Inspection on 17/04/07 for Friary Fields Care Home

This inspection was carried out on 17th April 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 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 01/04/08

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 Vanessa Gent Unannounced Inspection 17th April 2007 09:30 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.V334406.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.V334406.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 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.V334406.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 15th June 2006 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 whom 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 wash-basin. 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.V334406.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 £326 for low to £420 for high dependency residents. Friary Fields Care Home DS0000008764.V334406.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit was made to the home as part of a key inspection. It started at 09.45 and lasted 4½ hours. Information already held on file was used to plan the visit. The main method of inspection used is called ‘case-tracking’, which involves selecting a proportion of residents and tracking the care they receive through the checking of records, discussion with them, the care staff and observation of care practices. Six survey forms were received: two from residents and four from relatives. The two residents were helped to complete their forms by the same care staff person. Both residents replied “usually” to receiving care and support they need and staff being available when they need them. One also ticked that there are usually activities arranged that they can take part in and that they usually enjoy the food. The survey forms from relatives are positive about the level and quality of care given. Comments are included in the relevant sections in the report. The site visit focused on whether key standards and requirements from previous inspections had been met, how the residents and others feel about the service provided and how the residents’ needs are managed. Three residents’ assessments and care plans were examined to ensure the health, safety and welfare of the residents is checked and that residents are allowed dignity, autonomy and choice. Other evidence was gathered and a sample of other records were examined. Two of the staff on duty, eight of the twenty-two residents, including those being case-tracked, and several visitors spoke with the inspector. The provider and manager were available for most of this inspection visit. What the service does well: The home is run by a caring provider and manager who know each resident and their needs. The provider and manager support and encourage the staff team to provide good care to the residents. Nutritious, balanced meals and refreshments are provided regularly throughout the day. Friary Fields Care Home DS0000008764.V334406.R01.S.doc Version 5.2 Page 7 The rapport between the residents and staff is friendly and positive. Staff supervision is regular and staff feel that their work is supported through it. 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 Friary Fields Care Home DS0000008764.V334406.R01.S.doc Version 5.2 Page 8 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.V334406.R01.S.doc Version 5.2 Page 9 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.V334406.R01.S.doc Version 5.2 Page 10 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): 1, 3, 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents are not given enough information to be able to make an informed decision before coming to live at the home. The home cannot be sure it can meet the needs of all residents because of the person not being visited in their previous accommodation and a lack of assessment by the home’s staff. EVIDENCE: A copy of the statement of purpose and service users guide, updated in January 2007, has been provided. On page 5 it says that it is available in large print on request. Friary Fields Care Home DS0000008764.V334406.R01.S.doc Version 5.2 Page 11 Community Care Assessments are done by Social Services but no preadmission assessments are done by the provider or manager. This was discussed with the provider. He says that when Social Services have done their assessment, they phone the provider who shows the person’s representative around and offers them a particular room. The home’s own pre-admission assessment is only used for prospective residents who will fund themselves whilst living at the home. The lack of pre-admission assessments for all new residents may place them at risk of not having their care needs met. No written confirmation is sent out that informs the resident that the home can meet their needs. The provider only does a pre-admission assessment for privately-funded prospective residents. Friary Fields Care Home DS0000008764.V334406.R01.S.doc Version 5.2 Page 12 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 adequate. This judgement has been made using available evidence including a visit to this service. The care plans are not set out in an easy format to read and do not always contain full enough details to make sure that the care needs of all residents are met. Residents are treated with dignity and respect by staff and the manager and provider. EVIDENCE: The care plans could be better organised so that they are easy to read and understand by any staff or other people with access to them. Some information, which is important for the proper care of the residents, is missing from some care plans. Friary Fields Care Home DS0000008764.V334406.R01.S.doc Version 5.2 Page 13 Some of the care plans and assessments are not dated or signed so that the reader does not know who wrote them or when they were started from. Care staff only write in the daily evaluation sheets but do not actively contribute to the care plans fully. The provider or manager creates and reviews the care plans. There is no evidence that any resident or their representative has been involved in the creation or review of any care plans examined. Authority for the use of bedrails for one resident was obtained on a scrap of paper. There was no explanation of why the bedrails were necessary or what risk assessment had been done for using them. It was not written on the home’s headed paper, was not dated and the signatories were not identified to show who had given their permission. The care plan daily evaluation sheets examined are not updated regularly. Some have gaps of up to ten days without anything being recorded. Some information is missing from some care plans such as monitoring certain medical conditions and treatments and following up on treatments such as wound care. This may not provide safe and adequate care and may put residents at risk of neglect. It states in the care plans that they are reviewed monthly. A page containing the dates of review and the signatures of the person writing them is evident. However, only the date and signature is written. There is no information on what has developed, deteriorated or improved, so the reviews do not identify whether the residents’ needs are met. 