Inspection on 01/04/08 for Friary Fields Care Home

This inspection was carried out on 1st April 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Friary Fields Care Home 17/04/07

Friary Fields Care Home 15/06/06

Friary Fields Care Home 30/11/05

Friary Fields Care Home 01/07/05

Friary Fields Care Home 28/06/04

Friary Fields Care Home 05/03/04

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

CARE HOMES FOR OLDER PEOPLE Friary Fields Care Home 21 Friary Road Newark Nottinghamshire NG24 1LE Lead Inspector Jayne Hilton Unannounced Inspection 1st April 2008 08:50 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 Friary Fields Care Home DS0000008764.V361712.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. Friary Fields Care Home DS0000008764.V361712.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Friary Fields Care Home Address 21 Friary Road Newark Nottinghamshire NG24 1LE 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) 01636 706 105 01636 702 747 ashvin.ramchurn@ntlworld.com Mr Leckraz Ramchurn Mrs Devhootee Ramchurn Mr Leckraz Ramchurn Mr Ashvin Ramchurn Care Home 34 Category(ies) of Dementia (31), Old age, not falling within any registration, with number other category (3) of places Friary Fields Care Home DS0000008764.V361712.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. Rooms 10, 11 and 12 are not to be used for people with dementia due to their close proximity to a staircase. Only residents who are assessed as being able to call for assistance should be placed in rooms on the 2nd floor. Within the total number of beds, a maximum of 31 may be used for service users included within the category DE over 60 years old Within the total number of beds, a maximum of 3 may be used for the category OP The double bedroom is not used until the decoration is complete. The garden must be landscaped by summer 2006. Date of last inspection 17th April 2007 Brief Description of the Service: Friary Fields is owned by Friary Fields Limited and is a family-run care home. It provides personal care and accommodation for up to thirty-four older people of both sexes, thirty-one of who may be over the age of 60 years and may have dementia. The home provides short and long term care and will accept emergency admissions. It is situated in the riverside town of Newark, less than half a mile from the town centre. Shops, market, churches, library, theatre, pubs and historic sites of interest are some of the facilities and activities available in the town. The residents are housed in twenty-eight single and three double rooms. Six of the single and one double have ensuite facilities with toilet and washbasin. The six-ensuite rooms are located in the recently built extension. Communally, there are two lounges and an attractive, large conservatory on the ground floor. There is also a lounge on the first and second floors. The two dining areas are attached to the two ground floor lounges. There are nine toilets, five bathrooms and one shower room. A passenger and a stair lift give access to most rooms on the two upper floors although some rooms are only accessible via the stairs. The garden has been basically landscaped and provides a secure outdoor area. It has a greenhouse. There is car parking space for up to five cars. Friary Fields Care Home DS0000008764.V361712.R01.S.doc Version 5.2 Page 5 The provider keeps a printed copy of the latest inspection report at the home, which is available for people using or enquiring about the service. The fees range from £290 for low to £385 for high dependency residents. Extra services not covered by fees are hairdressing, dry cleaning, chiropodist, dentists, opticians, physiotherapy, clothing and personal effects. Friary Fields Care Home DS0000008764.V361712.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by CSCI [The Commission for Social Care Inspection] is upon outcomes for people living in the home and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This inspection took place over 6.5 daytime hours and was unannounced The main method of inspection used was called ‘case tracking.’ This involves selecting three residents and looking at the quality of the care they receive by talking to them, examining their care files and discussing how support is offered to them by staff members. Many of the people who live at this home have a very limited ability to understand and communicate. Therefore many judgements in this report are from observation and reading residents’ records and documents. Four people who live in the home however contributed views for the inspection and three returned surveys with the help of staff or relatives. Relatives were observed visiting the home but they declined to be interviewed. Three relatives were contacted by telephone and their views included in the report. Three members of staff and the provider/ manager were spoken with as part of this inspection, documents were read and medication inspected to form an opinion about the quality of the care provided to people living in the home. Prior to completing this visit the inspector assessed the homes previous inspection reports, the service history including complaints and adult protection referrals, and an Annual Quality Assurance Assessment [AQAA] completed by the registered manager. