Inspection on 19/07/06 for Friars Hall Nursing Home

This inspection was carried out on 19th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Friars Hall Nursing Home 11/07/07

Friars Hall Nursing Home 27/02/06

Friars Hall Nursing Home 12/05/05

Friars Hall Nursing Home 07/01/05

Friars Hall Nursing Home 02/06/04

Friars Hall Nursing Home 16/02/04

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

CARE HOMES FOR OLDER PEOPLE Friars Hall Nursing Home Friars Road Hadleigh Suffolk IP7 6DF Lead Inspector Jane Higham Unannounced Inspection 19th July 2006 09.55 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 Friars Hall Nursing Home DS0000024393.V304761.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. Friars Hall Nursing Home DS0000024393.V304761.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Friars Hall Nursing Home Address Friars Road Hadleigh Suffolk IP7 6DF 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) 01473 822159 01473 822682 Mrs Lalitha Samuel Mrs Laura A Hampson Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places Friars Hall Nursing Home DS0000024393.V304761.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 27th February 2006 Brief Description of the Service: Friar’s Hall is a privately owned care home providing both nursing and personal care to a maximum of 42 older people. The home is located on the outskirts of the small market town of Hadleigh, where amenities such as shops, pubs, church and post office are available. Buses run from the town centre to Ipswich, Colchester and Sudbury towns. The home stands in it’s own grounds at the end of a long gravel drive. It has a car parking area, a garden with some seating for service users and a staff residence where nurses from overseas can be accommodated while they completed adaptation courses to allow them to practice in the United Kingdom. The building is a converted and extended Victorian house, dating back to 1858, with a shaft lift giving access to both floors. There were 30 single bedrooms, 26 with en suite toilet facilities, and 6 double bedrooms (1 with en suite toilet). The premises have been under the current ownership for the last seventeen years. Friars Hall Nursing Home DS0000024393.V304761.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Unannounced Key Inspection of Friars Hall, a forty-two bedded nursing home for older people, situated in a rural area on the outskirts of the market town of Hadleigh. The inspection was carried out on 19 July 2006, over a period of eight hours. The key inspection focused on the care standards relating to Care Homes for Older People. The report has been written using accumulated evidence gathered prior to and during the inspection. Prior to the inspection, the home was provided with service user questionnaires to distribute. The Commission received thirteen questionnaires and information contained within these questionnaires has been included in this report. The National Minimum Standards and Care Homes Regulations 2001 are referred to throughout this report and any non compliance identified. All key standards were assessed as part of this inspection. The Registered Manager of the home was present throughout the inspection and assisted with the inspection process. The owner of the home also met with the Inspector and provided evidence that residents had been issued with placement contracts. The fees were stated as ranging from £359.00 to £640.00 per week. The Inspector had the opportunity to talk with both residents, visitors and members of staff who were on duty. What the service does well: The home has a detailed pre-admission assessment process to ensure that it will be able to meet the individual care needs of service users who come to live there. It is effectively and efficiently managed and all residents are issued with a placement contract. The home ensures that all residents have a care plan which is regularly reviewed and provides clear guidelines for staff on the level of support and interventions required by each person. Residents and family members are supported to make a complaint or raise concerns about the service through a detailed and robust complaints procedure. The home provides a very homely and welcoming atmosphere and accommodation is of a good standard. Staffing levels are appropriate to meet the individual needs of residents. Staff receive appropriate training, are competent and relate well to service users. Friars Hall Nursing Home DS0000024393.V304761.R01.S.doc Version 5.2 Page 6 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. Friars Hall Nursing Home DS0000024393.V304761.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Friars Hall Nursing Home DS0000024393.V304761.