Inspection on 30/11/05 for Friary Fields Care Home

This inspection was carried out on 30th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 17/04/07

Friary Fields Care Home 15/06/06

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 Stephen Benson Unannounced Inspection 30th November 2005 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Friary Fields Care Home DS0000008764.V269982.R03.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.V269982.R03.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 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.V269982.R03.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 peoplpe 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 1st July 2005 Brief Description of the Service: Friary Fields is a care home providing personal care and accommodation for 34 older people, 31 of whom may have 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 homes bedrooms are single, and 7 of the bedrooms have en-suite 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 were in the process of being landscaped. There is car parking available for 8 cars. Since the last inspection the home has had a six bedded extension registered. Friary Fields Care Home DS0000008764.V269982.R03.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second of two unannounced inspections carried out between April 2005 and March 2006. The inspection lasted for 3 ½ hours and the main method of inspection used was called case tracking which involved selecting 3 residents and tracking the care they receive. Due to issues that rose during the inspection there was only time for brief discussions with residents and a relative were spoken with. A discussion was had with the manager, care staff on duty and care practices were observed. The premises were not inspected in detail but various areas of the home were visited as part of the inspection What the service does well: What has improved since the last inspection? Friary Fields Care Home DS0000008764.V269982.R03.S.doc Version 5.2 Page 6 Since the last inspection the extension has been completed and has been registered increasing the homes registration by six rooms. Dementia has been added to the homes registration category and a number of physical adaptations were made to provide a safe environment for these residents including fitting window restrictors and raising a banister. One of the fire escape routes has been improved through the removal of hazards and providing lighting. The garden is currently being landscaped. What they could do better: When returning unused medication to the pharmacist this should not be left out unsupervised and all unused controlled drugs should be included in the medication that is returned. Residents should only have creams used on them that are their own and these should not be used communally. Residents should have their own shavers which should not be used on other residents and they should not be shaved in a communal room. When using a wheelchair, residents should have their feet placed on footplates to prevent the risk of injury. All complaints made should be recorded in the complaints book as well as in the daily notes and if there is any form of allegation of abuse made this should be reported through the adult protection procedures. Staff should be aware of the adult protection procedures and know about then home’s policy on whistle blowing if they should have any concerns about the well being of residents. Any radiators that so not have a low surface temperature should have a guard fitted to prevent the risk of burning. The manager should make sue that all staff know and follow the correct practices to prevent the risk of infection. There should be a training programme showing when staff will be provided with all the mandatory training. Please contact the provider for advice of actions taken in response to this Friary Fields Care Home DS0000008764.V269982.R03.S.doc Version 5.2 Page 7 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 DS0000008764.V269982.R03.S.doc Version 5.2 Page 8 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.V269982.R03.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: Friary Fields Care Home DS0000008764.V269982.R03.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 and 10 The homes practices in handling medication need to be strengthened and greater attention is required in promoting residents’ privacy and dignity. EVIDENCE: During the inspection the chemist came to collect medication to be returned. The manager collected a carrier bag from behind the office door, which had been left open. The manager agreed that the bag would have been left unattended for some of that time. When asked whether this had posed a risk the manager said that he did not feel that it had, as nobody knew it was there, residents don’t go into the office and there is always someone around. It was also said that this had been kept locked until taken out of the cupboard about 10 to 15 minutes previously, as the chemist was due. Medicine Administration Records (MAR) were in the main fully completed, although there were some gaps seen that could not be explained. The manager said that he would investigate the reason for these. Friary Fields Care Home DS0000008764.V269982.R03.S.doc Version 5.2 Page 11 The manager said there are not any residents who are able to self medicate and no residents are currently taking controlled drugs. There were two prescribed controlled drugs in the medicine cabinet for current residents bothdated back to July 2005. The manager said that these are not being taken at present. The manager said that only senior staff who have completed NVQ level 3 are giving out medication and a member of staff said that she is being encouraged to train to be able to administer medication. There were 4 tubs of aqueous cream seen in the bathroom belonging to different residents, two of which were open and the other two were not. Staff said that these were used to apply to residents after bathing and said that it was possible that cream belonging to one resident was applied to another. There was also a tub of E45 cream, which had a dispensing pump fitted. The manager said that he thought it was acceptable for this to be used communally. One resident was seen being shaved in the large communal dining room and lounge. There were other residents present at the time. This was drawn to the attention of the manager who said that he had told the member of staff hundreds of times. Further staff asked about shaving procedures said that the same electric razor ha been used on different residents. A supply of electric razors was shown in the bathroom, all kept in a drawer, and staff were asked to identify which resident they belonged to, but they were not able to do this. The manager later in the inspection produced two electric razors with paper stuck on with what appeared to be initials, which he said were there to identify which resident they belonged to. One member of staff said she was aware that residents have been shaved in communal areas and shared shavers although she would not do so herself. The member of staff who was seen shaving the resident said that he had never done so before and had only done so as he had been so busy. Staff said that there are three residents who have wet shaves and on going to their rooms only one of these had any shaving equipment in. Care plans did not include residents preferred method of shaving or how or where this should be carried out. A resident was seen being moved in a wheelchair without footplates. The manager said that this was normal practice where resident’s legs were not long enough to reach the floor so that the door and skirting board paintwork did not get damaged. There was no record evidenced within care plans to explain this. Friary Fields Care Home DS0000008764.V269982.R03.