Inspection on 09/09/08 for Frethey House

This inspection was carried out on 9th September 2008.

CSCI found this care home to be providing an Poor service.

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

Frethey House 06/09/06

Frethey House 15/11/05

Extracts from inspection reports are licensed from CQC, this page was updated on 26/11/2008.

CARE HOMES FOR OLDER PEOPLE Frethey House Frethey Lane Bishops Hull Taunton Somerset TA4 1AB Lead Inspector Kathy McCluskey Key Unannounced Inspection 9th September 2008 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.V370089.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.V370089.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) frethey@caringhomes.org www.caringhomes.org Affirmative Care Ltd Manager post vacant Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places Frethey House DS0000064474.V370089.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate up to 41 persons from the age of 60 years who require nursing care (OP). May accommodate up to three persons from the age of 50 years who require nursing care. 6th September 2006 Date of last inspection 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 41 people not less than 60 years of age, who require general nursing care. The home is not registered to provide care to people whose primary care needs are for their dementia or mental health needs. Affirmative Care Ltd has owned the home since July 2005, in January 2008 the Commission were informed that the major share of the company had been sold. The Responsible Individual is now Susan Murphy. The home has been without a registered manager since 1st July 2008 when the post holder resigned from the post. In January 2007, the Commission approved an application for the home to increase its registered numbers from 30 to 41. We were informed that the home’s current fees are between £570 & £775 per week. Extra costs include; hairdressing, personal items/toiletries, chiropody and escorts for appointments. Full details about the home’s fees/costs should be obtained from the home. Frethey House DS0000064474.V370089.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. The focus of this inspection visit was to inspect relevant key standards under the Commission’s ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service for each outcome group under four general headings. These are; - excellent, good, adequate and poor. This unannounced key inspection was conducted over one day (8hrs) by CSCI regulation inspector Kathy McCluskey. One of the company’s peripatetic managers and an acting manager were available throughout this inspection. We were given unrestricted access to all parts of the home and records requested for this inspection were made available to us. The home submitted their Annual Quality Assurance Assessment (AQAA) to the Commission within agreed timescales. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. Information has been included in this report where appropriate. We sent surveys to a number of people who use the service, staff working at the home and healthcare professionals to seek their views on the quality of the service provided. We received completed comment cards from 6 people using the service and 1 member of staff. Comments have been included in this report as appropriate. We would like to thank all concerned 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. Frethey House DS0000064474.V370089.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Nine statutory requirements were raised as a result of this inspection and one of the requirements was also raised at the last key inspection. We made seven good practise recommendations. The registered person needs to make arrangements to ensure that the home is effectively managed in the absence of a registered manager, as the current arrangements are insufficient. Frethey House DS0000064474.V370089.R01.S.doc Version 5.2 Page 7 The home need to ensure that care plans are up to date and fully reflective of individuals’ assessed needs to enable staff to meet peoples’ needs. Improvements are needed to ensure that people’s nutritional needs are monitored and met as care plans and procedures in place did not demonstrate that effective measures were in place. The home’s procedures for the management of wounds requires improvements because the care plan examined contained no reference to when the plan would be reviewed and from the records available, it was difficult to map the effectiveness of the current plan/treatment. It has been strongly recommended that the home reviews the assessed needs and dependency levels of all people currently using the service to ensure that staffing levels are appropriate during the day and night. The home’s procedures for staff recruitment do not fully protect people from the risk of harm or abuse. A serious concern letter was sent to the registered person following the inspection. The home’s arrangements for ensuring the health and safety of persons at the home require some improvements. We were unable to see evidence that the temperature of bath hot water outlets were being checked at least monthly to reduce the risk of scalding. Up to date servicing certificates were not available for the home’s shaft lifts and wheelchair lift. 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. The summary of this inspection report can be made available in other formats on request. Frethey House DS0000064474.V370089.R01.S.doc Version 5.2 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 Frethey House DS0000064474.V370089.