Inspection on 01/07/05 for Friary Fields Care Home

This inspection was carried out on 1st July 2005.

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

Friary Fields Care Home 01/04/08

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 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 Stephen Benson Unannounced 1 July 2005 09:30 st 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 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 C03 C53 S8764 Friary Fields V236313 010705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Friary Fields Care Home Address 21 Friary Road Newark Nottinghamshire NG24 1LE 01636 706 105 01636 702 747 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Leckraz Ramchurn Friary Fields, 21 Friary Road, Newark, Nottingham, NG24 1LE Mr Leckraz Ramchurn Mr Ashvin Ramchurn Care Home (CRH) 25 Category(ies) of Old age, not falling within any other category registration, with number (OP) of places Friary Fields Care Home C03 C53 S8764 Friary Fields V236313 010705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: N/A Date of last inspection 12th October 2004 Brief Description of the Service: Friary Fields is a care home providing personal care and accommodation for 25 older people. An application is currently being considered to include caring for people with dementia. The home provides short and long term care and will accept emergency admissions. The home is owned by Friary Fields Limited which is run as a family business The home is located in a residential area close to Newark town centre where there are shops, pubs, post office, theatre, churches and other amenities. The home was opened in 1982 and consists of an extended domestic dwelling. 21 of the home’s bedrooms are single, and none of the bedrooms have ensuite facilities. Bedrooms are located on 3 floors, some rooms are served by a passenger lift and others a stair lift. The gardens have been temporarily out of use due to building work and are to be landscaped in he near future. There is car parking available for 8 cars. Since the last inspection the home has built a six bedded extension which is hoped to be registered shortly. Friary Fields Care Home C03 C53 S8764 Friary Fields V236313 010705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the first of two unannounced inspections to be carried out between April 2005 and March 2006. The inspection lasted for 5 hours and the main method of inspection used was called case tracking which involved selecting 3 residents and tracking the care they receive through the checking of their records and discussing this with them. Other residents were spoken with and additional records were seen. A discussion was had with the manager, care staff on duty and care practices were observed. Other residents and relatives were spoken with as well as a visiting social worker. The premises were also inspected in light of an application received to vary the homes current registration. What the service does well: What has improved since the last inspection? What they could do better: The home should make sure that up to date tissue viability assessments are used when required. There were some Health & safety concerns, particularly with regard to the risk of residents falling down the stairs, and a hazardous exit route at the rear of the property, if evacuating along the fire escape – particularly at night. Windows on the 1st and 2nd floor have not been fully restricted to prevent any accident. Friary Fields Care Home C03 C53 S8764 Friary Fields V236313 010705 Stage 4.doc Version 1.40 Page 6 Careful consideration needs to be given as to which residents can be accommodated on the 2nd floor as this can only be reached by the lift. When recruiting staff from overseas the same recruitment checks should be carried out as for staff from this country. 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. Friary Fields Care Home C03 C53 S8764 Friary Fields V236313 010705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Friary Fields Care Home C03 C53 S8764 Friary Fields V236313 010705 Stage 4.doc Version 1.40 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 standard(s) 3 New residents are assessed prior to admission. EVIDENCE: The home require a community care assessment to be provided prior to admission to establish whether the needs of any potential resident can be met. Assessments were seen on files inspected, including one for the most recently admitted resident. Friary Fields Care Home C03 C53 S8764 Friary Fields V236313 010705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 and 8 The documentation allows for residents needs to be set out in the care plan but needs to be kept up to date. EVIDENCE: Care plans include a daily living assessment and these detail key areas of care and how these are to be met. Residents said that staff know the support they want and help them when needed. A record is made of all medical appointments in the daily notes. There are forms for monitoring the well being of residents where concerns are identified, however one resident who is confined to bed did not have a recent tissue viability assessment on file or details of support required in the care plan. Friary Fields Care Home C03 C53 