Inspection on 04/07/07 for Friday House

This inspection was carried out on 4th July 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Friday House 27/02/07

Friday House 28/02/06

Friday House 06/09/05

Friday House 07/02/05

Friday House 04/10/04

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

CARE HOME ADULTS 18-65 Friday House 141 March Road Friday Bridge Wisbech Cambridgeshire PE14 0LP Lead Inspector Andy Green Unannounced Inspection 4th July 2007 10:30 Friday House DS0000015182.V339612.R01.S.doc Version 5.2 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 Friday House DS0000015182.V339612.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 Adults 18-65. 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. Friday House DS0000015182.V339612.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Friday House Address 141 March Road Friday Bridge Wisbech Cambridgeshire PE14 0LP 01945 860186 01945 860166 friday.house@activecarepartnerships.co.uk the.willows@ashbourne.co.uk Exceler Healthcare Services Limited Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered acting manager (if applicable) Type of registration No. of places registered (if applicable) Acting manager post vacant Care Home 19 Category(ies) of Dementia (1), Learning disability (19), Learning registration, with number disability over 65 years of age (1) of places Friday House DS0000015182.V339612.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. One person under 65 years with dementia (DE) and an associated learning disability One person over 65 years with a learning disability (LD (E)) Categories detailed in Conditions 1 & 2 are for current residents only Date of last inspection 27th February 2007 Brief Description of the Service: Friday House is a large detached house set in extensive grounds in the village of Friday Bridge near to Wisbech. It is within walking distance of the village centre amenities and a reasonable driving distance of the market towns of March and Wisbech. The home is on a bus route. The accommodation is on two floors. There are two sitting rooms, a large games room and a dining room. The residents have access to extensive gardens. The home is registered for 19 but presently accommodates 17 as two double occupancy rooms have been changed to single occupancy. There are two double occupancy rooms in use with the remainder being single. The fees range from £415 - £967 per week. Copies of CSCI inspection reports are available to residents and their representatives on request from the home’s office. Friday House DS0000015182.V339612.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Andy Green, Regulation Inspector, undertook this key unannounced inspection on 4th July 2007. He met with the acting manager, senior staff, support workers and residents to gather views regarding the services that are provided in the home. A number of records were inspected including care plans, training records, staff files, menus, staff rotas, medication records, fire testing records and health & safety records. A tour of the building and grounds was also undertaken. There has been a change of manager at Friday House since the last inspection. The manager has moved on to another post within the company. A manager from one of the company’s other care homes has been seconded to provide management cover until a permanent manager is employed. There have not been any comment cards received prior to this inspection so comments will be incorporated in the next inspection report regarding the home. What the service does well: What has improved since the last inspection? The acting manager and staff team are working positively to develop and improve the care and services provided in the home. The atmosphere and morale is improved and there is now a greater emphasis placed on teamwork. There have been recent additions to the staff team, which has reduced the use of agency staff. An acting manager has been appointed along with senior support workers to provide a clear management structure in the home. Friday House DS0000015182.V339612.R01.S.doc Version 5.2 Page 6 The care planning process remains person centred to ensure that residents are involved as much as possible in making choices about their lives. Decoration and refurbishment of the premises are underway which will greatly improve the communal and individual space for residents. Supervision arrangements have improved to ensure that the staff’s practice and training needs rare regularly monitored. 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. The summary of this inspection report can be made available in other formats on request. Friday House DS0000015182.V339612.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Friday House DS0000015182.V339612.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Full assessments are carried out to ensure that residents needs can be met. EVIDENCE: The Statement of Purpose and Residents Guide has been amended since the last inspection but the details are now inaccurate, as the manager has moved on. The acting manager stated that she would review the document and make appropriate changes during this interim phase. It was also noted that the home is registered for 19 residents but they can only take a maximum of 17, as two of the double rooms are single occupancy. The acting manager was advised to submit a variation to the registration department at CSCI regarding the home’s registration to accurately reflect the services that are provided. There has been one admission to the home since the last inspection and the acting manager stated that all relevant information via the care management process is received prior to admission to ensure that the individual’s assessed needs can be met. Handwritten notes of the assessment that was made were seen. It is recommended that the home implement a pre-admission Friday House DS0000015182.V339612.R01.S.doc Version 5.2 Page 9 assessment form to record the care and support needs of the prospective resident. Relatives are encouraged to be involved in the referral process where appropriate. A number of visits to the home can be arranged for prospective residents before they make a decision to move in. Friday House DS0000015182.V339612.