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 3. Standard 6 is not applicable as the home is not registered to provide intermediate care. Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. The home has produced a Statement of Purpose and Service User Guide which provides people with information about the home and services offered. The home carries out assessments on anybody who is thinking about using the service to ensure that the home can meet their needs. EVIDENCE: A revised Statement of Purpose was submitted to the Commission earlier this year. The Statement of Purpose and Service User Guide provide people at the home and those thinking about moving there, with information about the home and services offered. Frethey House DS0000064474.V370089.R01.S.doc Version 5.2 Page 10 During this inspection we noted that these documents were available in all bedrooms viewed and in the reception area of the home. Six people living at the home completed comment cards for the Commission and five confirmed that they had received enough information about the home before they moved in. On examination of care plans we were able to see evidence that people had been appropriately assessed before they had been offered a placement at the home. The home obtains assessments from other healthcare professionals where available. Frethey House DS0000064474.V370089.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The home need to ensure that care plans are up to date and fully reflective of individuals’ assessed needs. Improvements are needed to ensure that people’s nutritional needs are monitored and met. The home’s procedures for the management of wounds requires improvements. Appropriate procedures are followed for the management and administration of peoples’ medication. EVIDENCE: During this inspection we examined four care plans. Care plans contained a comprehensive range of assessments but we found that care plans had not Frethey House DS0000064474.V370089.R01.S.doc Version 5.2 Page 12 been reviewed at least monthly and that care plans were not always reflective on individuals’ assessed needs. We looked at one care plan for a person who had on-going weight loss since April 2008. We found that the care plan had not been reviewed since 10/05/08 and subsequently the plan of care in place was not reflective of the person’s current needs. It could therefore not be ascertained what action was being taken to address their nutritional needs. Another care plan, also relating to a person with on-going weight loss, had not been reviewed since April 2008. We were able to see that staff were recording the person’s dietary intake, but no review had taken place and the person continued to loose weight. The acting manager was unable to confirm whether the home’s chef was made aware of any concerns regarding weight loss or what measures were in place to increase the calorific value of meals. We examined a care plan for a person who had developed a pressure sore at the home. This contained information about the size and status of the wound and of the frequency of dressings/treatment. Running records contained insufficient information about the effectiveness of the treatment or of the status of the wound. The majority of entries, over almost a two-month period, contained a statement; ‘wound cleaned and dressed’. There was no reference to when the plan would be reviewed and from the records available, it was difficult to map the effectiveness of the current plan/treatment. A third care plan had been reviewed in September 2008, but prior to that had only been reviewed in April and May 2008. We discussed our findings with the acting manager and company manager at the time of the inspection and requirements have been raised. Care plans did contain some information about the preferences of individuals’ and the home’s completed AQAA identifies that person centred planning/care is an area that they have marked for improvement. It also states that in the next 12 months, the home plans to provide staff training in person centred care. Two people we spoke with during the inspection were ‘not sure’ if the home were aware of their preferences. One person said that ‘they had never been asked’. Staff make daily entries for each person. We noted that these only identified the tasks that had been performed by staff and did not provide any information as to the well being of individuals. A recommendation has been raised. Six people using the service completed comment cards for the Commission. In response to the question; ‘Do you receive the care and support you need?’, four responded ‘Always’ and two ‘Usually’. All confirmed that they received the medical support they needed. We received a comment card from a member of staff who felt that there were ‘sometimes’ enough staff to meet people’s needs. During the inspection we spoke to three members of staff. Staff indicated that they could meet people’s ‘basic care needs’ but that it was ‘very rushed’. We were told that there had Frethey House DS0000064474.V370089.R01.S.doc Version 5.2 Page 13 been occasions where people could not be assisted with a bath due to ‘staff shortages’. Feedback was discussed with the acting manager and company manager at the time of the inspection and findings are detailed in Standard 27. People we spoke to at the inspection told us that the staff were ‘kind’ and that they were treated with ‘respect’. One person confirmed that they could request a female carer to assist them with personal care. During the inspection we heard