CARE HOMES FOR OLDER PEOPLE
Friarn House Residential Care Home 35 Friarn Street Bridgwater Somerset TA6 3LJ Lead Inspector
Kathy McCluskey Announced Inspection 31st January 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 Friarn House Residential Care Home DS0000050730.V271637.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Friarn House Residential Care Home DS0000050730.V271637.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Friarn House Residential Care Home Address 35 Friarn Street Bridgwater Somerset TA6 3LJ 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) 01278 445115 Mr John Whitehouse Mrs Estelle Louise Josephine Whitehouse Mr John Whitehouse Care Home 16 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (0) of places Friarn House Residential Care Home DS0000050730.V271637.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Registered for 16 persons in Categories DE(E) and OP Work to be carried out by 31st December 2005 to provide an assisted bathroom where the bath can be accessed from three sides. 13th September 2005 Date of last inspection Brief Description of the Service: Friarn House is a large terraced house situated in Bridgwater and is within easy access of the town centre and local facilities. The home has a good sized enclosed garden. Parking is limited to the surrounding streets. Friarn House is registered with the Commission for Social Care Inspection to provide personal care for up to 16 service users over the age of 65 years, who require care by means of old age or dementia. The home is not registered to provide nursing care. The registered providers are Mr and Mrs Whitehouse. The registered manager is Mr Whitehouse. Friarn House Residential Care Home DS0000050730.V271637.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This announced inspection was conducted over one day (4.5hrs) by CSCI Regulation Inspector Kathy McCluskey. The registered provider/manager Mr John Whitehouse and deputy manager Mr Alan Farkas were available throughout the inspection. At the time of this inspection fifteen service users were living at the home and the inspector was able to meet with the majority of service users and all staff on duty. Staff and service users were welcoming and helpful. All communal areas of the home were seen along with a selection of bedrooms. Records were examined relating to staff, service users and health and safety. Three completed CSCI comment cards were received from healthcare professionals. The inspector would like to thank the service users, staff and management 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. What the service does well:
Friarn House provides older people, who have dementia, with a safe, comfortable and homely environment. The home is located just a few minutes from the town centre. Since taking over the home over 2 years ago, the provider/manager has implemented a major programme of refurbishment and redecoration. Many areas of the home have already been improved and the programme is ongoing. These improvements have had a positive outcome for service users. The standard of cleanliness at the time of this inspection was high and there were no malodours. Domestic staff are employed. Prospective service users and/or their representatives are provided with the information they need to enable them to make an informed choice about moving to the home. The home takes appropriate steps to ensure that the assessed needs of prospective service users can be met. Appropriate Friarn House Residential Care Home DS0000050730.V271637.R01.S.doc Version 5.0 Page 6 documentation is maintained and prospective service users are invited to visit the home prior to making a decision. The home has established excellent links with appropriate healthcare professionals who provide regular support to the home. Three completed CSCI comment cards were received from G.P’s and a district nurse. These indicated that they were satisfied with the care provided by the home. The home’s care planning systems are clear and consistent. Appropriate risk assessments are completed. Friarn House offers service users a varied programme of activities. Where ever possible the home obtains social histories for individuals. Links with the local community are encouraged. The home ensures that additional staff time is allocated for activities. Staff spoken with informed the inspector that they always had time for ‘quality time’ with service users. This was evident at the time of this inspection. Service users benefit from a stable staff team who are provided with a good range of appropriate training including NVQ’s. The home does not use agency staff. Staff morale is high and this has a positive outcome for service users. Service users who were able to express a view commented on the kindness of staff. The inspector was able to unobtrusively observe interactions between staff and service users. Interactions were noted to be kind and respectful. The atmosphere was relaxed and staff assisted service users in an ‘unhurried’ manner. The provider/manager and the deputy manager promote an open and inclusive style of management where the views of service users, staff and visitors are encouraged and responded to. Staff spoken with stated that Friarn House was a ‘nice place to work’. All were very positive regarding the support they received and training opportunities available to them. Service users are provided with a wholesome and varied diet. The home makes good use of local fresh produce and meats. Service users spoken with were very positive about the quality and quantity of the food offered. The home takes appropriate steps to ensure the health and safety of service users, staff and visitors. What has improved since the last inspection?