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. What the service does well: The home is run by a caring provider and manager who know each person living in the home and their needs. The provider and manager support and encourage the staff team to provide good care to the residents. Friary Fields Care Home DS0000008764.V361712.R01.S.doc Version 5.2 Page 7 People living in the home said the food was very nice and that staff always treat them respectfully. The rapport between the residents and staff is friendly and positive. The service has a recruitment procedure that meets statutory requirements and the NMS. The procedure is followed in practice and there is accurate recording at all stages of the process. Staff supervision is regular and staff feel that their work is supported through it. Staff are well-trained and 70 if staff hold National Vocational Qualifications at level 2 or above. The home provides a physical environment that meets the basic needs of the people who live there. The home is comfortable and the provider manager has told us he has a programme to improve the decoration, fixtures and fittings. All relatives spoken with stated that staff, were always approachable and their relatives were happy living in the home. What has improved since the last inspection? Pre-admission assessments by the manager of the home are now being undertaken for prospective residents. The care plans have been re organised. The home has undergone some redecoration. The provider has been submitting notifications to inform the Commission for Social Care of any deaths of people living in the home. Activities provision in the home has improved. Written confirmation is now sent out that informs the resident that the home can meet their needs. There is now also some evidence that residents or their representative have been involved in the creation or review of care plans where possible. There is also now appropriate paperwork in place for assessing any limitations imposed Friary Fields Care Home DS0000008764.V361712.R01.S.doc Version 5.2 Page 8 on people, which identifies risks and is agreed by the individual or their representatives. What they could do better: Eight requirements have been set in respect of the following: Evidence must be provided to the Commission, which ascertains that the bedroom identified in the conditions of registration is suitable to meet the needs of the individual discussed at the inspection. Ensure Care plans and risk assessments are in place for the management of challenging behaviours, which inform staff, how to meet the individual needs and which promote consistent practice. Ensure care plans and risk assessments are in place for all individual healthcare needs and how these are monitored and met. To minimise any risk of harm to people living in the home the current systems in place for medication management should be reviewed. Make the appropriate safeguarding referral to Adult Social Care and Health in respect of the above event. This will ensure people living in the home are appropriately safeguarded under in accordance with the Public Interest Disclosure Act 1998 and Department of Health (DH) guidance No Secrets [Urgent Action required] Submit the appropriate notifications under Regulation 37 of The Care Standards Act 2000 to The Commission For Social Care Inspection. This will ensure people living in the home are appropriately safeguarded And that the Commission For Social Care Inspection can monitor all events which effect individual’s health safety and welfare. Undertake and document a security review of the premises, which includes an assessment in respect of the ground floor windows and take any appropriate action in respect of fitting restrainers. Incident Records must be kept as required by regulation Sixteen good practice recommendations have also been made. Friary Fields Care Home DS0000008764.V361712.R01.S.doc Version 5.2 Page 9 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. Friary Fields Care Home DS0000008764.V361712.R01.S.doc Version 5.2 Page 10 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 Friary Fields Care Home DS0000008764.V361712.R01.S.doc Version 5.2 Page 11 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): 2, 3 and 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The needs of people moving to the home are assessed and assured these will be met, however the service could be improved for people living in the home by adopting best practice principals of good Dementia Care. The service does not provide intermediate care. EVIDENCE: The conditions of Registration were reviewed at this visit. There was some evidence viewed in the care plan of one person, [who was residing in one of the specified rooms in the ‘ conditions of registration’] that indicated that the provider may be in breach of the condition set, however it was established that the information recorded was the view of the provider and not a clinical diagnosis or the individuals primary needs. Friary Fields Care Home DS0000008764.V361712.R01.S.doc Version 5.2 Page 12 It is therefore required that a professional review be requested to re-assess the persons changing needs to ensure the stated room is suitable to meet the individual needs. This information must be provided to the Commission. The service consults the assessment information to see if they can meet the prospective resident’s needs before they make the decision to accept the application for admission and offer a place. Evidence suggests that prospective residents mostly have a needs assessment before they go to live at the home. However the home does accept emergency admissions on a frequent basis. For most of the residents the home has received copies of the