staff communicating with people in a kind and respectful manner and we observed staff knocking on bedroom doors before entering. Two of the care plans examined contained an end of life plan that identified the individual’s preferences during their final days and following death. We were informed that these are being introduced for each person at the home. We looked at the home’s procedures for the management and administration of peoples’ medication. The home uses the Boots monitored dosage systems (MDS) with pre-printed medication administration records (MAR). We found all medicines to be securely stored. We sampled some MAR charts and found these to be appropriately completed. Protocols were in place for the use of ‘as required’ medication. Photographs of individuals had been attached to MAR charts to aid identification. The home follows the correct procedures for the receipt and disposal of medication. Correct procedures were being followed for the management and administration of controlled drugs. We noted that a number of vacutainers, which are used for blood samples, had exceeded their expiry date. This was brought to the attention of the acting manager at the time of the inspection who arranged for their disposal and for a new supply. As the home has large stocks of dressings and other items, it has been recommended that an audit system introduced so that expiry dates are regularly checked. Frethey House DS0000064474.V370089.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. The home has a varied activity programme available for people living at the home. Meals are freshly prepared at the home by the home’s catering staff and people are given the opportunity to express choice. EVIDENCE: We were informed that the home employs two activity co-ordinators who cover a 7 day period, 1000hrs – 1600hrs. A programme of activities was displayed in various areas of the home and was also available in the Service User Guide within people’s bedrooms. Activities planned for September included; one to one sessions, scrabble, reminiscence, art, flexercise, quiz, crafts, memory games, BBQ and music. An outside entertainer was also booked to provide music. We were informed that the home does not have its’ own minibus. Six people using the service completed comment cards for the Commission and in response to the question; ‘Are there activities arranged by the home that Frethey House DS0000064474.V370089.R01.S.doc Version 5.2 Page 15 you can take part in? 3 responded ‘Always’, 1 ‘Usually’ & 1 ‘Sometimes’. One responded not applicable. We spoke to a number of people during the inspection and all were positive about the range of activities and felt that the activity staff were ‘very good’. The home’s completed AQAA told us that the home can, ‘provide a specially adapted mobile phone with large display to allow residents to make calls from their bedrooms without assistance’ and ‘we provide a dedicated library for residents use with a changing selection of books provided by the library service’ People told us that their relatives were made to feel welcome when they visited. The home displays a range of information for visitors and the home’s completed AQAA states that the home ‘offers a warm welcome to visitors’ and that ‘visitors are encouraged to stay for meals’ and that ‘a coffee machine is provided in the lounge for visitors’ use’. The home displays a range of information for people living there and for visitors. This includes information on how to contact external advocates. Information is also available in the service user guide in peoples’ bedrooms. We were able to see that people were able to personalise their bedrooms. Some people had brought pieces of their own furniture. The home employs catering staff who cover a seven day period. All meals are freshly prepared at the home. People told us that choices were always available and that staff ask them on a daily basis what their preferences for the day are. During this inspection we were able to meet with the chef and observe lunch being served. The meal looked appetising and plentiful. We spoke to a number of people about the food and they told us the food was good and that there was ‘always plenty to eat’. The chef told us that he is given a satisfactory budget and that there are always food provisions available for people day or night. Six people living at the home completed comment cards for the Commission and in response to the question; Do you like the meals at the home?’, 4 said ‘usually’, 1 ‘sometimes’ and 1 ‘always’. People said that the meals were ‘improving’. Two people felt that there were ‘too many stews’. Frethey House DS0000064474.V370089.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. The home has satisfactory complaints procedures in place Procedures are in place to ensure that people are protected from the risk of harm or abuse. EVIDENCE: The home has a complaints procedure which is also included in the Service User Guide which is located in individuals’ bedrooms. Six people living at the home completed comment cards for the Commission and all confirmed that they knew how to make a complaint. We examined the home’s records relating to the five complaints they had investigated this year and we were able to see that these had been responded to within agreed timescales. One complaint was raised directly with the Commission regarding staffing levels at the home. This resulted in an additional random inspection, which was carried out by the Commission on 23rd April 2008. A copy of Somerset’s revised (May 2007) policy on Safeguarding Adults was made available to the managers at the time of this inspection and it has been strongly recommended that staff are made aware of the policy. Frethey House DS0000064474.V370089.R01.S.doc Version 5.2 Page 17 Training records indicated that all staff had received training in abuse in June 2008. The home has a range of satisfactory policies in place for staff to reduce the risk of harm or abuse to people. These include acceptance of gifts policy, restraint and whistle blowing. Frethey House DS0000064474.V370089.