As previously mentioned, the home continues with its planned programme of refurbishment and redecoration.
Friarn House Residential Care Home DS0000050730.V271637.R01.S.doc Version 5.0 Page 7 Since the last inspection the lounge and at least three bedrooms have been completely redecorated and fitted with new carpets and curtains. New doors have been fitted to en-suite toilets that previously had only the provision of curtains/sliding doors. The laundry has been relocated upstairs and work is well underway to provide a level access shower room on the ground floor. This is expected to be completed by the end of February. The commitment of the registered provider/manager to improve the environment since taking over the home has had a positive outcome for service users. There were no requirements or recommendations raised at 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. Friarn House Residential Care Home DS0000050730.V271637.R01.S.doc Version 5.0 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 Friarn House Residential Care Home DS0000050730.V271637.R01.S.doc Version 5.0 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. Standard 6 is not applicable as the home is not registered to provide intermediate care. Prospective service users are provided with the information they need to enable them to make an informed choice about moving to the home. The home’s procedures for assessing prospective service users are good. EVIDENCE: The home has produced a Statement of Purpose and Service User Guide. Both documents are available to service users, prospective service users and/or their representatives. The Statement of Purpose and Service User Guide detail the services offered by the home. The home’s current fee range is between £328 and £440 per week. Fees are determined by the assessed needs of the individual. Friarn House Residential Care Home DS0000050730.V271637.R01.S.doc Version 5.0 Page 10 Extra charges are met by service users for chiropody treatment, hairdressing, magazines/newspapers. The provider/manager takes appropriate steps to ensure that the needs of prospective service users can be met by the home. Prospective service users are fully assessed by the manager or the deputy, who will visit the prospective service user in their home or hospital. Assessments from other relevant health care professionals are obtained where available. Evidence of the home’s pre-admission assessments and other healthcare assessments were seen in the care records of the two most recent service users. Prospective service users and/or their representatives are invited to visit the home to meet staff and other service users. Day visits are also offered. Admission will only be offered if the home is sure that the assessed needs of the individual can be met. Examples were given to support this. The first four weeks of admission is considered a trial period. The home avoids emergency admissions and will only consider if they are able to conduct a pre-admission assessment first. This is felt to be positive. Once admission has been agreed, service users are issued with a copy of the home’s contract/statement of terms and conditions and, where appropriate, a copy of Social Services Financial agreement. Friarn House Residential Care Home DS0000050730.V271637.R01.S.doc Version 5.0 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 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 home’s care planning systems are clear and consistent and the home takes appropriate steps to ensure that healthcare needs are fully met. The home’s procedures for the management and administration of medication is generally good, though some improvements are needed. Service users are treated with respect. EVIDENCE: Care records for the two most recent service users were examined at this inspection. Care plans seen clearly identified the individual’s assessed needs and, instructions for staff on how needs should be met were clear and informative. Social/life histories are obtained for service users where ever possible and care records clearly identify individual’s preferences, likes, dislikes and hobbies. Friarn House Residential Care Home DS0000050730.V271637.R01.S.doc Version 5.0 Page 12 Appropriate assessments were seen in the care plans examined relating to moving and handling needs and reducing the risk of pressure sores. Risk assessments were seen relating to the risk of falls. Service users weight is monitored monthly. Records were seen. The inspector was informed that there were no service users suffering with pressure sores. The inspector was able to see evidence that the home takes appropriate steps to ensure that individual’s healthcare needs are met. All service users are registered with local G.P’s and the home confirmed excellent support from G.P’s and district nurses. The home also has very good support and input from mental health professionals. A community mental health liaison nurse visits the home on a monthly basis. At the time of this report, completed CSCI comment cards had been received from a visiting G.P and district nurse. Both indicated that they were happy with the provision of care offered at the home. The home takes appropriate steps to ensure that the preferences