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 and 6 Prospective residents can expect to be provided with sufficient information on which to base a decision about whether they want to undertake a placement although the level of information provided did not necessarily comply with regulation. Prospective residents could also be assured that prior to admission a full assessment of their individual needs would be carried out. All residents could be assured that they would be issued with a placement contract and have an opportunity to “try out” the home. Service users could enjoy periods of respite care but the home does not provide intermediate care. Quality in this outcome area is adequate. This judgement has been made using evidence including a visit to the service. EVIDENCE: The home was able to evidence that it has produced a combined Statement of Purpose and Service User Guide in the form of a brochure which is provided to all newly admitted and prospective residents. This document sets out the services and facilities that the home aims to provide, is well presented and includes external and internal colour photographs. Examination has highlighted Friars Hall Nursing Home DS0000024393.V304761.R01.S.doc Version 5.2 Page 9 that not all the required details as set out in Schedule 1 of the Care Homes Regulations 2001 are included. These omissions are: The name and address of the registered provider The qualifications of the registered provider and the registered manager. The relevant qualifications and experience of staff. The age range of the service users for whom it is intended that the accommodation should be provided. The arrangements for consulting service users about the operation of the care home. For the purposes of the inspection, the inspector examined the documentation regarding the admission of four service users. In all four cases the service users had been issued with a contract which included the terms and conditions of placement. The contracts are not kept on the premises but in the possession of the registered provider. Contracts must be available for inspection and therefore it may be beneficial if these documents are retained on the premises. The four service users selected for the purposes of case tracking had all been admitted to the home within the last six months. In all four cases the home was able to evidence that a detailed pre-admission assessment had been carried out by the registered manager. In the case of one resident who had been placed via the local authority an assessment by the responsible social worker had been carried out in addition to that carried out by the manager. Pre-admission assessments were detailed in their content and provided a good basis from which an individualised care plan could be produced. The Manager was reminded that pre-admission assessments should be dated. The terms and conditions document states that the first four weeks of placement will be regarded as a trial period. Prospective residents and their families are encouraged to visit the home before a decision is made about whether they or their family member would wish to live there. Of the thirteen questionnaires returned to the Commission, all respondents confirmed that they or their family member had received sufficient information on which to base a decision about whether they wished to live at the home. All respondents also confirmed that they had been issued with a placement contract. The home’s Statement of Purpose states that the home offers short term care, including rehabilitation. The home infact offers short term care when it has a vacancy which has not been used for permanent care. Discussions with the Manager highlighted that rehabilitative care ie intermediate care is not offered as the home does not provide intensive physiotherapy and occupational Friars Hall Nursing Home DS0000024393.V304761.R01.S.doc Version 5.2 Page 10 therapy support. In order to offer intermediate care these services need to be secured otherwise this statement and the description within the Service User Guide need to be removed. Friars Hall Nursing Home DS0000024393.V304761.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Residents living at the home can expect to be provided with an individual plan of care, which is reviewed on a regular basis and for their health care needs to be fully met. Procedures for the administration of medication did not necessarily provide residents with the opportunity to continue to maintain control and self-administer. However, residents are protected by the home’s systems for the administration and storage of medication. Service users living at the home can expect to be treated with respect and that their privacy is respected. Quality is this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: For the purposes of the inspection, the individual care plans of the four most recently admitted resident were examined. All four care plans were well set out, user friendly and clearly identified areas of need where support ws required. These plans gave clear guidelines as to what interventions were required to ensure that individual care needs of residents were met. Evidence was clearly available to show that care plans had been reviewed monthly and amended where a change in need had occurred. Friars Hall Nursing Home DS0000024393.V304761.R01.S.doc Version 5.2 Page 12 Care plans and daily records examined evidenced that the general health needs of residents were being met. In the case of one resident the care plan file contained the nursing notes for the district nursing services who were visiting the home to dress a resident’s broken skin area. A care plan had been provided for another resident in relation to the care and maintenance of a catheter. All care plans seen contained a pressure area assessment and a mobility/moving and handling assessment. Evidence needs to be provided to confirm that these assessments are being reviewed as part of the care planning process. The home is well-supported by community GP