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. People live in a comfortable and well-maintained environment and they are able to personalise their bedrooms. The home has appropriate specialist equipment in place. The standard of cleanliness is good and the home has procedures in place to reduce the risk of the spread of infection. EVIDENCE: In 2007, the Commission approved an application for the home to increase its’ beds from 30 to 41. As part of this application, the Commission carried out a full site visit where all additional bedrooms and communal space were examined. Frethey House DS0000064474.V370089.R01.S.doc Version 5.2 Page 19 The large gardens were also landscaped and these now provide a range of pleasant areas for the people living there. The gardens are also accessible to people in wheelchairs. In the home’s completed AQAA, it stated that they also have plans for a sensory garden. The home has two passenger lifts and a wheelchair lift giving access to accommodation on the first floor. All areas of the home are fitted with a nurse call system and people are provided with a ‘pendant’ so that they can easily alert staff when needed. Grab rails are appropriately sited throughout the home and the home have an adequate supply of moving and handling equipment and all bedrooms have the provision of adjustable beds. All bedrooms are for single occupancy and all are fitted with en-suite toilet facilities as a minimum. We viewed a number of bedrooms and found them to be comfortably furnished, pleasantly decorated and well maintained. It was apparent that people are able to personalise their rooms. Bedrooms are fitted with locks, which can be overridden by staff in the event of an emergency. Bedrooms are also fitted with lockable storage. The home has appropriate procedures in place to reduce the risk of the spread of infection. Notices and cleansing gels are displayed for visitors and staff hand washing facilities are appropriately sited throughout the home. We saw that staff have access to good supplies of protective clothing. The home employs domestic staff who cover a seven day period. At the time of this inspection all areas viewed were clean and free from malodours. Frethey House DS0000064474.V370089.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home needs to ensure that staffing levels are appropriate to the assessed needs/dependency levels of people living at the home. The home’s procedures for staff recruitment do not fully protect people from the risk of harm or abuse. EVIDENCE: We were informed that 36 people were currently receiving nursing care at the home and that staffing levels were as follows; Morning – 2 registered nurses and 7 care staff Afternoon/evening – 1 registered nurse and 6 care staff. Nights – 1 registered nurse and 3 care staff. We were told that there are currently vacancies for 3 registered nurses and 4 care staff. The home is currently using agency staff to cover shortfalls. Interviews were taking place during the inspection. During this inspection we spoke to a number of people living at the home and three members of staff. Frethey House DS0000064474.V370089.R01.S.doc Version 5.2 Page 21 People living at the home commented on the kindness of staff; ‘I am very satisfied with all of the staff’. Six people completed comment cards for the Commission and in response to the question; ‘Are the staff available when you need them?’, 3 said ‘Always’, 2 ‘Usually’ and 1 ‘sometimes’. They also made the following comments; ‘Staffing levels are insufficient to respond quickly to everyone’s needs’. Staff told us that morale was ‘low’ and that ‘it is hard with so much agency use’. Staff indicated that there had been occasions where there had only been 5 care staff during the morning and that this had resulted in staff not being able to assist people with baths. Staff also stated that they did not have time for ‘quality time’ with people. The home’s completed AQAA told us that 10 people were ‘bedfast’ and that 34 required two or more staff to help with their care during the day and at night. We noted that a high number of people required nursing in bed and staff spoken with confirmed that dependency levels were ‘high’. During this inspection we noted that people in bed looked clean and comfortable. The Commission conducted an additional inspection at the home in April of this year to look into concerns raised with us about staffing levels. Although no serious concerns were identified, it was recommended that the home should consider the use of a dependency rating tool when adjusting staffing levels as these had been reduced when the company was taken over. It has been strongly recommended that the home reviews the assessed needs and dependency levels of all people currently using the service to ensure that staffing levels are appropriate during the day and night. The home’s completed AQAA stated that of the 25 permanent care staff employed, 14 have achieved a minimum of an NVQ level 2 in care. This equates to 56 , which exceeds the recommended 50 of the National Minimum Standards. We examined the home’s procedures relating to staff recruitment. We requested and examined the recruitment files for the three most recently employed staff and found that the home was not following robust procedures. One file contained only one written reference. A verbal reference from the previous employer had not been followed up with a written reference. Another file had no written reference from the previous employer and one reference was addressed ‘to whom it may concern’. There was no evidence that the home had applied for this reference or that its’ authenticity had been checked. There was no CRB check for one carer who, it was confirmed, was not being supervised whilst on duty. We discussed procedures with the person who had been responsible for staff recruitment and it was concerning that they had not been made aware of the requirements relating to an employee who was working on a POVAfirst check pending a CRB. Frethey House DS0000064474.V370089.R01.S.doc Version 5.2 Page 22 We also discussed this with the company manager who was present and she gave her assurances that action would be taken to ensure that the employee did not work unsupervised. Requirements have been raised and a serious concern letter has been sent to the company’s responsible individual. We requested and examined induction programmes relating to the three most recently employed staff. Induction programmes made available to us detailed only a basic one or two day in-house induction. We were not provided with evidence that staff are following an induction programme which meets with the Skills for Care Common Induction Standards. A recommendation has been raised. Frethey House DS0000064474.V370089.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Improvements are needed to ensure that the home is effectively managed in the absence of a registered manager. The home has an annual quality assurance programme in place which seeks the views of people using the service and their representatives. Procedures are in place to ensure that people’s financial interests are safeguarded. The home must ensure that systems are in place to ensure that staff are appropriately supervised. The home’s arrangements for ensuring the health and safety of persons at the home requires some improvements. Frethey House DS0000064474.V370089.R01.S.doc Version 5.2 Page 24 EVIDENCE: The home does not currently have a registered manager. The previous post holder left employment at the end of June 2008. We were informed that interim management arrangements would be put in place and that a named registered nurse would be appointed as ‘head of care’. During this inspection one of the company’s peripatetic managers was present and she advised that she was providing management support this week. Through discussion with the acting manager (head of care), it was confirmed that she did not have any management experience and, as previously highlighted in this report, was not fully aware of the requirements relating to staff recruitment. We also found that care planning procedures were below an acceptable standard. We were informed at this inspection that a new manager was due to take up post in October 2008. A requirement has been raised that the registered person ensures that appropriate management arrangements are put in place in the interim. When we spoke with staff during this inspection, they told us that they did not feel supported. We were able to see that meetings had been held for all staff. One staff member stated that they ‘don’t feel listened to’. Under the heading ‘what we do well’, in the home’s completed AQAA stated, ‘regular supervision sessions’ There was no evidence that staff had received formal supervision sessions. We looked at records relating to seven staff and this identified that six staff had received their first supervision session of the year in September. One person’s last supervision was recorded as December 2007. Staff spoken with stated that they had no had any supervision sessions this year. Staff should receive formal supervision sessions at least six times a year. A recommendation has been raised. The home as a quality assurance programme in place. We were informed that questionnaires are sent out to people using the service and relatives on an annual basis. The results of the most recent surveys dated May 2008 were noted to be positive. The company has appointed a responsible individual who is responsible for conducting monthly unannounced visits in accordance with the Care Homes Regulations 2001. We requested the reports in relation to the monthly visits and were provided with reports for March, April, June and July 2008. In line with the requirements of this regulation, the registered person must ensure Frethey House DS0000064474.V370089.R01.S.doc Version 5.2 Page 25 that visits are conducted on a monthly basis and that reports are available at the home. We were informed that the home does not manage any money on behalf of the people living there. We were told that people and/or their representatives were invoiced on a monthly basis for any additional costs incurred and that receipts were supplied. We were also informed that the home does not act as financial appointee for any person using the service. We examined some of the home’s procedures for ensuring the health and safety of persons at the home. We also toured the premises. The findings are as follows; FIRE SAFETY – Records indicated that systems and equipment had been serviced