of a service user following death are respected. Records are maintained. The home’s procedures for the management and administration of medication were examined and were found to be well-maintained. The home uses the Monitored Dosage System (MDS) with pre-printed medication administration records (MAR). Medicines were seen to be appropriately stored with no excessive stock levels. MAR charts were appropriately completed and contained photos of service users and a list of staff signatures authorised to administer medicines. A sample of controlled drugs were checked and were found to be correct. The home is currently administering paracetamol as required to a small number of service users. The need to obtain written confirmation from the individual’s G.P for the administration of ‘homely’ remedies was discussed with the provider at the time of the inspection. The home needs to ensure that any spoiled or refused medicines are stored and returned to the pharmacy in line with its procedures for the management and administration of medication. The provider/manager and the senior staff member on duty confirmed excellent support from the pharmacist. Staff responsible for the administration
Friarn House Residential Care Home DS0000050730.V271637.R01.S.doc Version 5.0 Page 13 of medicines confirmed that they had received appropriate and up to date training. During the inspection, staff were observed interacting with service users in a kind and respectful manner. The atmosphere was relaxed. Interventions were unhurried. To ensure the privacy of service users, bathroom/toilet and bedroom doors are fitted with a lock which can be accessed by staff in the case of an emergency. Screening is available in the shared bedroom. Friarn House Residential Care Home DS0000050730.V271637.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Service users benefit from a varied programme of activities. Service users are supported to exercise choice and control over their lives. The home offers a varied and wholesome menu which utilises fresh produce. EVIDENCE: Since the last inspection, the home’s activities co-ordinator has left employment. Service users still benefit from a range of activities on a daily basis and a member of staff is allocated for this role. Service users recently enjoyed a visit from a harpist and story teller. On the day of the inspection, service users were enjoying a stimulating activity which promoted hand/eye coordination and provided gentle exercise. Some service users were enjoying having their hair done. Service users were also looking forward to dancing and music in the afternoon. The home has a varied programme of activities in place. The preferences of services users is taken into account and records relating to hobbies and interests were seen to be recorded in the care plans examined.
Friarn House Residential Care Home DS0000050730.V271637.R01.S.doc Version 5.0 Page 15 One service user informed the inspector that that they had recently enjoyed a trip into the town where they and another service user joined the local library. The inspector was informed that the home plans to have more outings from the Spring. The home shares a wheelchair accessible minibus with its sister home. The home welcomes visitors at any reasonable time in accordance with the wishes of service users. Service users choose where they see their visitors and are able to have the privacy of their own bedroom if they so wish. Service users are supported and encouraged to choose how and where to spend their day. On the day of this inspection, service users were observed moving freely around the home. Service users can access their bedrooms whenever they choose. All meals are cooked freshly at the home. The inspector was able to meet with the cook during the inspection. A four week menu was seen. Meals appeared varied and wholesome. Service users spoken with at the inspection were positive about the food and stated that there was ‘always plenty to eat’. Fresh meat, vegetables and fruit are delivered to the home weekly. On the day of the inspection, service users enjoyed a lunch of beef hotpot, two fresh vegetables and potatoes. The sweet was a fruit crumble. The kitchen appeared clean and well organised. There was a good stock of food which was appropriately stored. Friarn House Residential Care Home DS0000050730.V271637.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home takes appropriate steps to reduce the risk of harm or abuse to service users. The home has an appropriate complaints procedure in place. EVIDENCE: The home has a satisfactory complaints procedure in place. The inspector was informed that no complaints have been received by the home in the last 12 months. No concerns have been raised directly with the CSCI. Those service users able to express a view informed the inspector that they would raise any concerns with the management or staff. Staff spoken with during the inspection did not raise any concerns and were aware of action to be taken where required. The home is taking appropriate steps to reduce the risk of harm or abuse to service users. A whistle Blowing Policy is available and the home has policies relating to abuse. All service users are registered to vote.