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. Comments from relatives include, “We feel our [relative] is being well cared for”. “[Our relative] seems really happy and settled so I’m sure all her needs are met.” Medication practices were not scrutinised thoroughly at this visit although the inspector did observe staff on two occasions taking medicines to residents and signing the medication administration (MAR) sheets afterwards, as is good practice. The previous inspector had seen that the medication procedures were safe and adequate for the residents’ needs. Staff said they had received some training for giving the medications correctly and feel confident that their practice keeps residents safe. Residents are given more dignity when their personal needs are being attended to than was seen previously. This included where they are being shaved and Friary Fields Care Home DS0000008764.V334406.R01.S.doc Version 5.2 Page 14 when hoisted from chair to wheelchair in a communal area. The rapport between the residents and staff is friendly and positive. Friary Fields Care Home DS0000008764.V334406.R01.S.doc Version 5.2 Page 15 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 adequate. This judgement has been made using available evidence including a visit to this service. Residents’ records contain insufficient details to show that enough activities or community contact happen regularly or are appropriate for the needs of residents with dementia. Visitors and relatives are welcomed and feel they can talk with the provider or staff openly and at any time. Meals and refreshments are provided in sufficient quantity and quality to meet the needs and wishes of the residents. EVIDENCE: Although a list of activities was provided with the Pre-Inspection Questionnaire (PIQ) completed by the provider, there is little evidence that regular activities take place in the home. One staff got out a floor game of snakes and ladders Friary Fields Care Home DS0000008764.V334406.R01.S.doc Version 5.2 Page 16 during the inspection visit but residents and visitors say this is not a regular occurrence. There is no social or past history of residents in the care plans. This means that their preferences, likes, hobbies and interests are not recorded so cannot be taken into account. Some residents said they would like to be taken into the town sometimes but there are not enough staff to do this. Occasional entertainments are provided at the home. The residents and visitors who spoke with the inspector say they are not taken into the garden and cannot take visitors into the conservatory. Relatives who responded to the ‘Have Your Say’ survey said they are allowed access to the home at any reasonable time. “We have been told we can come any time day or night without arranging first which we all agree says a lot.” Most relatives say that where residents cannot keep in touch with their families, the provider and staff do. One comment received states, “Whenever you ring up they are most helpful”. One relative states, “It would be nice if possible to have some contact from [resident’s] end in the form of a phone call or little note” (This resident would need some assistance from staff to perform this task.) The service users guide states that the aim is to “ensure that your views are taken into consideration and that you have a real say in the development of services available to you in the Home”. There is little evidence of residents being given much autonomy and choice in their lives at the home but the provider, manager and staff say most residents are not able to decide what they want or need so they must assist them in this. Staff say they get to know the residents very well so know what they want and need. Meals and refreshments are provided regularly throughout the day. Most residents say they always enjoy the food; one states, “it is good”. Choice is not offered at the main lunchtime meal. The alternatives at teatime are mostly which variety of sandwich is wanted, although there is sometimes a hot food dish on the menu. Recording of nutritional intake in the care plans has improved since the last inspection. Staff sensitively assist the residents who need help when eating and ample time is given for the residents to enjoy their meal. Drinks and fluids are available and encouraged at all times throughout the day, with glasses and jugs of fruit squash or water kept near to the residents in the communal areas. Friary Fields Care Home DS0000008764.V334406.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. 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. Residents are safe and have confidence that the staff and the manager will listen to and take heed of them. EVIDENCE: Visitors say they feel they can take issues, concerns or complaints to the owner and manager and will be listened to. Most residents are not able to make complaints themselves but, at the inspection visit, were treated affectionately by the caring staff on duty. One relative comments, “We have been told how to make a complaint but have found no reason to do so”. Just prior to the last key inspection, a complaint was made about the “conditions their relative was in” and “the home is generally very dark”. The resident was moved to another home. The rooms of residents case-tracked are all clean and tidy. An Adult Protection issue was raised with Social Services by the local hospital staff after the admission for a second time of a resident. A case conference was subsequently held and measures put in place for monitoring the care the resident receives at the home. The resident and their family was keen for the Friary Fields Care Home DS0000008764.V334406.R01.S.doc Version 5.2 Page 18 resident to return to live at the home and said that they believed that the care had been good in the past and that the resident likes living at the home. Residents say and indicate that they feel safe and that the staff are lovely. Staff say they have received training in preventing abuse to vulnerable people and know how to keep them safe. The staff training matrix shows that training for Safeguarding Adults has been undertaken by all staff, although there is no date to confirm when it was done. The provider says all staff have watched the video entitled “Abuse in the Care Home” and the subject, as well as the home’s whistleblowing policy is discussed in each staff’s individual supervision sessions throughout the year. Friary Fields Care Home DS0000008764.V334406.