summary and care plans from the assessments carried out through care management arrangements. For residents who are self-funding the service is able to demonstrate how they have undertaken the assessment. They are generally undertaken satisfactorily, however the assessment documentation should be further developed to include any diversity needs of people as currently, only identifies religious needs of individuals. Individuals are provided with a statement of terms and conditions or a contract before admission to the home. It gives basic information on what people who live in the home can expect to receive for the fee they pay, and sets out terms and conditions of occupancy. Written confirmation is sent out that informs the resident that the home can meet their needs. The service specialises in providing Care for people with Dementia and now provides life history information and Mental Capacity Act 2005 (M.C.A. 2005) assessments are being developed within the care documentation. There are some signs and pictures around the home to aid orientation but people living in the home were observed finding difficulty to access a toilet and there is a lack of sensory stimuli around the home. The provision of these would enhance the quality of life for people with Dementia living in the home. Although the provider/manager was able to express detailed knowledge about individuals residing in the home and staff are trained there was no reference made to best practice in Dementia Care or Dementia Care Mapping, neither was this identified within the Annual Quality Assurance Assessment documentation. There was also a lack of evidence of quality review of their service in respect of this. Friary Fields Care Home DS0000008764.V361712.R01.S.doc Version 5.2 Page 13 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 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although improvement to the care plan documentation has been made, these still require further development to make sure that the care needs of all people living in the home are met. There are some areas of medication management to address to ensure people living in the home are not placed at risk of harm. EVIDENCE: Five people’s care plans were examined, these were mostly dated as last reviewed in October or November 2007 and one January 2008. One person was newly admitted. There is now some information on what has developed, deteriorated or improved and there was evidence within the care planning format, that where individual needs have changed, this has been addressed and a new care plan implemented. There is now also some evidence that residents or their representative have been involved in the creation or review of care plans where this is possible. There is also now appropriate paperwork in place for assessing any limitations Friary Fields Care Home DS0000008764.V361712.R01.S.doc Version 5.2 Page 14 imposed on people, which identifies risks and is agreed by the individual or their representatives. The care plans examined show that the manager normally liaises with healthcare professionals when they assess a need has arisen. The district nurse attends any residents with needs such as diabetes and skin wounds. The community liaison nurse is called in for people with continence issues. Some residents have contact with the community psychiatric practitioner. This ensures people living in the home have their healthcare needs met. Some information, which is important for the proper care of the residents, is still missing from some care plans, such as plans and risk assessments for managing challenging behaviour and monitoring individual medical conditions and treatments. [Diabetes, depression, visual impairment.] Although there was some evidence that individual health needs are monitored and appropriate action and intervention taken. This could be improved by separating out healthcare records from the daily evaluation sheets and implementation of health action plan sections with medication profiles. The use of nutritional screening tools and pressure area risk assessment tools would also improve the service to people living in the home and ensure their needs were fully reviewed and evaluated. Risk assessments are completed but these are basic and mainly focus on keeping residents safe. These could be improved by reviewing them regularly. The management of risk could be more positive in addressing safety issues while aiming for improved outcomes for people. Some of the care plans and assessments are still not dated or signed so that the reader does not know who wrote them or when they were started from. The provider/manager stated that the community pharmacist undertook an audit of the homes medication management system in March 2007, but the report could not be located. Medication records are up to date for each resident but the system for recording medicines received and audited requires attention. A number of handwritten entries of prescriptions were not signed or witnessed and this is not safe practice. Medication was observed, to be signed appropriately after administration, however the staff member whilst administering medication to residents in the lounge dining area, left medication blister packs and packets of [Adcal] and other medication unattended on a dining table. The use of an appropriate trolley would ensure the system was safe, particularly as the home provides care for people with Dementia. Friary Fields Care Home DS0000008764.V361712.R01.S.doc Version 5.2 Page 15 Staff spoken