff member. Although a risk assessment had been completed and this ancillary staff member did not work unsupervised, the home must ensure that two satisfactory references are received prior to staff commencing employment. Where there are difficulties/delays in receiving written references, a the home should seek and record a verbal reference in the interim. Frethey House DS0000064474.V304259.R01.S.doc Version 5.2 Page 26 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, 32, 33, 34, 35, 36, 37 and 38 The quality for this outcome group is excellent. The home is effectively managed by a manager who promotes an open and inclusive style of management. The home is pro-active in seeking the views of service users, staff and other stakeholders. The home takes appropriate steps to ensure the health and safety of service users, staff and visitors. EVIDENCE: Since the last inspection the CSCI have approved an application for Sue Hull to be registered manager. Frethey House DS0000064474.V304259.R01.S.doc Version 5.2 Page 27 Sue is a registered general nurse with many years experience in caring for older people. Sue has worked at the home since 1993 and took up the post as acting manager in November last year. She is currently working towards the Registered Managers Award and has kept her clinical skills and knowledge up to date through various appropriate training courses. The registered manager is supported by a deputy manager and very supportive providers. During the inspection and through discussion with staff and service users, it was very apparent that Sue has a very good knowledge as to the needs and preferences of service users. Service users stated that they found her very approachable and always willing to listen. Service users indicated that any concerns would be acted upon promptly. Comments received from relatives and health care professionals were also very positive. Staff were very positive about the registered manager and providers and stated that they were very supportive. Sue promotes an open and inclusive style of management. This was confirmed by service users and staff. Regular meetings are held and a committee, made up of service users and relatives, has been recently set up. The members meet on a regular basis with the management team. Minutes of all meetings were viewed at this inspection. The home is pro-active in seeking the views of service users and other stakeholders. Quality questionnaires are sent out on twice yearly. The inspector was able to view a selection of completed questionnaires which had been completed in July of this year. Comments were very positive. The home also seeks the views of potential service users. Some service users moved to the home and some did not. All comments were very positive. The home has appropriate employers liability insurance and the providers made the home’s capital expenditure report available to the inspector. This demonstrated a commitment to on-going investment into the home. The home manages small amounts of money on behalf of a small number of service users where requested. Appropriate records are maintained with receipts available. Balances were not checked at this inspection. On examination of staff records, the inspector was able to see that staff had received a recent annual appraisal. Staff supervision records will be examined at the next inspection. Frethey House DS0000064474.V304259.R01.S.doc Version 5.2 Page 28 All records seen at the inspection were well maintained, up to date and stored in accordance with the Data Protection Act 1998. A tour of the premises was carried out and the following records were examined relating to Health and Safety; FIRE SAFETY – The home has a detailed fire risk assessment dated 07/02/06 which was completed by an external agency. The home maintains records relating to weekly in-house tests on the home’s fire detection and fire alarm systems. Monthly checks are made on the emergency lighting systems. Annual servicing is carried out by an external agency on all fire detection and fire fighting equipment. This was last carried out on 28/07/06. All staff have received up to date training in fire safety. EQUIPMENT SERVICING – Servicing records were examined. All equipment relating to moving and handling are serviced every six months. Hoists and mechanical baths were last serviced 22/08/06. Wheelchairs were last serviced on 16/07/06. GAS SAFETY – The home has an up to date annual Landlords Gas Safety certificate dated 25/10/06. ELECTRICAL SAFETY – Portable appliance testing was found to be up to date. Appliances were last checked in February, March and April of this year. The home has an up to date Electrical Hardwiring Certificate. To ensure the safety of service users, radiators are guarded, wardrobes are secured to the wall and upstairs windows are fitted with a restrictor. During the inspection it was noted that the decorator had left the restrictors off of one upstairs window and one wardrobe. This was brought to the attention of the manager and providers at the time who took action to address. It was noted that cleaning materials in two bathrooms were not stored in a locked cupboard. These were immediately removed by the manager and the registered provider stated that appropriate locks would be fitted the next day. All other cleaning materials were stored in accordance with COSHH requirements. Frethey House DS0000064474.V304259.R01.S.doc Version 5.2 Page 29 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 4 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 4 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 4 3 3 3 3 3 Frethey House DS0000064474.V304259.R01.S.doc Version 5.2 Page 30 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP29 Regulation 19(1) & Schedule 2.5 Requirement The registered person must ensure that staff do not commence employment until two satisfactory written references have been received. Timescale for action 15/09/06 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.V304259.R01.S.doc Version 5.2 Page 31 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.V304259.R01.S.doc Version 5.2 Page 32 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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