services and records of GP visits to the home are contained within the residents daily notes. Paramedic services and physiotherapy services are attached to the local surgery. In addition to community health services, residents are offered support by trained nursing staff who are on duty at the home throughout the day and night. Of the thirteen service user questionnaires returned to the Commission, eleven respondents confirmed that they always received the care and attention they needed and two stated that this was usually received. On the day of the inspection, there were no residents responsible for the administration of their own medication. Standard 9.1 of the National Minimum Standards: Care Homes for Older People recommends that through a risk assessment process, residents are given the opportunity to retain control over their own medication. The home’s Service User Guide provides information about resident medication but states that “medication is administered by the trained designated staff on duty to meet the prescribed needs”. This statement does not offer residents the opportunity to retain control over their own medication on a risk assessed basis if desired and should be amended. Procedures for the administration and safe keeping of resident medication were examined and practice observed. Medications were stored in a fit for purpose medication trolley and were administered in an appropriate and secure manner. Medication is delivered to the home pre-dispensed via a monitored dosage system (blister packs) Medication Administration Records (MARS sheets) were completed correctly. There was some confusion as to the manner in which refused or “spoiled” medication was disposed of, although the home’s procedure gave clear guidelines on this. The Manager therefore needs to ensure that all staff responsible for the administration of medication have a clear knowledge on the way in which these medications should be disposed of. The home’s philosophy of care which is outlined as part of the Statement of Purpose, states that the provider will respect the privacy and dignity of service users making sure that in old age people residents are treated with positive attitudes. Thirty single bedrooms are provided and twenty-six of these are provided with ensuite facilities to enable maximum privacy. Bedrooms are fitted with appropriate door locks with an override device which allows staff members to gain access in the case of an emergency. Staff interactions with Friars Hall Nursing Home DS0000024393.V304761.R01.S.doc Version 5.2 Page 13 residents were observed to be respectful and staff were also observed knocking on the doors of resident’s rooms before entering. Friars Hall Nursing Home DS0000024393.V304761.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Residents living at the home can expect to be provided with a menu of meals which are both nutritious and varied. Residents can also expect to be supported to maintain contact with family and friends and to be provided with a range of activities which are appropriate to their needs, abilities and preferences. Residents were not necessarily consulted about their preferred daily routines. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The Inspector looked at the activities that were available for service users. Whilst there was no plan of activities, the home was able to evidence that a range of activities were provided. All activities offered were logged into an “activities book”. Recent activities offered included photography, painting, manicures and a church service. A member of the care staff has responsibility for the provision of activities and works on a supernumerary basis three times a week. The Manager advised that the other activities available to residents include singalongs, and arts and crafts. On the day of the inspection, the Inspector witnessed residents enjoying a gentle “keep-fit” session. Of the thirteen service user questionnaires returned to the Commission, only two Friars Hall Nursing Home DS0000024393.V304761.R01.S.doc Version 5.2 Page 15 respondents reported that they were not offered activities; one because they liked to maintain their privacy and the other respondent did not understand the question. The home’s Service User Guide states that there is an open visiting policy, although residents are requested to respect the privacy and dignity of other residents. On the day of the inspection, several residents were being visited by friends and family. It was clear from the inspection that residents were encouraged to make choices around what they would like for meals and to bring in personal possessions to make their own rooms look homely. However it was noted that individual care plans did not contain much information about individual personal preferences in relation to daily routines etc. As stated under Standard 9 of this report, residents at the present time are not giving the choice about whether they would wish to continue to self medicate. On the day of the inspection, the Inspector observed the mid-day meal being served to residents. The choices for this meal had been displayed on a chalk board and a member of care staff advised that residents had chosen their meal option the day before. Choices on the day comprised a cold meat salad or fish pie. Feedback from residents in relation to the quality of the meal were