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Inspection on 06/09/05 for Friday House

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

This inspection was carried out on 6th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

Despite the large size of this home, a homely atmosphere is maintained. Service users are confident and sociable. The staff training programme is excellent as is the quality assurance programme. The manager and her staff strive to promote the independence of the service users. They lead full and active lives with the majority having regular daytime activities and a varied social life. The home has its own transport in the form of a small bus and a car. Service users are encouraged to have control over all aspects of their lives and are included in staff recruitment and staff meetings.

What has improved since the last inspection?

New high quality leather sofas have been purchased and the lounge recarpeted. New exercise equipment has been provided for the games room at the service users request. Risk assessments are in place and recorded in care plans. One service user is now managing their medication and others are working toward doing so. Staff have had refresher training in care planning and communication.

What the care home could do better:

The information on making a complaint contained in the service users personal files is out of date.

CARE HOME ADULTS 18-65 Friday House 141 March Road Friday Bridge, Wisbech Cambridgeshire PE14 0LP Lead Inspector Jenny Cangy Unannounced 6th September 2005 @ 13:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 I03 I53 s15182 FRIDAY HOUSE v246789 060905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Friday House Address 141 March Rd. Friday Bridge, Wisbech, Cambridgeshire PE14 OLP Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01945 860186 01945 860 166 friday.house@carepartnerships.com Exceler Healthcare Services Limited Louise Whittaker Care Home 19 Category(ies) of Learning Disability (LD) registration, with number of places Friday House I03 I53 s15182 FRIDAY HOUSE v246789 060905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 07/02/05 Brief Description of the Service: Friday House is a large detached house set in extensive grounds on the edge of the Fen village of Friday Bridge. It is within walking distance of the village amentities and a reasonable driving distance of the market towns of March and Wisbech. The home is on a bus route. The accomodation is on two floors with bedrooms on both floors. There are two sitting rooms a large games room and a dining room. The service users have access to a large well kept garden. The home is registered for 19 but presently accomodates 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. Friday House I03 I53 s15182 FRIDAY HOUSE v246789 060905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection began at 13.00 and the inspector was admitted to the home by a member of staff who asked the inspector to sign the visitors’ book. The manager and her deputy were on duty and both were involved in the inspection process. Some service users were in the dining room finishing their lunch and the manager introduced them. The standards not met and those not inspected at the last inspection were reviewed. Service users care plans and personal files were seen and personal finances discussed. A tour of the home was undertaken and all the service users were spoken to and eagerly participated in the tour. This inspection was unannounced What the service does well: What has improved since the last inspection? What they could do better: The information on making a complaint contained in the service users personal files is out of date. Friday House I03 I53 s15182 FRIDAY HOUSE v246789 060905 Stage 4.doc Version 1.40 Page 6 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. Friday House I03 I53 s15182 FRIDAY HOUSE v246789 060905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Friday House I03 I53 s15182 FRIDAY HOUSE v246789 060905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4&5 The service users are provided with all the information and help they need to enable them to make an informed choice about living in Friday House. EVIDENCE: All prospective service users have a full needs led assessment and a gradual introduction to the home. They visit several times and have overnight stays prior to moving in. Another service user is given the responsibility of befriending them during this period. All service users have a contract of terms and conditions and statement of purpose and service user guide. These are kept in a ring binder in each service users room. Friday House I03 I53 s15182 FRIDAY HOUSE v246789 060905 Stage 4.doc Version 1.40 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8,9&10 Service users are able to exercise informed choice in all aspects of their daily lives within a risk assessment framework. All needs are met. EVIDENCE: All service users have a care plan that contains all the information required to meet their needs. Care plans are updated monthly at least and more often if necessary. Staff support service users to the greatest level of independence they can manage. Service users are involved in all aspects of the running of the home including interviewing new staff, participating in staff meetings, planning menus, activities and holidays. There is a confidentiality policy that is shared with partnership organisations such as those providing day services and education. Friday House I03 I53 s15182 FRIDAY HOUSE v246789 060905 Stage 4.doc Version 1.40 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,15,16,17 Service users have full and varied social lives within the local community and at home. Their rights as citizens are respected. EVIDENCE: Independent skills are continuously being developed both within the home and in the community. Some service users attend education courses in life skills. Others work as volunteers in local charity shops. Some participate in paid work in the gardens and washing cars. Relationships and friendships are supported and family contacts maintained. A local vicar visits regularly and service users who wish can attend the local church. A balanced diet is maintained and service users participate in menu planning. Staff do not enter any service users rooms without knocking and do not enter their rooms if they are out of the building. The shared rooms are spacious and have the means to afford privacy Friday House I03 I53 s15182 FRIDAY HOUSE v246789 060905 Stage 4.doc Version 1.40 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18.19,20,21 Service users receive personal care to the level they need and prefer. Physical and emotional needs are met. EVIDENCE: Service users all have a key worker and their care plan contains all the information needed to ensure all their personal, emotional and physical care needs are met. There is a good relationship with the community learning disability team and local GP. One service user manages their own medication and another is working towards doing so. Not all service users have a care plan to identify their preferences regarding ageing, illness, and death. The ones without are those who will not discuss the issues and get distressed if pushed. Friday House I03 I53 s15182 FRIDAY HOUSE v246789 060905 Stage 4.doc Version 1.40 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 Service users are protected from harm and their views listened to and acted on. Some information to enable this is in need of updating. EVIDENCE: There is a complaint procedure in each service users possession and complaints are taken seriously and acted on. However the information on how to get in touch with the CSCI is out of date in the service users folders. It is accurate on the notice board. All staff have had Protection of Vulnerable Adult (POVA) training and have an update session booked for next month. The company regard this as part of the essential training for staff. Friday House I03 I53 s15182 FRIDAY HOUSE v246789 060905 Stage 4.doc Version 1.40 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24&29 Friday House provides a comfortable, safe, homely environment for the people who live there. EVIDENCE: All service users have a key to lock their bedroom door if they wish. Outside professional help is sought if specialist equipment is needed for any individual. There is plentiful shared space that is appropriately furnished in a domestic style. Friday House I03 I53 s15182 FRIDAY HOUSE v246789 060905 Stage 4.doc Version 1.40 Page 14 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35,36 A well-balanced staff team who have appropriate training and skills supports Service users. EVIDENCE: All staff have appropriate job descriptions. Statutory training is up to date and additional training is freely available and ongoing. Recruitment procedures are thorough with two written references and POVA and Criminal records bureau enhanced checks being acquired for every member of staff. Six staff have NVQ level2 in care and 5 are working toward NVQ level 3. One staff is currently working toward NVQ level2. The majority of staff are First Aid qualified and there is always a first aider on duty. All staff have formal supervision at least six times per year. Supervision records are kept. Friday House I03 I53 s15182 FRIDAY HOUSE v246789 060905 Stage 4.doc Version 1.40 Page 15 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,39,40,41,42,43 The home is well managed by an efficient and open manager who maintains all records, policies and procedures appropriately. EVIDENCE: The manager is a qualified psychiatric nurse who has many years experience working with the client group. She is well known to all her staff and service users and is available to them in working hours and out of hours in an emergency. The company has an excellent quality assurance programme that ensures every aspect of the home is reviewed at least monthly by the manager and six monthly by an external auditor. The manager has to submit monthly returns to head office with action plans. There are two staff members who are responsible for monitoring Health and Safety matters. The manager has a budget to work to and budgetary advice is available. All records required are kept and up to date. Friday House I03 I53 s15182 FRIDAY HOUSE v246789 060905 Stage 4.doc Version 1.40 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 4 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x 3 x Standard No 11 12 13 14 15 16 17 3 3 3 3 3 4 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 4 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Friday House Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 3 I03 I53 s15182 FRIDAY HOUSE v246789 060905 Stage 4.doc Version 1.40 Page 17 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA 22 Regulation 22(5)(7) Timescale for action The registered person must by 30th update the personal copy of each September service users complaint 2005 procedure to include the correct address and phone number for contacting the CSCI Requirement RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Friday House I03 I53 s15182 FRIDAY HOUSE v246789 060905 Stage 4.doc Version 1.40 Page 18 Commission for Social Care Inspection CPC1, Capital Park Fulbourn Cambridge CB1 5XE 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 Friday House I03 I53 s15182 FRIDAY HOUSE v246789 060905 Stage 4.doc Version 1.40 Page 19 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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