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 24, 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Whilst the home is kept clean and tidy, some areas of the home do not provide a comfortable, attractive, homely or safe environment for the residents to live in and enjoy. EVIDENCE: The decorative state of the older part of the home is still poor, as identified at previous inspections. The corridors are poorly lit, decorated in dark shades and look ‘drab’. The doors to some residents’ rooms are painted in a dark green colour and may not be easily identified by residents who forget where they are. Friary Fields Care Home DS0000008764.V334406.R01.S.doc Version 5.2 Page 20 Upstairs, the exit doors from some corridors are not clearly marked, which could cause or increase confusion for some residents. One resident says, “the home is OK but it’s not easy for some of them to find their way round”. Another resident could not easily find the exit door when the inspector asked to be shown to the stairs from a first floor landing. They then said the door is usually kept open. This door, however, is a fire door and must be kept closed. It was seen at the last inspection that the door between the dining room and corridor to the extension bedrooms and conservatory bangs loudly when closed. This is still in need of attention as it is annoying for residents sitting close by. Some bedrooms are in need of re-decorating and re-carpeting. Others, especially in the recent extension, are attractive, roomy and comfortable. One resident says that the room they have in the new wing is lovely. Some furnishings look worn and ‘shabby’, as quoted by a resident, and are in need of maintenance and repair. This was also identified at previous inspections. The provider reported in the pre-inspection questionnaire (PIQ) that the decoration is ongoing but has not provided a business plan to demonstrate how this is going to be carried out in the coming months. Two people who visit the home said that there is not always hot water available in the residents’ bedroom wash basins. At the visit, the sinks in the rooms of the residents whose care the inspector looked at in detail, had hot enough to wash in. Both the personal and communal areas of the home are clean and tidy although many carpets are quite worn and faded. Comments on the survey forms include, “They keep a clean friendly atmosphere”; “I feel … cleanliness is paramount”. Residents say they are not allowed or encouraged to use the conservatory; that it is mostly kept locked and only used by staff for training sessions and meetings. A complaint received states, “the conservatory door was always locked and no access to residents”. This is confirmed by visitors who contacted the inspector and residents the inspector spoke with. The provider maintains that residents have access to the conservatory and that the door to it is not locked. The conservatory was used in the morning for a meeting with Social Services and in the afternoon, the manager used it for training staff and during the inspection. 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. One visitor said that they have never seen residents taken out into the garden. Friary Fields Care Home DS0000008764.V334406.R01.S.doc Version 5.2 Page 21 Specialist equipment seen in use includes pressure-relieving mattresses and cushions, an electric hoist and a mechanical hoist. Friary Fields Care Home DS0000008764.V334406.R01.S.doc Version 5.2 Page 22 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. Staff are supported, basically trained and in sufficient numbers to keep the residents safe, happy and comfortable. EVIDENCE: Residents say that there are usually enough staff on duty for their needs. One resident said that the staff always come to them when they ring or call. The inspector confirmed this by observing staff during the inspection visit. Two residents say they would like to be taken into the town occasionally but there are not enough staff to provide this service. One relative comments, “[the resident] is kept clean and well looked after regarding his health”; “We cannot think that he could be looked after and cared for better and they put our minds at rest knowing he is getting 24-hour care”; “we are well satisfied with the service [the resident] gets”; “I feel that everyone takes care”; “we are very happy with the support”; “the care is very personal and friendly almost a family unit is created”. Friary Fields Care Home DS0000008764.V334406.R01.S.doc Version 5.2 Page 23 The staff files showed that the provider and manager follow the appropriate recruitment procedures, with references, (Criminal Records Bureau) CRB and POVA first checks being done for all staff employed and recruited. A senior staff says that they are involved in the induction process of new staff employed and that new staff shadow the more senior staff until they feel confident. The induction booklet seen shows that induction takes place over the first few days but that no follow up recorded. The PIQ says that seven staff have already achieved National Vocational Qualifications (NVQ) courses at Level 2 or higher. Seventy-one per cent of all care staff have started or completed NVQs. Staff say that the provider and manager support them with training. The provider, in the PIQ, states that since the last inspection, training has been given in fire prevention, communication, abuse awareness, policies and procedures, dementia care, moving and handling and health and safety. It does not state who has attended these courses and whether all staff are up-todate with their training. The inspector was supplied with the staff training matrix after the inspection visit. It shows that all staff have done basic training or are in the process of completing training units, although no dates