with were aware of the need to treat individuals with respect and to consider dignity when delivering personal care. However a staff member was observed not respecting the privacy of a person living in the home whilst assisting the person to dress. The provider/manager witnessed the practice and promptly directed the staff member to close the bedroom door. The rapport between the residents and staff was observed to be friendly and positive. Friary Fields Care Home DS0000008764.V361712.R01.S.doc Version 5.2 Page 16 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 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in the home are mostly helped to exercise some choice and control over their lives and receive a balanced diet and enjoy their food. Social activity varies according to the individual and specialist support and assistance in engaging in the activities of life needs to be provided to ensure best practice and ensure individual needs are fully met. EVIDENCE: The service understands the right of individuals to take control of their lives and to make their own decisions and choices. The Provider/manager and staff spoken with told us that they respect the individual choice to go to bed when they wish and when they wish to get up and regarding their preferences in respect of personal care, which may sometimes conflict with times of their medication and meals. Healthcare action plans should include these types of issues and ensure that management of them are fully documented and included within the review process. People using the service may experience isolation and lack friends, advocates and community contact. Not all people living in the home have regular contact Friary Fields Care Home DS0000008764.V361712.R01.S.doc Version 5.2 Page 17 with family and friends, the provider/manager told us they try very hard to maintain contact for individuals living in the home with relatives etc, but with difficulty sometimes. Care plans should contain care plans for this process, which would provide a record of any contacts made and the outcome of the contact. There was evidence that there has been some improvement to the activities provision and certianly on the day of the inspection people were engaged in a movement to music session by an outside facilitator in the morning and in the afternoon a person living in the home played the organ for a short time. Music and dancing provided a positive and happy atmosphere and people involved in the area [even if just choosing to watch,] were observed to be engaged and smiling. The provider/manager and staff expressed that people living in the home were not always willing to participate in activities on offer and some just wished to rest. There were some records of participation for two days in February and one in March seen but this had not been consitently recorded by staff. Which therefore, did not provide an accurate picture of individuals participation in any of the social activities provided. On speaking with staff they viewed activities as Bingo, Quizz and Dominoes etc and confirmed that entertainers visited the home and religious services provided on a monthly basis. There was little evidence that people are able to go for walks in the park, bus trips or are provided with opportunities to take part in vegetable peeling, cleaning brass wear, making cakes, helping in the garden or repair jobs around the home. These may help establish emotional security and a consostent sense of identity for a person with Dementia. The provider manager and staff spoke of a planned boat trip in the summer. A relative said there is little activities in the home and residents don’t get out much. Staff spoken with did identify that some people did not like noise but did not demonstrate good knowledge of the importance of sensory stimuli or innovation in respect of engaging with people with dementia, such as the importance of smells touch, use of cuddle boxes or other theraputic activities. Staff spoken with said that sometimes they havent got time to do activities due to meeting other needs of people in the home and confirmed that an activities person was employed recently but left as they could not motivate the people in the home. Training for staff in this area would improve the lifestyle of people living in the home. Friary Fields Care Home DS0000008764.V361712.R01.S.doc Version 5.2 Page 18 The food in the home is of satisfactory quality, well presented and meets the dietary and cultural needs of people who use the service. Staff are trained to help those individuals who need help when eating and are sensitive in their approach. Individuals have very little choice of what they eat however. People living in the home told us that they enjoy their food. Friary Fields Care Home DS0000008764.V361712.R01.S.doc Version 5.2 Page 19 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 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Most people living in the home and their relatives know how to make a complaint and say they feel safe in the home, however the provider/manager has not been following the correct procedures for reporting incidents in the home, which indicates people living in the home may not be fully safeguarded from harm. EVIDENCE: The service has a complaints procedure that meets the NMS and regulations, which is up to date and displayed on notice boards in the home. Some individuals say they know how to make a complaint but others do not. Staff said they are aware of the complaints procedure