very positive. One resident reported that the food at the home was “bloomin marvellous”. Another resident reported that when they had come into the nursing home they were very frail and had no appetite but that the food was so good that they had put on weight. The meal was served pre-plated directly from the kitchen. At the end of the meal the chef came into the dining room and asked people whether they would like a second helping and several residents took up this option. It was good to note that the chef knew each resident by name and had a good rapport with them. The majority of residents were seated in the home’s dining room to enjoy their mid- day meal. The dining room had several small dining tables each seating about four or five people. It was noted that the way in which the meal was served meant that not all residents on a table were served at the same time, therefore some had finished their meal before others on their table were served. As mealtimes are a social event best practice would suggest that the serving of a meal should be arranged so that all residents on one table receive their meal at the same time. It was also noted that several of the resident group required assistance and encouragement with eating. Whilst staff were seen to be actively assisting some residents with their meal, some residents were not receiving the help and encouragement that they clearly required. To ensure that all residents receive the assistance with eating that they require it may be beneficial to have two sittings for the mid day meal. It was identified in the assessment of one resident that they required assistance with eating as they had a poor appetite. Staff at the home were monitoring the residents food intake by completing a food intake chart every day. Friars Hall Nursing Home DS0000024393.V304761.R01.S.doc Version 5.2 Page 16 Friars Hall Nursing Home DS0000024393.V304761.R01.S.doc Version 5.2 Page 17 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 and 18 Residents can expect to be provided with sufficient information to enable them to make a complaint or raise any concerns they may have about the service. The home’s policies and procedures contribute to the safeguarding of residents from abuse. Quality in this outcome are is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was able to evidence that it has a very detailed complaints procedure a copy of which is included as part of the Service User Guide, made available to each resident and their advocate(s). A copy of the complaints procedure is also displayed at various sites around the building and therefore accessible to all visitors to the home. The home has received few complaints but a log is maintained of all received complaints, their nature, the investigation undertaken, the outcome and the following actions. Since the previous inspection the Commission has received no complaints in relation to this service. Of the thirteen service user questionnaires returned to the Commission, six respondents confirmed that they always knew how to make a complaint, three indicated that they usually knew and one indicated that they sometimes knew. One respondent reported that they brought up any concerns they may have with the Manager on their weekly visit to the home, one reported that it was not necessary to complain and one left the question unanswered. Friars Hall Nursing Home DS0000024393.V304761.R01.S.doc Version 5.2 Page 18 Whilst the home was able to evidence that it has a procedure on the recognition and reporting of abuse, it did not have a copy of the local authority procedure for the reporting of suspected abuse. Information was provided to the Manager on where a copy of this procedure could be obtained. All staff receive training on the recognition and reporting of suspected abuse as part of the Skills for Care Induction Training package. Friars Hall Nursing Home DS0000024393.V304761.R01.S.doc Version 5.2 Page 19 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 - 26 Residents living at the home can expect to be provided with accommodation which is well maintained, clean, homely and appropriate to their needs and abilities. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Friars Hall is a Victorian building dating back to 1858 which has been extended to provide appropriate accommodation for older people. The building stands in three acres of well kept and attractive grounds which include a gazebo and water feature. On the day of the inspection which was exceptionally hot shaded areas were available within the garden for the use of residents. In addition to the main building there is a detached bungalow within the grounds offering accommodation to nursing staff from oversees who are working at the home. Friars Hall Nursing Home DS0000024393.V304761.R01.S.doc Version 5.2 Page 20 Accommodation is sited on two floors and level access is available throughout via a shaft lift. The home has 30 single bedrooms, 26 of which have ensuite facilities and six double bedrooms, one of which has the benefit of an ensuite. Communal areas consisted of two lounges, a large dining room and a conservatory. Communal areas were very pleasant, had been furnished comfortably and were maintained to a good standard of decorative order and repair. On the day of the inspection, the Inspector looked at a selection of resident rooms. In the newer part of