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Inspection on 21/11/05 for Friary House

Also see our care home review for Friary House for more information

This inspection was carried out on 21st November 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Friary House has an established and stable staff team many of whom have worked at the home for several years. Staff worked well as a team and had developed good relationships with the residents and with each other. The registered manager is suitably qualified and with the support of the staff maintains a relaxed and homely atmosphere. All residents spoken with expressed a genuine fondness and appreciation for the work the staff did. A total of seven resident`s comment cards were received and all indicated that each person was satisfied with the level of personal care and two people specifically added personal comments "very well looked after, the staff and care has been excellent".

What has improved since the last inspection?

Since the last inspection Friary House has successfully been awarded The Investors in People award and credit must go to all the staff and management for this achievement. A comprehensive annual report has been submitted to the Commission. Information to complete this report was based on feedback and answers obtained from a series of questionnaires circulated to each resident. Topics of the questionnaires included: -catering, personal care / support, daily living, premises and management.

What the care home could do better:

Recruitment procedures must include the required information & documents as listed in Schedule 2 of the National Minimum Standards, Care Homes Regulations for each member of staff working in the home. Some parts of the premises are at present undergoing improvement and this programme of work must be completed without undue delay.

CARE HOMES FOR OLDER PEOPLE Friary House 26 Carlton Road North Weymouth Dorset DT4 7PY Lead Inspector Marion Hurley Unannounced Inspection 21st November 2005 11:30 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 House DS0000026804.V264885.R01.S.doc Version 5.0 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 House DS0000026804.V264885.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Friary House Address 26 Carlton Road North Weymouth Dorset DT4 7PY 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) 01305 782574 www.kfcare.co.uk Mr Michael Antony Fry Mr Peter Fry Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Friary House DS0000026804.V264885.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th April 2005 Brief Description of the Service: Friary House residential care home for elderly people is established in a large detached property situated in a quiet residential area of Weymouth. It is close to local shops and other amenities and a short bus trip away from Weymouth seafront. It is one of two homes owned by Mr M Fry, the other home being Kingsley Court. Mr M Fry has been the registered proprietor since 1985 and his son Mr P Fry became the registered manager in 2000. The accommodation is arranged over three floors, accessed by a passenger lift and main staircase. The service users bedrooms are situated on all levels; many are generously sized and all have en-suite facilities. Communal areas include a lounge and a separate dining room. The home is set in grounds surrounded by hedges and trees. The back garden is inaccessible to the service users and is mainly lawn with mature apple trees. The front garden is paved and small. Limited street parking is available outside the home for visitors. Friary House DS0000026804.V264885.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection has been undertaken as part of the normal inspection process legally required in accordance with the Care Standards Act 2000. Friary House was assessed according to the Care Homes for Older People, National Minimum Standards. The inspection took place over seven hours three of which were spent in the home. During the course of the visit eight staff were present and the registered manager was available. A total of five residents were spoken with two privately in their bedrooms and a further three joined in a general discussion in the lounge. Records and documents relating to those standards assessed were examined and read. Requirements and recommendations from the previous inspection remain within the previously issued timescale and therefore were not assessed again at this inspection. A further requirement has been issued concerning poor recruitment practises. What the service does well: Friary House has an established and stable staff team many of whom have worked at the home for several years. Staff worked well as a team and had developed good relationships with the residents and with each other. The registered manager is suitably qualified and with the support of the staff maintains a relaxed and homely atmosphere. All residents spoken with expressed a genuine fondness and appreciation for the work the staff did. A total of seven resident’s comment cards were received and all indicated that each person was satisfied with the level of personal care and two people specifically added personal comments “very well looked after, the staff and care has been excellent”. Friary House DS0000026804.V264885.R01.S.doc Version 5.0 Page 6 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 contacting your local CSCI office. Friary House DS0000026804.V264885.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Friary House DS0000026804.V264885.R01.S.doc Version 5.0 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 the following standard(s): Standards 1,2,3 & 5 were assessed and met at the previous inspection and NMS 6 is not applicable at Friary House. EVIDENCE: Friary House DS0000026804.V264885.R01.S.doc Version 5.0 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 the following standard(s): 9 • Residents receive prescribed medicines at the correct times and in correct amounts, those wishing so can manage their own medicines EVIDENCE: The storage of the medicines and the medication records were all examined and found to be safely and well maintained. The Mar charts were all correctly signed and the file had sample signatures of those staff who administered the medication. The storage system was clear and securely locked with an additional locked storage for controlled drugs when in use in the home. At the present time no resident is prescribed controlled drugs. There are four residents who are self medicating and each has a completed risk assessment concerning their individual vulnerability regarding the potential hazards in self-medicating. Each resident’s risk assessment is reviewed monthly. This is good practice and ensures their individual capacity to safely manage their own medication is continually monitored. The Pharmacy supplying the medicines to Friary House completed their annual review in October 2005 and their report stated procedures and administration of medication was satisfactory