Inspection on 14/02/06 for Fridhem

This inspection was carried out on 14th February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Fridhem 01/08/06

Fridhem 10/08/05

Fridhem 21/02/05

Fridhem 19/01/05

Fridhem 11/11/03

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

CARE HOMES FOR OLDER PEOPLE Fridhem 79 Station Road Heacham Kings Lynn Norfolk PE31 7AB Lead Inspector Mr Christopher Handley Unannounced Inspection 14th February 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Fridhem DS0000027394.V282556.R01.S.doc Version 5.1 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. Fridhem DS0000027394.V282556.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Fridhem Address 79 Station Road Heacham Kings Lynn Norfolk PE31 7AB 01485 571455 01485 571455 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) Mrs Angela Bailey Mr Mark John Bailey, Ms Helen Moore Care Home 24 Category(ies) of Dementia (8), Old age, not falling within any registration, with number other category (16) of places Fridhem DS0000027394.V282556.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION ,Conditions of registration: Date of last inspection 10th August 2005 Brief Description of the Service: Fridhem provides residential care for up to twenty four older people, including eight people who have dementia. It is situated in the village of Heacham, approximately three miles from the holiday resort of Hunstanton. The home is situated in a quiet street which becomes busier during the tourist season. There is good access to the shops and local facilities. The bedrooms are on the ground and first floor, and have views over the gardens. There is a passenger lift between the floors. The home is a large traditional Norfolk house which has had extension added to it over time. There are small gardens which have sitting out facilities. There is a car park at the front of the home. The home receives any nursing or medical services from the local health centre. Fridhem DS0000027394.V282556.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, part of the annual inspection programme. The Inspection commenced at 9.30am, and was completed at 2.10pm. A wide range of documentation and records were inspected. The Inspector interviewed 6 residents and 5 visitors who were in the home during the inspection. He also briefly spoke to a representative of a religious organisation. Five members of staff were interviewed, and a tour of the home was undertaken. Ms Helen Moore, Proprietor, was present for the inspection. What the service does well: 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. Fridhem DS0000027394.V282556.R01.S.doc Version 5.1 Page 6 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 Fridhem DS0000027394.V282556.R01.S.doc Version 5.1 Page 7 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 of these Standards were inspected. EVIDENCE: Fridhem DS0000027394.V282556.R01.S.doc Version 5.1 Page 8 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): 7&9 The care plans are improving, but care plans for people with dementia need to be implemented. The home has a safe and sound medicine system. EVIDENCE: All residents have an individual care plan and these were seen, three of them were read by the Inspector. They are kept in a locked trolley in the office. Each care plan has a photograph of the resident on the front. The four essentials of care planning are present namely assessment, planning, implementation and review, and there are instruction for staff. This has improved since the last inspection and plans now show involvement of residents/relatives in reviews of care. This fulfils part of the recommendation made in the Inspection dated 10/8/05. The Proprietor said that not all residents wish to get involved in their care plans or sign the documents. Other documentation includes a Daily Record, a Dependency Profile, a Nutritional Risk Assessment and Manual Handling Assessment. Fridhem DS0000027394.V282556.R01.S.doc Version 5.1 Page 9 In the documentation seen there were a number of blank spaces and some need to be neater. The Inspector makes a recommendation concerning these matters. At present the home does not have dedicated care plans for residents who have dementia. The Proprietor has one sample, but intends to obtain others before deciding which one will be used for the residents who have dementia. The Inspector recommends that the home should have specific care plans for the residents who have dementia. Residents and relatives should be involved in the development of these documents. The Inspector recommends that training in using the new care plans should be provided for staff to ensure that the system chosen will work well. The Proprietor showed the Inspector the medicine system. The medicine trolley is kept locked to the wall when not in use. The inside of the trolley was neat and tidy, and there were no loose or unidentified medicines. The home has a Medidose system. At present there are three residents who have Diabetes, one of whom requires oral medication the others are diet controlled. The boxes are kept neat and tidy and in alphabetical order. The medicine records are neatly completed with the initial of the person who administered the medicines. All staff who administer medicine have had certificated training for this, the Proprietor said. The home keeps a record of the initials of staff who administer medicines. There are no Controlled Drugs in use in the home, the Proprietor said. There are no residents who self medicate. The home has a detailed medicine policy and enjoys good working relations with the supplying Pharmacist, the Proprietor said. If staff had any concerns about the effects of any medicine on a resident, they would contact the prescribing doctor. All medicines are reviewed by the prescribing G.P. on a regular basis, the Proprietor said and