and would pass any made to them to the provider/manager to deal with but they did not acknowledge the importance of listening to, and then acting on residents’ concerns. There are no complaints logged in the home. There are policies and procedures for safeguarding people who use the service but these were not up to date with local agreed protocols. The provider/manager told us he was not aware of the new protocol and that he felt CSCI should have informed him of it. Links with external agencies are adequate but there is a lack of understanding of safeguarding procedures and Friary Fields Care Home DS0000008764.V361712.R01.S.doc Version 5.2 Page 20 how they work. This means that the health and welfare of people living in the home may be compromised. The Annual Quality Assurance documentation submitted by the provider was not fully completed in respect of safeguarding people living in the home. There was evidence in a persons care notes of an event, which should have been reported to the Commission under Regulation 37 and also referred as a safeguarding event to Adult Social Care and Health. A requirement made at the previous inspection in respect of notifications of safeguarding issues was found therefore not to be met and an Urgent Requirement notice served for the event to be reported and actioned as appropriate and for all future allegations and incidents of abuse to be followed up and actioned promptly to ensure people living in the home are fully safeguarded from harm. The provider/manager made the necessary referral in our presence and he agreed to submit the required notification to CSCI within the timescale set. Not all staff spoken with were familiar with the ‘whistle blowing’ procedures, despite undertaking training in safeguarding. Staff are provided with training in safeguarding and did demonstrate a good knowledge of what constituted poor practice and abuse and said that they would not tolerate this and would report appropriately. Staff told us they felt equipped to deal with any challenging behaviours presented by people living in the home and that they had training in this area, but also said that there was no consistent way of managing behaviours. [No care plans which give clear direction to staff] and that some staff approaches worked better than others. This is an area, which requires improvement to ensure that staff, are aware that Challenging Behaviour is a form of communication, and that systems are appropriately in place for consistent and best practice. A sample of resident’s financial records were briefly viewed and found to be satisfactory. People living in the home say that they are satisfied with the care in the home and feel safe. Friary Fields Care Home DS0000008764.V361712.R01.S.doc Version 5.2 Page 21 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, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a clean, physical environment that meets the needs of the people who live there. EVIDENCE: The home provides a physical environment that meets the basic needs of the people who live there. The home is comfortable and the provider /manager has told us he has a programme to improve the decoration, fixtures and fittings. However no documentation or business plan was provided as evidence of this. There was clearly ongoing re-decoration of the premises on the day of the inspection. There were some maintenance issues observed in the home, which the provider/manager did attend to some on the day of the inspection when pointed out, which indicates maintenance tends to be reactive rather than Friary Fields Care Home DS0000008764.V361712.R01.S.doc Version 5.2 Page 22 proactive. [Door locks that were not fully in working order, a sash window being held open by a toilet roll as the restrictor was missing, bedding that was torn and frayed] Residents can personalise their rooms. They also say they the home is clean, warm, well lit and there is usually sufficient hot water. There has been some consultation with residents about the décor, especially for their own rooms. Some en-suite facilities are available. The garden provides a secure outdoor area for residents to sit in although residents told the inspector that they are not taken out in it. One staff said they take residents out in the garden in good weather. The garden has been landscaped and the condition of registration in respect of this should be removed. However the concrete path leading from the ramp to the seating area is uneven and therefore may present a trip hazard to people using it. Specialist equipment seen in use includes pressure-relieving mattresses and cushions, an electric hoist and a mechanical hoist. The home had received a delivery of new toilet support frames the day before the inspection. These need to be fitted however. There are no window restrictors on the ground floor and this security risk was pointed out to the provider/manager, who agreed to undertake a risk assessment in respect of this. One person’s bed was noted to be placed against a radiator that was not covered. The Provider/manager placed a temporary cover on this to safeguard the resident from possible surface burn or injury until a permanent cover could be accessed. The Provider stated in the Annual Quality Assurance Assessment that they recognise they could have have clearer signage so as to help residents find their way around the home and improve maintence of some of the homes furnishings. They also said it is their intention to change flooring in areas where it is old