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are treated with dignity and respect and receive personal care and support to meet their assessed needs. EVIDENCE: The care plans of three residents were inspected and they contained detailed and appropriate information. The care plans are recorded in a Person Centred Plan format, which incorporates the resident’s views, choices and preferences as much as possible. Information included the likes and dislikes, support and personal care needs, guidelines for the delivery of care and records of visits made by healthcare professionals. Daily notes were also seen and contained appropriate information describing events and appointments, which have occurred during the residents’ day. Regular reviews of care plans take place and include any updates or changes in care. This was evidenced in the care plans seen during the inspection. Friday House DS0000015182.V339612.R01.S.doc Version 5.2 Page 11 It was encouraging to see that the changes and improvements to the care planning process have been maintained. The acting manager stated that report writing training for all staff is being scheduled by the end of July 2007 to ensure that there is a consistent approach in the recording of information in care pans and daily notes. A risk assessment procedure continues to be in place to ensure that residents are protected from potential harm both within the home and when accessing the community. The acting manager stated that she would continue to monitor care planning with staff and key workers to ensure that there is a consistent approach. Friday House DS0000015182.V339612.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The range of activities offered, both at home and in the community, is not adequate to make sure residents are kept occupied. EVIDENCE: A wider range of activities and opportunities for personal development needs to be introduced so that residents have interesting things to do both in the home as well as in the local community. During the inspection there was little evidence of residents engaging in any organised activity in the home. Residents were, however mixing socially with staff in the dining area and recreation room. Other residents were either watching television or spending time in their bedrooms. A number of residents attend local day services. One of the residents has a keen interest in lorries and vans and he has recently become happily involved in a van cleaning enterprise. Friday House DS0000015182.V339612.R01.S.doc Version 5.2 Page 13 Residents make some trips to the local community, with staff assistance. This includes personal and house shopping, day trips and holidays. Activities have not significantly improved since the last inspection of the home. There was no evidence of any of the residents in the home during the day of any organised activities apart from watching television. The acting manager agreed that she had not seen evidence of any significant organised activities in the week that she had been involved with the home. There was a board displaying some activity options during the week but it was not clear how much residents had been involved. As the care staff also undertake cleaning and the cooking of meals there seems to be limited time to undertake activities with residents. It was recommended that the home employ an activities co-ordinator to organise both individual and group activities in the home. The recruitment of a cook and cleaning staff would also free up quality time for care staff to engage more socially with residents. The acting manager has agreed to send updates to CSCI regarding the further development of activities in the home. A requirement regarding activities was made at the last inspection and will be restated in this report. Residents benefit from a varied menu in the home and receive a choice of meals to meet their dietary needs and preferences. Residents are consulted regarding the planning of menus and they are involved in the shopping and preparation of food where possible. Friday House DS0000015182.V339612.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care is provided appropriately and clear guidelines regarding the safe administration of medication are followed. EVIDENCE: There have been no significant changes to personal and health care since the last inspection. Evidence seen in care in care plans and visits from healthcare professionals are recorded as appropriate. Residents continue to assisted by staff to access outpatient appointments at local hospitals or surgeries. This was evidenced in the care plans seen during the inspection. Staff continues to assist residents with personal care when needed and clear guidelines are recorded in care plans. It was observed that care staff interacted and spoke with residents in a friendly, sensitive and social manner, which was appropriate to residents’ individual needs. Staff were also observed to knock on resident’s bedroom doors before entering. Friday House DS0000015182.V339612.R01.S.doc Version 5.2 Page 15 Risk assessments were in place on individual files with evidence of reviews to ensure that risks to residents are adequately dealt with. Evidence of up to date risk assessments was seen on three of the resident’s files. Medication records were accurate and up to date. Friday House DS0000015182.V339612.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints process to make sure that residents and their representatives are able to raise concerns and have them dealt with appropriately. EVIDENCE: The home has a satisfactory complaints procedure in place to ensure that all concerns are fully investigated and actioned appropriately. There have been no complaints raised with the home since the last inspection. CSCI has not received any complaints since the last inspection. The acting manager stated that POVA training is confirmed for the end of July for all care staff to ensure they are up to date with current practice. Friday House DS0000015182.V339612.