the building bedrooms were of a high standard, very attractively furnished with good use of co-ordinating soft furnishings. Many of the rooms had been made to look very homely by the occupant with the addition of personal belongings, small items of furniture, photographs and paintings. Furnishings provided in the bedrooms located in the original part of the building were more worn and some items would benefit from replacement within the near future. All bedrooms had been provided with a remote controlled colour television. In addition to the ensuite facilities provided in a large proportion of the bedrooms, the home has adequate communal bath, shower and toilet facilities. It was noted that one communal bathroom with toilet, sited on the upper floor of the home, contained a broken toilet seat and exposed plaster and brick work around the cistern. Throughout the home, the standard of cleanliness was very good. It was noted that in one shared room on the first floor of the building, the door from the washbasin vanity unit was missing, so that personal toiletries were exposed as were rough edges presenting a health and safety risk. A melamine strip was missing from the unit exposing a porous surface which is likely to attract germs and bacteria. Of the thirteen service user questionnaires returned to the Commission, nine reported that the home was always clean and four reported that it was usually maintained to a good standard of cleanliness. Residents spoken to were very positive in their comments about accommodation provided. One visitor to the home commented that their family member’s room was really lovely. A resident commented on how much they liked their room as it had a double aspect and overlooked the attractive gardens. The family member of one resident commented that although they were happy with the accommodation provided, their parent occupied a shared room and had found it rather disconcerting as they had had three different “room mates” within a short period of time. The building was equipped with aids and adaptations to assist service users with poor and restricted mobility. It was noted that some bedrooms doors did not have a room number or name on the door which would assist residents with orientation problems to find their room. Friars Hall Nursing Home DS0000024393.V304761.R01.S.doc Version 5.2 Page 21 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 Residents living at the home are cared for by an appropriate number of staff to ensure that their needs are met. Residents can expect to be cared for by staff who have relevant qualifications and who are competent to carry out their roles and responsibilities. The home’s recruitment procedures do not fully ensure the protection of residents. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection, in addition to the Manager, the home was staffed during the morning by a Registered Nurse and seven members of care staff. This level decreases in the afternoon and evening to one trained nurse supported by five members of care staff. During the night period, residents are supported and cared for by one registered nurse and three members of the care staff. In addition to the nursing staff, the home employs a total of ten care staff one of whom has attained an NVQ Level 2 and 3, three who have attained an NVQ Level 2 and there are an additional two carers who are currently working towards an NVQ Level 2. During the inspection, the Inspector examined the personnel files of the three most recently employed members of staff. Two of the three staff were overseas nurses currently undertaking adaptation training. The most recently Friars Hall Nursing Home DS0000024393.V304761.R01.S.doc Version 5.2 Page 22 employed member of staff had been secured through an agency which specialises in providing adaptation training opportunities for overseas nurses. It was noted that whilst the agency had ensured that the staff member had two references supporting their placement at the home, these were addressed “to whom it may concern”. These were therefore not acceptable and should be provided directly in relation to the placement at the home and addressed either to the agency involved or to the manager of the home. Evidence was available to show that an Enhanced Disclosure had been obtained prior to the staff member commencing duties. It was noted that the second nurse, whilst not engaged through an agency, also had provided references supporting their placement which were addressed to “to whom it may concern”. It was also identified that this nurse had commenced duties prior to the confirmation of a POVA check being carried out. The third personnel file examined was that of a member of the care staff. Satisfactory references had been provided but the home had accepted an Enhanced Disclosure which had been carried out by a previous employer. To ensure the safety of residents the service must ensure that an application for an Enhanced Disclosure is made for each person who is employed by the service and that disclosures are not regarded as portable. The Manager was in the process of producing an overall training record for staff which provided an audit trail of what training had been undertaken by each staff member. This document was nearing completion. The home was able to evidence that all newly employed staff are provided with the Skills for Care