this is recorded. Fridhem DS0000027394.V282556.R01.S.doc Version 5.1 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 have a wide range of choice, some with staff assistance, in their daily life. The home provides a good catering service. EVIDENCE: The residents interviewed told the Inspector that they have a wide range of choice in their lives. They can choose when they get up, and when they go to bed, what they eat, what they wear, and personal appearance e.g. what hair style they have, and many other small but important matters. Some residents require assistance from staff to making choices. Few residents are able to handle their own financial affairs, the Proprietor said, and this was confirmed by the residents and relatives who were interviewed. In the main it is relatives who deal with residents monies. Residents have chosen to bring in personal possessions with them, and many of these were seen by the Inspector when he toured the home. Such items included photographs, ornaments and small items of furniture. Fridhem DS0000027394.V282556.R01.S.doc Version 5.1 Page 11 Residents have access to their personal notes, but the Proprietor said that none had chosen to see them. The menus were seen and they appeared nutritious, varied, and interesting. The wording on the menu says that special menus are provided, the Proprietors could consider informing the residents what are the choices for people who need special diets. . The Inspector spoke to the cook and she informed him that she asks residents if they had enjoyed their meals, and they confirmed that they did so. The residents interviewed spoke very highly of the catering, saying: “They always taste nice”, “They are always nice and hot”, “There is always a choice”. Based on what was read and what the Inspector was told, it is clear that the home provides a good catering service. Fridhem DS0000027394.V282556.R01.S.doc Version 5.1 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): 16 & 18 The home has an effective complaints procedure. All staff have had training in Adult Abuse Awareness. EVIDENCE: The Proprietor said that the home had not had any complaints since the last inspection. Residents interviewed said that if they had any concerns they would raise them with staff, and knew that they would be dealt with very quickly. Staff interviewed knew the importance of dealing with any concerns or complaints quickly. The home has a clearly set out complaints procedure displayed in the entrance of the home. The home has the good practice of having this document in large print, which enables any one who may have poor sight to read it. The home has a procedure/advice for staff to deal with Adult Abuse allegations. Staff interviewed were aware of the importance of this matter. In the inspection dated 10/8/05 it stated that the Proprietors and some of the staff had undertaken training in this matter, but not all staff. It was recommended that because of the importance of this all staff should undertake this training and the Proprietor informed the Inspector that this has been done. Fridhem DS0000027394.V282556.R01.S.doc Version 5.1 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): 19 & 26 There is on going maintenance programme in the home. The home is clean and odour free, and the laundry works well. EVIDENCE: The home is located just off the main street in Heacham. There is a car park, and small garden at the front of the home, and a large garden at the rear of the home. The Inspector was shown the home’s programme of renewal of fabric and decoration. This clearly shows all the major items to be carried out in the home. The decoration of the home is good, especially the lounges and dining room. Fridhem DS0000027394.V282556.R01.S.doc Version 5.1 Page 14 In the last inspection mention was made of window catches needing attention and the Proprietor said that she had made arrangement for this to be done. As yet the company had not commenced the work and she is going to pursue this. The Inspector now makes this a requirement. There are plans for a major upgrading to take place in the home, and the Inspector plus his Regulatory Manager had visited the home to discuss these. As yet this work has not commenced as the planning authorities have not given approval. The Proprietor, who is keenly awaiting the approval, undertook to keep the Inspector informed on this. One of the consequences of this delay is that items, e.g. furniture etc, will have to be moved around, and there will be some disruption in the home, and the Proprietor is advised to keep this to a minimum, and to keep the residents, relatives and the Commission informed on an ongoing basis. One of the effects of this disruption could be seen on the day of the inspection. In the quiet room there were lots of extra items, and the Proprietor is advised to keep the home as tidy as possible in the circumstances. On the day the Regulatory Manager visited the home it was noticed that the radiator at the bottom of the stairs was hot, and the Proprietor intends to have the heating to this radiator turned off, as covering the heater will narrow the space for passage. Heating levels in the hall and surrounding areas will need to be monitored. If this becomes a problem, the radiator should be replaced with a “cool touch” type. On the morning of the inspection the home was clean and free from offensive odours. Whilst touring the home the Inspector visited the laundry and the laundry person kindly explained how the system works. Soiled linen is not carried through areas where food is prepared or stored. The laundry floor is impermeable. There are hand-washing facilities in place. There are polices and procedures in place, for the control of infection and the safe handling and disposal of clinical waste. One of the washing machines is a large commercial variety. In the