and no recommendations were made following this review/inspection. Friary House DS0000026804.V264885.R01.S.doc Version 5.0 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 the following standard(s): 14 & 15 • Residents are helped to exercise choice and control over their lives. • A balanced and varied diet is provided. EVIDENCE: Observation and discussion with residents demonstrated that they choose their preferred lifestyles within the home according to their individual preferences. One resident said they prefer their own company and spent most of their time in their room. It was clear from discussion with staff that they respect this resident’s wishes. Other residents use the communal lounge as they wish and on the day of this visit three ladies were resting in the lounge after lunch. Residents can choose at what time they go to bed and are not awakened in the morning unless they request to be called. A designated cook is employed though there are occasions when care staff cook the meals. The main meal is at mid-day and a choice is always available. Despite there not being a menu on display the care staff inform the residents in the morning what the main meal is going to be. If the resident wants an alternative the cook is informed. A minimum of two fresh vegetables are served daily with this main meal. Teatime is more of a snack meal but again all the residents are offered a daily choice. Very little prepared food is purchased as the cook believes in serving good quality home made meals and this was evident on the day of the inspection. Friary House DS0000026804.V264885.R01.S.doc Version 5.0 Page 11 A cleaning schedule was seen and this is kept up to date with weekly and daily chores plus a six monthly total clean. The temperatures of appliances were not recorded daily and this needs to be done. Residents were asked if they enjoyed their meals and emphatically all stated they did and appreciated the “home cooking” Friary House DS0000026804.V264885.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 were assessed and met at the previous inspection . EVIDENCE: Friary House DS0000026804.V264885.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 & 26 were assessed at the previous inspection and met. EVIDENCE: Friary House DS0000026804.V264885.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 & 30 • Practises in relation to staff recruitment need improvement as residents are potentially placed at risk through the lack vigorous checks ensuring their protection. • Progress has been made for staff to gain their National Vocational Qualifications (NVQs). EVIDENCE: Several of the staff members at Friary House have been in post for a number of years. Staff commented that they worked well as a team. Separate domestic and catering staff are employed. There is a fortnightly rota, which suits all the staff, and this rarely changes. There are usually two care staff working in the morning and two in the afternoon plus the senior care worker and the Registered Manager and secretary who are all supernumerary on the daily rota. Four residents self care and the remainder require varying levels of personal care. One resident commented that whilst the staff were excellent they felt they all had to work very hard to get all their work done and sometimes this gave a sense of “rushing”. The staff file of the most recently recruited member was examined and it was found not to contain either a CRB check or evidence of a POVA first check. This was discussed with the registered manager who explained they thought that these checks were still portable. Another staff file was examined and whilst it contained relevant information it was not well organised and there was no checklist stating when references had been applied for and successfully returned. Friary House DS0000026804.V264885.R01.S.doc Version 5.0 Page 15 There was written evidence to demonstrate that all staff receive statutory training this was further evidenced is discussion with staff. Two staff have successfully completed NVQ 2 and one member the NVQ 3. Two staff members are studying for their NVQ level 2 and one for the NVQ level 3. The registered manager is studying NVQ level 5. Friary House DS0000026804.V264885.R01.S.doc Version 5.0 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): 35 • All residents either manage their own money or have personally nominated a significant person of their choice to do so on their behalf. EVIDENCE: The Registered Manager stated that he does not manage any of the resident’s financial affairs and no money is held on the resident’s behalf. If a resident does not wish to maintain any funds in the home then the registered manager will purchase or make any small payments on their behalf and this will then either be collected from the person managing the resident’s financial affairs or added onto their monthly account. Records were seen of these transactions and there were invoices for each item /payment. Friary House DS0000026804.V264885.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x x x X N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x x x x x x x x x STAFFING Standard No Score 27 x 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x x x x x Friary House DS0000026804.V264885.R01.S.doc Version 5.0 Page 18 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 OP29 Regulation 19 Requirement The registered person must ensure all the required information & documents as listed in Schedule 2 are kept in respect of each member of staff working in the home The grounds must be accessible to all residents. This refers to the rear and side area. This requirement is carried forward from the previous inspection and remains within the required timescale of November 2005. Work is in progress to meet this standard. This standard was not assessed & the requirement remains within the original timescales. The laundry walls must be washable. This requirement is carried forward from the previous inspection and remains within the required timescale of November 2005. Work is in progress. This standard was not assessed & the requirement remains within the original timescales. DS0000026804.V264885.R01.S.doc Timescale for action 30/11/05 2 OP26 23(2)(o) 31/03/06 3 OP33 16(2)(j) 31/03/06 Friary House Version 5.0 Page 19 4 OP38 24(1) The registered provider must produce a report following the monthly visits and send a copy to the Commission. This requirement is carried forward from the previous inspection (timescale not met 28/02/05). This standard was not assessed & the requirement remains within the original timescales. 31/03/06 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 OP15 Good Practice Recommendations A daily record of the temperatures of the fridge and freezers should be maintained. Friary House DS0000026804.V264885.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 House DS0000026804.V264885.R01.S.doc Version 5.0 Page 21 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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