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 A wholesome appealing balanced diet is provided. EVIDENCE: Breakfast consists of a choice of cereals, porridge and toast with a hot drink. The main meal is at lunchtime and although a choice is not provide alternatives are available if wanted. Meal records showed that these are provided. There is a roast dinner served on Sundays and in midweek, which was seen served at this inspection. There were ample portions and residents said they like the Yorkshire puddings. A relative said that the food is very good. Choices of sandwiches are usually provided at teatime. Friary Fields Care Home DS0000008764.V269982.R03.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Complaints and allegations are not being responded to appropriately. EVIDENCE: The home has a complaints procedure and uses a complaints log to record any complaint in. The procedure was not looked at as part of this inspection. There were some entries seen in daily record sheets indicating that a resident had raised a complaint, however no record was made in the complaints log. One instance referred to a resident complaining about two staff but no further reference was seen to this and the manager could not recall the details. There was one recorded complaint, which stated that a resident had accused a member of staff of threatening to lock her in her room all day without any food or water. This had not been treated as an allegation of abuse under the adult protection procedures. Staff were not aware of the adult protection procedures or if the home had a whistle blowing policy. Friary Fields Care Home DS0000008764.V269982.R03.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 25 and 26 Resident’s live in safe, comfortable surroundings, which are clearn and hygiene. EVIDENCE: Domestic staff are employed to attend to the cleaning of the building. Protective gloves and aprons are provided and staff said they are meant to change these after each resident, but were not certain that this is done all the time. Friary Fields Care Home DS0000008764.V269982.R03.S.doc Version 5.2 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 and 30 Current staffing levels are satisfactory but they will need to be increased when the new extension comes in to operation. There is no system in place at present to ensure that staff receive the required training. EVIDENCE: There is a minimum of three care staff on duty from 7 am until 10pm, then 2 waking staff on duty overnight. The home has 2 managers, both of whom work full time and there is a cook and domestic on duty each day. It is intended to increase the staffing levels as new residents are admitted into the recently registered extension. Four adaptation nurses have been recruited who it is intended will be coming to work at the home early in the New Year. Three staff have completed NVQ level 3 and two staff are currently working towards NVQ level 2. Records indicating staff training were examined, although there was no evidence of a training plan. A programme would plot the training received by all staff and indicate any gaps and allow the registered person to plan effectively to offer mandatory training and budget for this. Friary Fields Care Home DS0000008764.V269982.R03.S.doc Version 5.2 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 There are suitable arrangements in place to manage the home. Suitable arrangements are in place to assist residents with their finances. Arrangements are in place to promote the health, safety and welfare of residents EVIDENCE: The home has one registered manager but the day-to-day management of the home is shared out between the registered manager and his son, who has achieved the registered manager award. The manager said that they have not undertaken any quality assurance surveys during the year but intend to so during the next month. Friary Fields Care Home DS0000008764.V269982.R03.S.doc Version 5.2 Page 17 Relatives are encouraged to manage residents’ finances but the home does operate a system to manage residents personal needs allowance. Records seen showed that each transaction has 2 witnesses, either two staff or one staff and the resident concerned. The fire log showed that fire safety tests are carried out weekly and a fire alarm test was held during this inspection. The manager said that the required tests are carried out to prevent the risk of Legionella. Portable electrical appliances were marked as having being tested within the last month. The boiler has not been serviced within the last 12 months and is due for a service which the manager said was in the process of being arranged. Friary Fields Care Home DS0000008764.V269982.R03.S.doc Version 5.2 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 X X X X X X 3 3 STAFFING Standard No Score 27 3 28 3 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Friary Fields Care Home DS0000008764.V269982.R03.S.doc Version 5.2 Page 19 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. 2. 3. Standard OP9 OP9 OP9 Regulation 13 13 13 Requirement Timescale for action 30/11/05 Ensure that all medication is kept securely at all times when not under the supervision of staff Return any controlled drugs to 01/01/06 the pharmacist not in current use Ensure that creams are only 30/11/05 used for the prescribed resident and seek the views of an infection control nurse as to the communal use of cream with a dispensing pump fitted. Ensure that residents are shaved in a manner that respects their privacy and dignity and that they are shaved with their own razor. Ensure a record is made of all complaints made Ensure that any allegations of abuse are reported through the adult protection procedures Ensure that staff are aware of the adult protection procedures and the homes whistle blowing policy 30/11/05 4. OP10 12 5 6 7 OP16 OP18 OP18 22 12 13 30/11/05 30/11/05 01/02/06 Friary Fields Care Home DS0000008764.V269982.R03.S.doc Version 5.2 Page 20 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. 2. Refer to Standard OP30 OP30 Good Practice Recommendations Prepare a training plan to ensure that all staff receive the required training. Footplates must be used when using wheelchairs Friary Fields Care Home DS0000008764.V269982.R03.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Nottingham Area Office 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 DS0000008764.V269982.R03.S.doc Version 5.2 Page 22 - 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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