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment of the home provides residents with a safe, comfortable, clean place to live. However, there are areas in the home, which need refurbishment and redecoration. EVIDENCE: The home continues to generally meet the needs of the residents, and continues to be kept clean and free from unpleasant odours. Since the last inspection decoration and refurbishment has begun to the downstairs communal areas and kitchen. The dining area will be moved to one of the lounges near to the front of the building and the current dining area will be decorated and refurbished to provide a lounge area in the centre of the home which has always been a traditional meeting area of the home. The remainder of the house will be redecorated and refurbished in line with the maintenance plan that has been forwarded to CSCI. Friday House DS0000015182.V339612.R01.S.doc Version 5.2 Page 18 The acting manager confirmed that she would send updates to CSCI regarding the progress being made. She also confirmed that residents would be involved in the choice of colours for their bedrooms and communal areas. The handyman continues to deal with the day-to-day repairs in the home and the maintenance of the gardens. The acting manager stated that the dining area will be relocated to another area in the home and the current dining area will be redeveloped to provide a more homely and comfortable space. The acting manager also stated that catering arrangements would be organised, to minimise disruption to residents, whilst refurbishments/decorations are being made to the kitchen. It is recommended that the cooker be replaced as part of the refurbishments to the kitchen as it poses a potential health and safety concern due to the large heating surfaces. Friday House DS0000015182.V339612.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s recruitment processes ensure that residents are protected from harm, but staffing levels may not be adequate to meet the needs of residents. EVIDENCE: Two staff files were seen and they contained the required information including two references and evidence of satisfactory POVA/CRB checks. A staff-training programme is in place to ensure that mandatory and client specific training is delivered. Training in the last 12 months has included moving & handling, fire safety, first aid, health & safety, crisis prevention, medication (via Boots), infection control and epilepsy. It was recommended that an individual training record sheet is included in each staff file along with certificates of achievement. The acting manager stated that she would up date staff files accordingly. The acting manager stated that she will be organising NVQ training over the next few weeks is all levels of care staff to meet expected nationally agreed Friday House DS0000015182.V339612.R01.S.doc Version 5.2 Page 20 As mentioned previously in this report staffing levels in the home do not always allow sufficient staff time for involvement in activities with residents both in the home and when accessing the community. Care staff continue to have responsibility for all domestic tasks and cooking as well as providing basic care and support. The care staffing levels and domestic tasks must be reviewed to ensure that residents social needs can be adequately met. The addition of an activities co-ordinator, cook and cleaner would be of great benefit. A requirement regarding staffing levels in the home was made at the last inspection and will be restated in this report. The staff rota was inspected and was accurate. The full names of all staff are now recorded. Staff supervision has improved since the last inspection. The acting manager is aware that this was an area of concern at previous inspections and that she would ensure that staff receive recorded supervise sessions on at least 6 occasions during the year. Friday House DS0000015182.V339612.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,41,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well managed by an acting manager to ensure care and support is delivered and monitored through quality assurance processes. EVIDENCE: Since the last inspection the manager has recently moved on to another post within the company. Another manager from one of the company’s care homes has been seconded to provide management in the home until a manager has been appointed and inducted for the home. Consequently the home does not have a registered manager at present. This was highlighted in the last report. Friday House DS0000015182.V339612.R01.S.doc Version 5.2 Page 22 The acting manager had been in post for approximately one week. During the inspection it was often difficult to locate all the required documents but they were eventually found. It is clear that the administrative processes need to be improved including the storage of required files and documents so that they are accessible and can be easily retrieved. The acting manager stated that she will be improving the management processes in the home. Records of fire alarm and emergency lighting were inspected and there has been a general improvement. However it was noted that emergency lighting tests had not been carried out in June 2007. Friday House DS0000015182.V339612.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 X 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 3 3 X 3 2 X Friday House DS0000015182.V339612.R01.S.doc Version 5.2 Page 24 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 YA12 Timescale for action 16(2)(m)(n) The home must provide a range 30/09/07 of activities to meet residents’ preferences and needs. This was a requirement from the last inspection and failure to comply may result in legal action being taken against the home. 18(1)(a) The home must provide sufficient staff to meet service users needs at all times. This was a requirement from the last inspection and failure to comply may result in legal action being taken against the home. 30/10/07 Regulation Requirement 2. YA33 Friday House DS0000015182.V339612.R01.S.doc Version 5.2 Page 25 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 3 Refer to Standard YA2 Good Practice Recommendations It is recommended that the home devise a pre-admission assessment form to record the care and support needs of the prospective resident. It is recommended that individual training records are held in each staff file. It is recommended that the management and administrative processes are reviewed to ensure a consistent and clear approach. YA35 YA38 Friday House DS0000015182.V339612.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Friday House DS0000015182.V339612.R01.S.doc Version 5.2 Page 27 - 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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