Friarn House Residential Care Home DS0000050730.V271637.R01.S.doc Version 5.0 Page 17 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 on-going improvements in the home’s environment have a positive outcome for service users. Service users live in a comfortable and homely environment. Service users have comfortable bedrooms which they are encouraged to personalise. The home is clean and free from malodours. EVIDENCE: Friarn House, although not purpose built, appears suitably adapted to meet the needs of service users. Accommodation is arranged over two floors. Access to the first floor is via two stair cases. One is fitted with a stair lift. The home would not be conducive to those service users who required a wheelchair to mobilise.
Friarn House Residential Care Home DS0000050730.V271637.R01.S.doc Version 5.0 Page 18 The home has a very pleasant and well maintained garden with seating for service users during the summer months. Since taking over the home over 2 years ago, the provider/manager has implemented a major programme of refurbishment and redecoration. Much work has already been done and the programme is on-going. The major improvements already carried out have had a positive outcome for service users and staff. Since the last inspection, the outside of the home has been painted, the lounge has been redecorated and has been fitted with new carpets and curtains and three further bedrooms have benefited from complete redecoration/refurbishment. Doors have been fitted to previous screening/curtains on en-suite toilets. The inspector was able to see evidence that one bedroom had been completed redecorated with new curtains and carpet following feedback from a visitors quality questionnaire. Since the last inspection, work has been completed to relocate the laundry area to make way for a level access shower room. This is expected to be completed by the end of February. The provider/manager should be commended for his commitment to improving the standard of the environment for service users. Service users have access to a very comfortable dining area, good size lounge and pleasant conservatory. A small ‘quiet’ room is also available to service users and visitors. The home currently has 3 bathrooms, 1 of which is located on the ground floor. Two baths are fitted with seats. As previously mentioned, work is nearing completion on a level access shower room. The home has 14 single bedrooms, 11 of which are fitted with en-suite toilet facilities and 1 double bedroom, which also has an en-suite toilet. All bedrooms are fitted with a wash hand basin as a minimum. A selection of bedrooms were seen at this inspection and it was evident that service users are encouraged to personalise their rooms. All bedrooms seen were beautifully decorated and furnished. Service users who were able to express a view informed the inspector that they liked their rooms. A nurse call system is sited throughout the home. On the day of this inspection, all areas of the home seen were very clean and free from malodours.
Friarn House Residential Care Home DS0000050730.V271637.R01.S.doc Version 5.0 Page 19 The home takes appropriate steps to reduce the risk of the spread of infection. Staff handwashing facilities are appropriately sited throughout the home. Friarn House Residential Care Home DS0000050730.V271637.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Service users benefit from a stable and motivated staff team who receive appropriate training. Staff morale is high and this has a positive outcome for service users. The home follows good staff recruitment procedures though further improvements are needed. EVIDENCE: The home benefits from a stable staff team. Staff morale was noted to be high. This was confirmed by staff spoken to and through observation. The home does not use agency staff. Staff spoken with at the inspection did not express any concerns about staffing levels. Staff confirmed that they always had time to spend ‘quality time’ with service users. This is very positive. 3 carers are on duty between 0800hrs and 1400hrs, 2 between 1400 & 1800hrs and 2 carers from 1800 – 2200hrs. Nights are covered by 1 waking & 1 sleep-in staff. The provider/manager and the deputy manager work in addition to the care hours provided and also provide on-call cover.
Friarn House Residential Care Home DS0000050730.V271637.R01.S.doc Version 5.0 Page 21 Staff stated that they felt very well supported and had good training opportunities. As raised at the last inspection, staff again described Friarn House as a ‘nice place to work’. The provider/manager appears committed to staff training and has purchased a training package for staff. The provider/manager and staff informed the inspector that this was providing useful information for staff. Staff are encouraged to undertake NVQ training. This was confirmed by a staff member who is currently undertaking an NVQ level 3 in care. The home maintains a staff training matrix and the inspector was able to see evidence that staff had received up to date mandatory training. The home follows appropriate recruitment procedures. Recruitment records for the most recent employee were examined at this inspection and were found to contain all information as required in Schedule 2 of the Care Homes Regulations 2001. The provider/manager was advised to ensure that systems were in place to verify the authenticity of references applied for by a recruitment agency. Friarn House Residential Care Home DS0000050730.V271637.R01.S.doc Version 5.0 Page 22 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 Service users and staff benefit from an open and inclusive style of management. Staff are appropriately supervised and the home is run in the best interests of service users. The home takes appropriate steps to ensure the heath and safety of service users, staff and visitors. EVIDENCE: The registered provider/manager is Mr John Whitehouse. Mr Whitehouse has been the owner/manager of the home since November 2003. Mr Whitehouse is currently undertaking the NVQ4 awards in Care and Management and the NVQ assessor’s award, D32/33.
