Inspection on 27/06/07 for Friars Mead

This inspection was carried out on 27th June 2007.

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 23/01/06

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 Mrs Alison Butler Key Unannounced Inspection 27th June 2007 10:00 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.V344593.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 Mead DS0000019391.V344593.R01.S.doc Version 5.2 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 friars.mead@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.V344593.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th August 2006 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. For information and the current rate of fees contact the home direct. 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.V344593.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector conducted this unannounced inspection. The majority of the time was spent talking with those who live at the home and visors. Care and administration records were checked. What the service does well: What has improved since the last inspection? What they could do better: Some improvements are needed in the recorded of the medication and this was discussed during he inspection. Friars Mead DS0000019391.V344593.R01.S.doc Version 5.2 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Friars Mead DS0000019391.V344593.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 Mead DS0000019391.V344593.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 is not applicable to Friars Mead. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service have their needs assessed prior to admission, thus ensuring that those needs can be met. EVIDENCE: Those who use the service are fully assessed prior to choosing to live at Friars Mead. Staff gather information from families and other professionals and use this to form the basis of the care plan. Prior to moving in, individuals are invited for a half-day to join in activities and aid staff to further the assessment process. There is a six-week trail period and then a further review takes place to ensure the home are able to meet their needs appropriately and a decision is made whether they wish to move into the home or not. Friars Mead DS0000019391.V344593.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual care plans detail the care needs required and show the health care needs are met. Some areas of the medication system need to be monitored. EVIDENCE: The care plans detail the action required by staff to meet the needs of the individuals. The G.P. visits the home once a week and those using the service are able to request a visit if required. The G.P. will also meet with relatives if required and the individual has granted permission. Good interaction was observed between staff and those living at the service. Staff were seen to knock and wait prior to entering rooms. Discreet support was being offered to individuals as appropriate. Examination of the medication administration records revealed that, whilst on the whole they were well kept, some areas for improvement were needed where medication entering the home was not signed in on all occasions. In addition, the bring-forward system should be used consistently to enable a full audit to take place at any time. When information is handwritten on the recording sheet, the author should ensure they sign it and the next person Friars Mead DS0000019391.V344593.R01.S.doc Version 5.2 Page 10 should then check the information. The manager stated that these matters would be implemented immediately and therefore a requirement was not made on this occasion. The temperature of the storage is area is taken and recorded and where necessary any action would be taken if the temperature exceeds the recommended guidance stated for the medication storage. Those who use the service spoke highly of the care that staff provide and that they have their needs met and are given respect and kindness. Friars Mead DS0000019391.V344593.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those who use the service have activities on offer and they can choose to join in or not. Meals are of a good quality. EVIDENCE: Discussions took place with those who live at the home and they told the inspector they are able to join in the activities if they choose. A number of those spoken to prefer to spend the morning in their rooms to enjoy some peace and quiet before they join the others after lunch in the various lounges around the home. Activities are advertised on the notice board in the dining room. Those that join in the activities said that they very much enjoy them and sometimes just to choose to watch the others rather than taking part themselves. Some order a daily paper to keep themselves up to date with the national news and events. The meal of the day was soup or melon, roast beef, potatoes and vegetables or ham salad, jelly & ice cream or cheese and biscuits. The inspector joined them for lunch and the meal was very tasty, hot and well presented. There is a choice of sherry, wine or soft drink available on Wednesdays and Sundays when a roast dinner is served; this was very much enjoyed by those spoken to. Friars Mead DS0000019391.V344593.R01.S.doc Version 5.2 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a complaints procedure in place and those using the service are protected from abuse. EVIDENCE: There is a meeting held every six weeks and involves the manager and the chair of the board of Abbeyfield. This gives everyone the opportunity to voice any concerns or issues they may have. The manager has an open door policy and anyone is able to speak with her at anytime. Those spoken to during the inspection were clear of whom they could talk to if they had any concerns or issues with any aspect of their care at Friars Mead. All staff are subject a Criminal Records Bureau check prior to commencing employment at Friars Mead. Training is mandatory for all staff in adult protection that covers forms of abuse. Friars Mead DS0000019391.V344593.R01.S.doc Version 5.2 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, safe and well maintained, ensuring a safe and pleasant environment for those who live there. EVIDENCE: A tour of the home showed that it was clean, safe and well maintained. The main lounge was in the process of being decorated and should be completed by the end of the week. New furniture has been ordered in consultation with those who live at the home. There is a maintenance person who is able to deal with minor repairs. There are a number of fan assisted gel air fresheners around the home, which creates a pleasant odour. The balcony on the upper floor is to be repainted over the coming months and the kitchen is having air conditioning fitted to make it a more comfortable environment for the kitchen staff. There are good infection control measures in place with the use of liquid soap, paper hand towels and some alcohol hand gel in various areas of the home. Friars Mead DS0000019391.V344593.R01.S.doc Version 5.2 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those who use the service are protected through the recruitment procedures and staff receive appropriate training to meet the needs of those who live at Friars Mead. EVIDENCE: All staff receive an induction programme on commencing employment, this covers policies and procedures of the home. After three months of employment they are enrolled on to an NVQ course. There is an on-going training programme in place to ensure staff maintain their skills and competency to meet the needs of those who use the service. Adequate numbers of staff are deployed to meet the needs of the individuals. Staff recruitment was not examined at this inspection as previous inspections have found them to be in good order and all checks made prior to them commencing employment. Friars Mead DS0000019391.V344593.R01.S.doc Version 5.2 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in the best interest of those living there. Health, safety and welfare of all who enter are protected by a system of checks. EVIDENCE: The manager and deputy have both attained the registered managers award. The manager has arranged for appropriate door closures to be placed on doors that are required to be open during the day but will shut if the fire alarm system is activated. Fire records were well recorded and any action taken is detailed within them. Monies held on behalf of those who live at the home showed that they were well kept and receipts obtained for all purchases. Next of kin receive a copy of the balance sheet at the end of every month. This gives them an indication of Friars Mead DS0000019391.V344593.R01.S.doc Version 5.2 Page 16 when additional money would be required for their relative to spend as they wish. Equipment is checked and recorded appropriately. Friars Mead DS0000019391.V344593.R01.S.doc Version 5.2 Page 17 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 3 X X N/A 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 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 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 X 3 X 3 X X 3 Friars Mead DS0000019391.V344593.R01.S.doc Version 5.2 Page 18 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.V344593.R01.S.doc Version 5.2 Page 19 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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