and looks faded and attend to external redecoration of the homes building during the summer. They also state thay have asked staff to prompt and encourage the residents to use the conservatory and garden more. The provider/ manager and staff spoken with indicated that they have difficulty persuading some people to have regular baths/showers. It is recommended that although the bathroom facilities are functional they may be more encouraging if designed attractively to encourage people to use them. There is a fire risk assessment in place for the home and staff records and staff spoken with confirmed they are trained in infection control. Gloves and Aprons were in use. Friary Fields Care Home DS0000008764.V361712.R01.S.doc Version 5.2 Page 23 Friary Fields Care Home DS0000008764.V361712.R01.S.doc Version 5.2 Page 24 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are supported, adequately trained and in sufficient numbers to keep the residents safe, happy and comfortable. EVIDENCE: There are enough qualified, competent and experienced staff to meet the health and welfare of people using the service. Staffing rotas take into account the needs and routines of the people using the service. However a staff member commented that they did not always find time to spend with people for activities. The service recognises the importance of training, and tries to delivers a programme that meets any statutory requirements and the NMS. The service has a recruitment procedure that meets statutory requirements and the NMS. The procedure is followed in practice and there is accurate recording at all stages of the process. The manager/provider stated in the Annnual Quality Assuranc Assessment “Around 70 of our staff are NVQ 2 or equivalent qualified with 50 having achieved NVQ 3 or equivalent”. Friary Fields Care Home DS0000008764.V361712.R01.S.doc Version 5.2 Page 25 The staff training matrix was viewed at the inspection visit. It shows that all staff have done basic training or are in the process of completing training units, although there are still no dates supplied with the matrix to show when training was actually completed. Friary Fields Care Home DS0000008764.V361712.R01.S.doc Version 5.2 Page 26 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, 32, 33, 34, 36, 37, and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and safety of people living in the home is protected, however quality assurance systems in the home are not effective and therefore this needs further exploration by the provider/manager. Record keeping requires improvement to ensure records required by regulation are kept, are accurate and up to date. EVIDENCE: The manager is qualified and has the necessary experience to run the home. The provider is a registered nurse. The manager has achieved the Registered Manager’s Award. Friary Fields Care Home DS0000008764.V361712.R01.S.doc Version 5.2 Page 27 The manager trains and develops staff who are generally competent and knowledgeable to care for the residents. Staff say that the provider and manager are very supportive. Most of the sections of the AQAA [Annual Quality Assurance Assessment] were completed and the information gives a reasonable picture of the current situation within the service. The evidence to support the comments made is satisfactory, although there are areas where more supporting evidence would have been useful to illustrate what the service has done in the last year, or how it is planning to improve. The AQAA gives us some limited detail about the areas where they still need to improve. The ways that they are planning to achieve this are briefly explained. The data section of the AQAA was completed satisfactorily. The home has provided a suggestion box but has had no response. The provider/manager showed us the quality monitoring surveys that had been devised and stated that they had no responses returned by any relatives or visiting professionals. He also stated they did not have any other audit processes in place to assess the quality of service provided. The provider /manager stated that he had sent out surveys also on behalf of CSCI [Commission For Social care Inspection] Relatives spoken with said they had not received either surveys. Three surveys were received from people living in the home that were positive. There was evidence that the home promotes and maintains Equality and Diversity within its service provision. Staff supervision records were viewed and staff confirmed these took place every three months. The provider/manager has notified the Commission about any deaths of people living in the home but not about other events which effect the health and well being of people living in the home [see Complaints and Protection]. Accident records were viewed and these were appropriately completed, however records of incidents are not kept. Care plans are stored securely in the manager’s office. The manager has developed a health and safety policy that generally meets health and safety requirements and legislation. A security review should be undertaken of the premises in respect of window restrictors. [See Environment section also] Friary Fields Care Home DS0000008764.V361712.R01.S.doc Version 5.2 Page 28 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 3 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 2 2 2 3 2 2 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 2 3 X 3 1 3 Friary Fields Care Home DS0000008764.V361712.