Induction Training package, which includes all areas of mandatory training ie moving and handling, basic food hygiene and infection control. At the time of the inspection, five trained nurses and a housekeeper were about to undertake the appointed persons First Aid training. Five staff members were undertaking a distance learning course on health and safety at a local college. The Manager of the home has achieved the Registered Manager’s Award and two members of the nursing staff have also been proposed to undertake this qualification. Feedback from residents and visitors to the home in relation to staffing was very positive. One service user described how they had received such good nursing care that their physical health had improved markedly. They reported that the staff were “lovely and really supportive” A relative visiting the home at the time of the inspection advised that their parent was well looked after by the staff who were always available to provide help and support. Of the thirteen service user questionnaires returned to the Commission, all indicated that residents felt that staff listened to them and acted upon what they said. Two residents commented that sometimes it was difficult to communicate with the overseas nurses as English was not their first language. Friars Hall Nursing Home DS0000024393.V304761.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Residents can expect to live a home which is efficiently and competently managed. Residents can expect that the home is run with their best interests to the fore. Systems used for the safe storage and administration of resident finances are adequate but additional security measures should be adopted. Current practices would not necessarily ensure the health and safety of residents. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has an established management structure and is run in an effective and efficient manner. The Registered Manager is a qualified nurse and has many years experience in the care of older people and has obtained the Registered Manager’s Award. One visitor to the home remarked on how well Friars Hall Nursing Home DS0000024393.V304761.R01.S.doc Version 5.2 Page 24 organised the home was and described the manager has “having things well sorted.” The home does not hold resident meetings but a satisfaction questionnaire had been distributed to service users and their families earlier in the year. The Inspector was advised that feedback in relation to the service had all been very positive. The home is privately owned and the owner is present on about 3 or 4 days per week to ensure the quality of the service provided. The systems used for the administration and safe keeping of resident finances was examined. Amounts of cash held for service users were stored in a secure manner in separate cash bags. All transactions carried out by or on behalf of service users were recorded on appropriate records. It was noted that each transaction entered was only signed by one staff member. In order to offer residents protection against financial abuse good practice would suggest that two staff signatures are entered at the time of any money being withdrawn or deposited. Whilst the Manager advised that a regular audit of residents’ monies was carried out there was no evidence to suggest this took place. Evidence of this audit should be entered on each transaction sheet. In relation to the safety of residents, records in relation to the testing of fire equipment were examined. These showed that although in the main fire alarms were tested on a weekly basis they tended to be somewhat sporadic. There had been no documented tests in relation to emergency secondary lighting since October 2005. The home was able to evidence that it held relevant electrical and gas safety certificates. During the inspection several issues in relation to the health and safety of service users were identified. These are: * Two service users selected for the purposes of care tracking had safety rails fitted to their bed. Whilst appropriate parties had been consulted about this addition, no risk assessment had been carried out. * In the case of the four service users selected for the purposes of care tracking, none had been subject to a general risk assessment in order to minimise risks associated with their daily lives within the home. * Two footstools had been left in the open doorway of the conservatory to deter residents from using this exit into the garden. This presented a risk in relation to residents tripping or falling over the footstools and onto the steps below. * On three occasions during the mid-day meal one service user was observed slipping from their wheelchair despite the use of a lap strap. This caused the resident some distress. Friars Hall Nursing Home DS0000024393.V304761.R01.S.doc Version 5.2 Page 25 * The home must inform the Commission of all event occurring in the home as detailed under Regulation 37 of the Care Homes Regulations 2001. * The floor in the passenger lift is raising and currently presents a trip hazard. Friars Hall Nursing Home DS0000024393.V304761.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 2 3 3 x 3 2 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 2 Friars Hall Nursing Home DS0000024393.V304761.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? 