Inspection on 23/01/06 for Friars Mead

This inspection was carried out on 23rd January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 Mead 27/06/07

Friars Mead 06/09/05

Friars Mead 10/02/05

Friars Mead 15/06/04

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

CARE HOMES FOR OLDER PEOPLE Friars Mead Rockliffe Avenue Kings Langley Hertfordshire WD4 8DR Lead Inspector Patricia Rogan Unannounced Inspection 23rd January 2006 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Friars Mead DS0000019391.V279899.R01.S.doc Version 5.1 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 Mead DS0000019391.V279899.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Friars Mead Address Rockliffe Avenue Kings Langley Hertfordshire WD4 8DR 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) 01923 270 304 01923 270 324 friarmead@btopenworld.com Abbeyfield Hertfordshire Residential Care Society Limited Mrs G Hockey Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Friars Mead DS0000019391.V279899.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th September 2005 Brief Description of the Service: Friars Mead is located in a residential area of Kings Langley at the end of a culde-sac, adjacent to a sheltered accommodation complex. Local shops are nearby, with Watford and Hemel Hempstead town centres only short bus rides away. The home, owned and operated by the Hertfordshire Abbeyfield Society, offers personal care and accommodation for up to 27 elderly people. It is not registered to care for people with dementia. The home was purpose-built in 1991 and provides accommodation on two floors served by a lift. All bedrooms are singles with en-suite facilities although one is sufficiently large to be used as a double and some of the other bedrooms have interconnecting doors, making them particularly suitable for married couples. There are two lounge/dining rooms on the first floor and a larger lounge/dining room on the ground floor. Each floor has a small domestic style kitchen for the use of service users and relatives or friends for making light refreshments. Limited car parking is available to the front of the building. To the rear of the building, there is an enclosed garden with a water feature and sheltered patio areas. Friars Mead DS0000019391.V279899.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during one day. It was the second inspection of the inspection year and the outcome of the inspection was very positive. The majority of the residents, some members of staff and visitors to the home were asked for their views. Record keeping, policies and procedures were inspected, including risk assessments, staff training and health and safety monitoring. A tour was made of the building and communal areas, bathrooms and some bedrooms were inspected. Where key standards were assessed at the previous inspection of 6th September 2005, these have not been assessed again. Reference should be made to the report of that inspection for details. What the service does well: 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 Mead DS0000019391.V279899.R01.S.doc Version 5.1 Page 6 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 Mead DS0000019391.V279899.R01.S.doc Version 5.1 Page 7 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): These standards were inspected 6th September 2005. Please see the inspection report of that date. Standard 6 is not relevant to Friars Mead. EVIDENCE: Friars Mead DS0000019391.V279899.R01.S.doc Version 5.1 Page 8 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): 11 There are policies and procedures in place for the care and support of residents who are dying and for the care and support of relatives at the time of the relative’s death. The guidelines are clearly set out and staff who were spoken to during the inspection showed that they were aware of the need for a sensitive yet practical approach towards end of life care. EVIDENCE: Two residents spoke of the ‘kind way the staff look after everyone when a resident dies.’ Favourable responses from relatives and visiting professionals further demonstrated the skills and sensitivity of the staff when a resident is dying or has died. There are many letters from bereaved relatives thanking for the manager and the staff for their support at time of great distress. Friars Mead DS0000019391.V279899.R01.S.doc Version 5.1 Page 9 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): 14 During the inspection, several care plans were examined in depth and many residents were asked whether they were consulted about their views. EVIDENCE: The care plans were very detailed and it was evident that staff recognised the individuality of the residents. Residents said they were often asked for their views about the care they received. When writing the resident’s long and short term goals, the record would have greater impact if it was written from the resident’s perspective. This should not cause additional work for staff as they already fully involve residents in the review process. Friars Mead DS0000019391.V279899.R01.S.doc Version 5.1 Page 10 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): 17 There are strict, comprehensive policies in place which set out the resident’s right to legal protection and this is strictly adhered to. EVIDENCE: During discussion with the manager and staff, it was evident that they are aware that resident’s have legal rights. Residents are supported if they wish to vote or would like to have access to independent advocates or have private legal representation. Friars Mead DS0000019391.V279899.R01.S.doc Version 5.1 Page 11 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): 25 Health and safety manuals are clearly set out. The manager ensures there are regular checks of all areas of the building. Fire drills are carried out and all staff are trained to assess risks and to report anything untoward. The premises and the environment is always monitored to ensure a high standard of safety and comfort is maintained. There are risk assessments in place for each resident and for all practical tasks and for all areas of the premises. EVIDENCE: Recording of health and safety checks and risk assessments are in place and up to date. It would be helpful to staff if there was a little more detail on the resident’s individual risk assessment, so that new members of staff are aware why there is a possible risk. The premises are maintained to a high standard and furnishings are replaced as needed. There are plans to paint the exterior of the building. Friars Mead DS0000019391.V279899.R01.S.doc Version 5.1 Page 12 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): 30 There is a comprehensive training schedule for all staff to reflect the roles they have within the team. Regular supervision and appraisals also identify learning needs and measures are put in place to ensure appropriate training is given. EVIDENCE: The manager and some members of staff were asked about their access to training and all responded that training was ongoing and that staff are supported during the training. The induction schedule for any new member of staff is already defined and new members of staff initially work alongside other more experienced staff members until the new person is confident and competent to work alone. Friars Mead DS0000019391.V279899.R01.S.doc Version 5.1 Page 13 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): 33,34,35,37. The training and procedures all keep the resident as the important focus. All financial transactions are scrupulously recorded and audited. Service users’ finances are safeguarded by the policies and procedures which are in place. There are clearly set out policies and procedures for all aspects of the running of the home. All records which were inspected were accurate and up to date. EVIDENCE: There was positive feedback from all residents and relatives about the care and support they have from the manager and members of staff. Professionals who visit the home also said they felt residents were very well cared for. Discussion with the accountant volunteer who was administering some of the finances further evidenced that there is a commitment from all concerned to safeguard the interests of the residents. Friars Mead DS0000019391.V279899.R01.S.doc Version 5.1 Page 14 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 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 X X X X X X X 3 X STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 3 3 X 3 X Friars Mead DS0000019391.V279899.R01.S.doc Version 5.1 Page 15 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Friars Mead DS0000019391.V279899.R01.S.doc Version 5.1 Page 16 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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. 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