have been supplied with the matrix to show when training was completed. The staff files the inspector saw contain certificates for training done but some of these were not within the past three years. The provider states in the PIQ that only one staff member holds a first aid certificate although the training matrix shows that most staff have qualified in basic first aid. Friary Fields Care Home DS0000008764.V334406.R01.S.doc Version 5.2 Page 24 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, 36, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The provider and manager support and encourage the staff team to provide good care to the residents. However, the wishes, preferences and choices of the residents or their representatives are not always known well enough to ensure that the home is in their best interests. Not all areas of the home are maintained well enough for the safe care of the residents. EVIDENCE: Friary Fields Care Home DS0000008764.V334406.R01.S.doc Version 5.2 Page 25 Relatives and residents say that the home is run by a caring provider and manager who know each resident and their needs well. The provider is a registered nurse. The manager has achieved the Registered Manager’s Award. One staff says, “The manager is a good listener. You can talk to him. He is there for you one hundred percent. I’m happy; I love my job. There’s a nice atmosphere. Every day is different.” Residents and relatives were given a survey questionnaire to air their views but this is not a regular event. The provider has not demonstrated, through the business plan or other means, how he has put the ideas and suggestions made into practice. Residents’ meetings are not held as the provider and staff say that many cannot put their wishes and thoughts into meaningful words. Relatives do not have meetings although the provider says they can go to him at any time. Staff meetings are not held as standard practice. In the previous inspection report, the inspector stated, “Residents’ finances are securely kept and records signed and kept accurately … ” Residents’ records seen show that this is still the case. Staff say that the provider and manager are very supportive. The staff files show that supervision sessions are held regularly for all staff. Staff say they can go to the provider and manager with any issues or problems and they will help them sort it out. The provider has not provided the commission with notifications of any incident, accident, event or death that has occurred either at the home or to any resident of the home. This is required by law. It was brought to the inspector’s attention that an incident had occurred between two residents but no record was found of a notification of it to the commission. The matter was discussed at the inspection visit and a copy of the form to comply with Regulation 37 of the Care Homes Regulations 2001 was left for the provider to photocopy and use in future. Staff say they are trained in health and safety and keep the residents safe. Safe methods of moving and handling were observed during the inspection visit. Fire safety is not observed in all areas of the home, as a fire door is reported to be kept open on the upper floor. When closed, the exit door to the stairs is inadequately marked and some residents would be unable to easily find a quick and safe exit in event of a fire. The provider keeps records of equipment maintenance. Friary Fields Care Home DS0000008764.V334406.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 X X X 2 X 2 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 2 X 3 3 X 2 Friary Fields Care Home DS0000008764.V334406.R01.S.doc Version 5.2 Page 27 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 OP3 Regulation 14(1)(c) Requirement Full assessments of prospective residents, involving them or their representative, must be made before offering accommodation at the home. This is to ensure the home can meet their needs. It must be confirmed in writing to the prospective resident or their representative that the home can meet the needs of the resident. This is to ensure the resident knows what to expect in the home when moving in. The risk assessments in the care plans must be dated and signed and describe clearly the full process that staff need to follow to care appropriately for the resident. Each care plan issue must be reviewed in sufficient detail to demonstrate how the resident’s care is being monitored. The resident or their representative must be enabled to be involved in the creation and review of care plans wherever possible and as they wish to be. This is to ensure that DS0000008764.V334406.R01.S.doc Timescale for action 30/06/07 2. OP4 14(1)(d) 30/06/07 3. OP7 15 30/06/07 4. OP7 15(1) 30/06/07 5. OP7 15(1,2) 30/06/07 Friary Fields Care Home Version 5.2 Page 28 6. OP12 16(2)(n) 7. OP14 12(2,3); 16(2) 8. OP19 23(2)(d) 9. OP24 23(2)(d) 10. OP38 23(4) 11. RQN 37 the residents know that they are being cared for appropriately. Activities that are sufficient in quantity, variety and often enough to suit the needs and wishes of the residents must be provided. The residents or their representative must be allowed and encouraged to exercise choice in their lives at the home. This is to enable them to live as they want in the home. The re-decoration of communal areas such as the corridors and lounges that have not been included in an improvement programme since the last inspection must be completed to provide a homely, pleasant and safe environment for the people who live there. The re-decoration of residents’ personal accommodation must be planned and put into action to provide them with a comfortable, homely and pleasant environment. All fire doors must be kept closed at all times and exits must be clearly marked to ensure that all residents are safe. 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. 31/05/07 31/05/07 31/07/07 31/07/07 30/04/07 30/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Friary Fields Care Home DS0000008764.V334406.R01.S.doc Version 5.2 Page 29 No. 1. Refer to Standard OP1 Good Practice Recommendations The provider should make the service users guide readily available in formats that residents can readily read and understand. Friary Fields Care Home DS0000008764.V334406.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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.V334406.R01.S.doc Version 5.2 Page 31 - 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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