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP4 Regulation 14 Requirement Timescale for action 01/07/08 2. OP7 14,15 3. OP7 OP8 14 4. OP9 13 [2] Evidence must be provided to the commission, which ascertains that the bedroom identified in the conditions of registration is suitable to meet the needs of the individual discussed at the inspection. Ensure Care plans and risk 01/06/08 assessments are in place for the management of challenging behaviours, which inform staff, how to meet the individual needs and which promote consistent practice. Ensure care plans and risk 01/06/08 assessments are in place for all individual healthcare needs and how these are monitored and met. 01/05/08 Ensure that appropriate medication management systems are in place; By using a medication trolley in the home to ensure medication is not left unattended. Ensuring two people check and Friary Fields Care Home DS0000008764.V361712.R01.S.doc Version 5.2 Page 30 sign handwritten prescription entries on the medication records. By having a clear audit trail of medicines received in the home. This will ensure any risk of harm to people living in the home is minimised. • You must make the appropriate safeguarding referral to Adult Social Care and Health in respect of the above event. This will ensure people living in the home are appropriately safeguarded under in accordance with the Public Interest Disclosure Act 1998 and Department of Health (DH) guidance No Secrets 6 OP18 OP37 17, 37 Urgent Action required The provider is required to send a list of all deaths, incidents, accidents, events or allegations of abuse that occur to any resident of the home. Previous timescale 30/04/07 not fully met in respect of events or allegations of abuse. • You must submit the appropriate notification under Regulation 37 of The Care Standards Act 2000 to The Commission For Social Care Inspection. 04/04/08 5 OP18 12[1][a] 04/04/08 This will ensure people living in the home are appropriately safeguarded And that the Commission For Friary Fields Care Home DS0000008764.V361712.R01.S.doc Version 5.2 Page 31 Social Care Inspection can monitor all events which effect individual’s health safety and welfare. 7 OP25 12[1][a] 13[4] [a] Undertake and document a security review of the premises, which includes an assessment in respect of the ground floor windows and take any appropriate action in respect of fitting restrainers. Incident Records must be kept as required by regulation 01/06/08 8 OP37 17 schedule 3, 37 01/06/08 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 OP3 Good Practice Recommendations Further develop the pre-inspection assessment to include identification of any diversity or cultural needs of individuals as well as any religious needs and identify date and place the assessment took place. Improve the services and environment provided for people with Dementia based on good practice and use of Dementia Care Mapping. Continue to develop the care plans to ensure all individual and specific needs are evaluated in detail and that this is undertaken on a monthly basis. Further improve record keeping practices to ensure all care plans and risk assessments are dated when completed. Incorporate health Action Plan/Profiles within care plans and which running records of interventions and professional visits can be easily accessed and audited. Introduce nutritional screening tools and risk assessments for assessing individual at risk of developing pressure areas. Ensure the practice of staff promotes privacy and dignity DS0000008764.V361712.R01.S.doc Version 5.2 Page 32 2 3 4 5 6 7 OP4 OP7 OP7 OP8 OP8 OP10 Friary Fields Care Home for people living in the home at all times. 8 9 10 OP13 OP12 OP15 Record contact with relatives/friends and representatives within the care records in conjunction with appropriate implementation of care plans for this purpose. Training for staff in activities for people with Dementia would improve the lifestyle of people living in the home. The service could also be improved by the production of innovative menus, visual cues for eating areas, the provision of choice options and finger food options and choice of whether they wish to wear protective aprons and style of protection used i.e. napkins. Improve the systems for day to day repairs and general maintanance in the home and produce a development plan for cyclical and onging decoration and improvement. Attend to the concrete path leading from the ramp to the seating area in the garden, which is uneven and therefore may present a trip hazard to people using it. People living in the home would benefit from sensory stimuli and clearer signage of facilities such as toilets. The provider/ manager and staff spoken with indicated that they have difficulty persuading some people to have regular baths/showers. It is recommended that although the bathroom facilities are functional they may be more encouraging if designed attractively to encourage people to use them. Provide dates with the training matrix to show when training was actually completed. Provide training for staff in Equality and Diversity. 11 12 13 14 OP19 OP20 OP19 OP19 OP21 15 16 OP30 OP30 Friary Fields Care Home DS0000008764.V361712.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact 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. Extracts may not be used or reproduced without the express permission of CSCI Friary Fields Care Home DS0000008764.V361712.R01.S.doc Version 5.2 Page 34 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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