Friarn House Residential Care Home DS0000050730.V271637.R01.S.doc Version 5.0 Page 23 Mr Whitehouse holds current certificates in first aid, manual handling, infection control, food hygiene, management & administration of medication and certificates in dementia care. He also has an NVQ3 in promoting independence. Mr Whitehouse is supported by his deputy, Mr Alan Farkas. Mr Whitehouse and Mr Farkas provide 7 days a week cover to the home. Staff confirmed that the provider/manager promotes an open and inclusive style of management. Staff confirmed excellent support from Mr Whitehouse and Mr Farkas. Both the provider/manager and the deputy manager are very much ‘hands-on’ and both demonstrated a good knowledge of the needs of service users at the home. Meetings are held on a regular basis for staff with minutes maintained. The views of service users are sought on a ‘day to day’ basis as formal meetings are not felt to be appropriate. The last staff meeting was recorded as 20/01/06. The inspector was able to see evidence that staff had received regular supervision sessions and that appropriate topics, including training needs, had been discussed. The inspector was able to sample a selection of completed quality questionnaires which had been sent out by the home to service users and visitors/families. Comments were noted to be very positive and, as previously mentioned in this report, the home had responded to one relatives request for a bedroom to be decorated. The inspector was informed that the home does not currently manage any monies on behalf of service users. FIRE SAFETY – The home conducts weekly checks on the home’s fire detection systems and monthly checks on emergency lighting. Records were seen. Fire detection systems and fire fighting equipment are serviced by an outside contractor on an annual basis. This was last done in February 2005. Staff training appeared up to date with the last training conducted on 20/01/06. The home has also recently introduced an annual fire awareness questionnaire for staff. ELECTRICAL SAFETY – The home’s portable appliances (PAT) are tested annually. This was last carried out in December 2005. The home has an up to date electrical hardwiring certificate. GAS SAFETY – The home’s last annual gas safety check was conducted on 28/01/06. Friarn House Residential Care Home DS0000050730.V271637.R01.S.doc Version 5.0 Page 24 ACCIDENTS – The home maintains appropriate records for all accidents. All accident records were seen to be appropriately stored in accordance with the Data Protection Act 1998. The manager analyses accidents monthly and takes appropriate action where required. Results seen were unremarkable. HOT WATER OUTLETS/SURFACES – The home maintains records of monthly checks on all hot water outlets. Records seen indicated that bath hot water outlets were within HSE recommended limits. All bath hot water outlets have been fitted with thermostatic controls. EQUIPMENT SERVICING – The home has two stair lifts. Servicing records seen indicated that these were last serviced on 06/01/06. The home’s 2 bath hoists and 1 mobile hoist were serviced on 27/01/06. - Nurse Call bells are checked in-house on a weekly basis. - To ensure the safety of service users, all upstairs windows are restricted, radiators covered and any free standing wardrobes are secured to the wall. - The home has a qualified first aider on every shift. Friarn House Residential Care Home DS0000050730.V271637.R01.S.doc Version 5.0 Page 25 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Friarn House Residential Care Home DS0000050730.V271637.R01.S.doc Version 5.0 Page 26 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 OP9 Regulation 13(2) Requirement The registered person must ensure that correct procedures are followed for the disposal of spoiled/refused medicines. The registered person must ensure that systems are in place to confirm the authenticity of references supplied by a recruitment agency. Timescale for action 27/02/06 2 OP29 19 27/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations The registered person should ensure that written confirmation is obtained from service users G.P’s for any homely remedies to be used. Friarn House Residential Care Home DS0000050730.V271637.R01.S.doc Version 5.0 Page 27 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
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