inspection dated 10/8/05 a requirement was made that the Proprietors obtain written confirmation that the facilities meet with the water supply regulations. The Proprietors have obtained this written approval, and the requirement is fulfilled. As part of the major improvement programme to commence soon, it is intended to increase the size of the laundry and to decorate it, the Inspector was informed. Fridhem DS0000027394.V282556.R01.S.doc Version 5.1 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 & 30 There are good staffing levels in the home. The NVQ training programme is going well. Staff have a wide range of training. EVIDENCE: On the morning of the inspection the home was well staffed and this was the normal staffing cover the Proprietor said. There were 4 care assistants, 1 domestic person, 1 laundry lady, 1 domestic lady, 1 cook, and the Proprietor, and this agreed with the off duty record. Based on his observations of the residents, and the content of the care notes read, it is the Inspector judgement that this staffing level meets the current needs of the residents. The staff on duty have had a variety of training, which is described in Standards 28 and 30. The Proprietor said that if needed she would bring in additional staff. Based on the observation of the Inspector and his discussion with staff, he got the impression that they were a group of a hard working people who enjoy caring for older people and work well together. Fridhem DS0000027394.V282556.R01.S.doc Version 5.1 Page 16 The Proprietor said that there were11 staff who have NVQ II and 4 currently undertaking it. There are a total of 16 care assistants so the proportion of staff who currently have NVQ II is 68 . The minimum figure required is 50 . Other staff have requested to take it as well, the Proprietor said. At the present rate of progress the home will soon have a 100 trained work force. This is to be commended. The home provides an Induction and Foundation programmes of training. In the report dated 10/8/05 there was some doubt as to whether these training programmes met TOPPS (Skills for Care) specification. This matter has since been clarified and the Proprietor informed the Inspector that the programmes meets TOPPS specification. Other training provided includes, Fire Prevention Training, First Aid Training, Moving and Handling, Medication training, Dementia Training, Behavioural Management training, Continence Awareness, Stroke Awareness, Diabetes Awareness, Basic Food Hygiene, Nutritional Awareness in the Elderly, Adult Abuse Awareness, Depression in Dementia, and Infection Control. As can be seen from the above list, the home provides a comprehensive training programme, which develops the knowledge and skills of staff and maintains the health of residents in the home. All are warmly commended for this. Fridhem DS0000027394.V282556.R01.S.doc Version 5.1 Page 17 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, 36 & 38 Residents financial interests are safeguarded. Staff receive supervision. The health, safety and welfare of residents is promoted and protected. EVIDENCE: The home holds personal monies for 22 residents. In some cases, personal monies are held by relatives, the Proprietor said. The Proprietor said that the home only holds personal allowances for residents. The monies are kept in the safe in the office. The amount held is clearly recorded on a dedicated form which has all the necessary details for effective traceability of the money. The entries are clearly written. The monies are kept in separate containers, one of which was checked and found to be correct against the record. The Inspector recommends that numbered receipts are provided to persons handing in money to further improve the traceability record of the money. Fridhem DS0000027394.V282556.R01.S.doc Version 5.1 Page 18 Staff supervision is carried out and is recorded by the Proprietor. The supervision covers , practice, philosophy of care, and career development. Staff spoken to confirmed this, and said that they had benefited from this. The home now has all the documentation required to meet Standard 38, the Proprietor said, and this documentation is kept in the office. At present some of it was on loan to staff that are undertaking the NVQ training programme, but they will be to returning it, the Proprietor said. In the inspection dated 10/8/05 a requirement was made that there should be window restrictors in place. The Proprietor has made arrangement for this to be done, but as yet the work has not been carried out and the requirement is repeated. Fridhem DS0000027394.V282556.R01.S.doc Version 5.1 Page 19 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 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 3 X 2 Fridhem DS0000027394.V282556.R01.S.doc Version 5.1 Page 20 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 OP38 Regulation 13.3 c Requirement It is required that there are window catches in place. Timescale for action 10/07/06 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 OP7 Good Practice Recommendations 1. It is recommended that entries in the care planning documentation be neater and more legible. 2. That all spaces requiring information should be completed. It is recommended that training be provided for staff in how to use the new care plans for people who have dementia, prior to their implementation. It is recommended that when personal monies are handed in for residents a numbered receipt is given. It is recommended that the Proprietors implement a care plan which will meet the needs of residents who have dementia. 2. 3. 4. OP7 OP35 OP7 Fridhem DS0000027394.V282556.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Fridhem DS0000027394.V282556.R01.S.doc Version 5.1 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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