by an external contractor on 20/08/08. Records indicated that the home tests fire alarm systems on a weekly basis. It has been recommended that records detail the zone checked. Records demonstrated that monthly checks are carried out on the home’s emergency lighting systems. Staff training records indicated that all staff had received fire training in August 2008. The home has a fire risk assessment in place though this was not examined at this inspection. ELECTRICAL SAFETY – Records showed that annual testing on portable appliances was last carried out on 09/01/08. GAS SAFETY – The home has an up to date annual landlords gas safety certificate dated 09/10/07. EQUIPMENT SERVICING – six monthly servicing certificates were available for mobile and fixed hoists. Servicing was last carried out on 08/07/08. The home were unable to locate up to date servicing certificates for the lifts. Records seen related to servicing last carried out on 18/01/08. It has been required that the home forwards the Commission up to date servicing records for the two shaft lifts and wheelchair lift. HOT WATER OUTLETS/SURFACES – To reduce the risk of scalding, hot water outlets have been fitted with thermostatic controls. As these devices are not fail safe, the home must ensure that hot water outlets on baths and showers are checked monthly to ensure that temperatures do not exceed Health & Safety Executive (HSE) safe upper limits. Records made available to us indicated that temperatures were last tested on 22/05/08. Radiators are fitted with a guard. We viewed records relating to in-house ‘weekly health and safety checks’. These had not been completed since July 2008. Frethey House DS0000064474.V370089.R01.S.doc Version 5.2 Page 26 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 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 4 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x 2 x 3 1 x 2 Frethey House DS0000064474.V370089.R01.S.doc Version 5.2 Page 27 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 OP7 Regulation 12(1) & 15(1) & (2)(b) Requirement The registered person must ensure that care plans are up to date and are fully reflective of individuals’ assessed needs. (care plans should be reviewed at least monthly) The registered person must ensure that appropriate action is taken where there are concerns about any weight loss of an individual. Consideration should be given to consulting with a dietician. The registered person must ensure that effective procedures are in place for the management of pressure sores. Consideration should be given to the use of tracings or photographs. Timescale for action 17/10/08 2. OP8 12(1)(a)& (b) 17/10/08 3. OP8 12(1)(a)& (b) 17/10/08 Frethey House DS0000064474.V370089.R01.S.doc Version 5.2 Page 28 4. OP29 19(1) & Schedule 2.5 The registered person must ensure that staff do not commence employment until two satisfactory written references have been received. Previous timescale of 30/04/08 not met. One reference should be from the most recent employer. 10/09/08 5. OP29 13(6), 19 & Schedule 2 (7) The registered person must not 10/09/08 allow an employee to work unsupervised pending a full CRB check. ( A documented risk assessment should be in place to demonstrate that employees are aware of the restrictions imposed on them and to identify the supervision arrangements) The registered person must make arrangements for the home to be managed by a person competent to do so. The registered person must ensure that the responsible individual makes monthly visits to the home in accordance with this regulation. Copies of the reports must be made available at the home. The registered person must provide the Commission with up to date servicing records for the home’s two passenger lifts and wheelchair lift. The registered person must ensure that bath and shower hot water outlets are checked at least monthly to ensure that temperatures do not exceed HSE safe upper limits. 06/10/08 6. OP31 8(1)(a) & 9(2)(b)(i) 26(3) & 4 7. OP33 06/10/08 8. OP38 13(4) 13/10/08 9. OP38 13(4) 06/10/08 Frethey House DS0000064474.V370089.R01.S.doc Version 5.2 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP7 OP9 OP18 OP27 Good Practice Recommendations Entries in daily record sheets should contain information as to the well-being of individuals, rather that just identifying the tasks that staff have performed. An audit system should be introduced to ensure that expiry dates on dressings and other items are regularly checked. It is strongly recommended that staff are made aware of Somerset’s Safeguarding Adults Policy (May 2007) It is strongly recommended that a suitably skilled person reviews the assessed needs and dependency levels of all people using the service to ensure that current staffing levels are appropriate to their needs both during the day and night. The registered person should ensure that newly appointed staff follow an induction programme which meets with the Skills for Care Common Induction Standards. To ensure that staff are appropriately supported, the registered person should ensure that staff receive formal supervision sessions at least six times a year. The registered person should ensure that records relating to in-house fire alarm tests include information regarding which zone has been tested. 5. 6. 7. OP30 OP36 OP38 Frethey House DS0000064474.V370089.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V370089.R01.S.doc Version 5.2 Page 31 - 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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