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 OP1 Regulation Sch.1 Requirement The Registered Persons must ensure that the home’s Statement of Purpose contains the information as detailed under Schedule 1 of the Care Homes Regulations 2001. The Registered Persons must ensure that it has the services to provide rehabilitative care and if not the statement regarding the provision of this service must be removed from the home’s Statement of Purpose. The Registered Persons must ensure that, through a risk assessment process, residents are offered the opportunity and choice to administer their own medication. The Registered Persons must ensure that staff have a clear understanding of the home’s procedure on the disposal of “spoiled” or “refused” medication. The Registered Persons must ensure that the repair work required in the upper floor communal bathroom is carried DS0000024393.V304761.R01.S.doc Timescale for action 31/08/06 2 OP6 Sch.1.6 31/08/06 3 OP9 12(2) 31/08/06 4 OP9 13(2) 31/08/06 5 OP19 23(2)(b) 19/07/06 Friars Hall Nursing Home Version 5.2 Page 28 6 7 OP24 OP24 16(2)(c) 23(2)(c) 8 OP29 Sch.2.3 9 OP29 Sch.2.7 10 OP29 Sch.2.7 11 OP38 23.4 12 OP38 23.4 13 OP38 13(4) out and that the room is made inaccessible to service users until such time as this work is complete. The Registered Persons must ensure that furniture which is worn is replaced. The Registered Persons must ensure that in one of the upper floor bedroom, the door to the vanity unit and the melamine strip must be replaced. The Registered Persons must ensure that written references received in support of an application for employment at the home are personally addressed to the Manager or other member of the management team. The Registered Persons must ensure that prospective staff members do not commence their duties until at least a POVA check has been carried out. The Registered Persons must ensure that an application for an Enhanced Disclosure via the Criminal Records Bureau is completed for every newly employed member of staff. The Registered Persons must ensure that fire alarms are tested on a weekly basis and that these tests are recorded within the appropriate fire log book. The Registered Persons must ensure that emergency secondary lighting is tested on a monthly basis and that these tests are logged within the appropriate fire log book. The Registered Persons must ensure that a risk assessment is carried out for each service user in relation to any identified risks involved in their daily lives and DS0000024393.V304761.R01.S.doc 29/09/06 14/08/06 19/07/06 19/07/06 19/07/06 19/07/06 19/07/06 14/08/06 Friars Hall Nursing Home Version 5.2 Page 29 14 OP38 13(4) 15 OP38 13(4) 16 OP38 37 17 OP38 13(4) routines. The Registered Persons must ensure that open doorways are not obstructed and therefore presenting a health and safety risk. The Registered Persons must ensure that where residents require a wheelchair it is appropriate to their needs and abilities and does not put them at risk. The Registered Persons must ensure that a notification is submitted to the Commission in relation to occurrences as stated in regulation 37 of the care Homes Regulations 2001. The Registered Persons must ensure that the raised floor located in the passenger lift is repaired or replaced as it constitutes a trip hazard. 19/07/06 19/07/06 19/07/06 14/08/06 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 2 3 Refer to Standard OP2 OP3 OP7 Good Practice Recommendations The Registered Persons should ensure that resident placement contracts are available for inspection. The Registered Persons should ensure that pre-admission assessments in relation to prospective residents are dated. The Registered Persons should ensure that evidence is available to confirm that resident moving and handling assessments and pressure area assessments are reviewed as part of the care plan. The Registered Persons should ensure that resident care plans contain information about their preferred daily routines and preferences. The Registered Persons should ensure that at meal times residents sitting at one table receive their meal at the DS0000024393.V304761.R01.S.doc Version 5.2 Page 30 4 5 OP14 OP15 Friars Hall Nursing Home 6 OP15 5 6 7 8 OP18 OP24 OP33 OP35 same time. The Registered Persons should ensure that sufficient staff are available at meal times to ensure that where necessary residents are assisted and supported to eat their meals. The option of two separate sittings should be explored. The Registered Persons should ensure that the home has a copy of the local authority procedure on the Protection of Vulnerable Adults. The Registered Persons should ensure that all bedroom doors are either numbered or have some form of identifying symbol on them in order to aid orientation. The Registered Persons should ensure that resident meetings are offered as a forum for raising any concerns or queries they may have. The Registered Persons should ensure that financial transactions carried out on behalf of service users are supported by two staff signatures and that evidence is available to show that a regular audit of residents’ financial accounts has been carried out. Friars Hall Nursing Home DS0000024393.V304761.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Friars Hall Nursing Home DS0000024393.V304761.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. 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