S8764 Friary Fields V236313 010705 Stage 4.doc Version 1.40 Page 10 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 standard(s) 12, 13 and 14 Residents have opportunities to take part in activities and spend time with friends and family. EVIDENCE: Residents have the choice of 2 lounges, and were seen involved in differing activities. Residents said they enjoyed playing various games and liked doing word searches. A group of residents were seen playing a board game during the inspection. A member of staff was seen taking requests from residents when going to the shops, including buying a pair of slippers and purchasing a lottery ticket. Visitors are welcome at any time and can see residents in private. One resident described going out with her friend and another said that her family visits her. Staff said that residents are able to make choices over their daily routines. Residents were seen choosing how they were going to spend their time and discussing the colour of some new slippers. Friary Fields Care Home C03 C53 S8764 Friary Fields V236313 010705 Stage 4.doc Version 1.40 Page 11 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 standard(s) None EVIDENCE: Friary Fields Care Home C03 C53 S8764 Friary Fields V236313 010705 Stage 4.doc Version 1.40 Page 12 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 standard(s) 19, 20 and 22 Residents have been disrupted by the current building work. Some work is required in order to promote the safety of residents. EVIDENCE: There have been a number of temporary arrangements made due to the recent building work. Residents said that they had got used to the changes but were looking forward to being able to use the main lounge again. A variation request to care for people with dementia is currently being considered by The Commission for Social Care Inspection. The suitability of the accommodation was considered during this inspection. As an older building it has considerable character and many interesting features, but these also have some associated risks. Rooms by a staircase (10, 11 and 12) are unsuitable for use with people with dementia. The banisters at the top of this staircase pose a potential hazard and this needs to be addressed. Access to the 2nd floor can only be achieved by the use of the lift and residents need to be accompanied by staff when using this. Only residents who have been assessed as being able to call for assistance should be placed in these rooms. Windows on the first and second floor have not been adequately restricted. Friary Fields Care Home C03 C53 S8764 Friary Fields V236313 010705 Stage 4.doc Version 1.40 Page 13 The fire escape route was hazardous and poorly lit and its suitability needs to be assessed by the fire officer. Friary Fields Care Home C03 C53 S8764 Friary Fields V236313 010705 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 & 30 The home has the correct recruitment procedures, however these are not being followed in all cases. EVIDENCE: Correct recruitment procedures are followed for staff who are employed from this country, however the home has recently employed some staff from overseas. These staff have been recruited through an employment agency who collected the required references and criminal records check in order to secure a work permit. The home must follow their full recruitment procedures for all staff irrespective if they have already provided similar information to another body. Records in staff files showed that there was a good range of basic staff training available in the home. Friary Fields Care Home C03 C53 S8764 Friary Fields V236313 010705 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None EVIDENCE: Friary Fields Care Home C03 C53 S8764 Friary Fields V236313 010705 Stage 4.doc Version 1.40 Page 16 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 2 3 x 3 x x x x STAFFING Standard No Score 27 x 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x x x x x Friary Fields Care Home C03 C53 S8764 Friary Fields V236313 010705 Stage 4.doc Version 1.40 Page 17 NO 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. 2. 3. 4. 5. 6. Standard 8 19 19 19 13 29 Regulation 12 13 13 13 13 19 Timescale for action Ensure that monitoring forms are 1st August kept up top date 2005 Risk assess the banisters on the 1st back stairs and take any action September identified 2005 Ensure all windows are suitably 1st restricted so that a resident September could not fall out 2005 nd Assess residents using the 2 1st floor to ensure they are able to September summons assistance if required 2005 Seek the views of the fire offioer 1st regarding the suitablity of the September fire escape 2005 All staff must be recruited 1st August following the correct procedures 2005 Requirement 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 Good Practice Recommendations Friary Fields Care Home C03 C53 S8764 Friary Fields V236313 010705 Stage 4.doc Version 1.40 Page 18 Commission for Social Care Inspection Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Friary Fields Care Home C03 C53 S8764 Friary Fields V236313 010705 Stage 4.doc Version 1.40 Page 19 - 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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