Inspection on 07/11/05 for Frindsbury House

This inspection was carried out on 7th 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Frindsbury House 13/06/05

Frindsbury House 24/03/05

Frindsbury House 02/02/05

Frindsbury House 16/02/04

Frindsbury House 08/10/03

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

CARE HOME ADULTS 18-65 Frindsbury House 42 Hollywood Lane Frindsbury Rochester Kent ME3 8AL Lead Inspector Lucy Ansell Announced Inspection 7th November 2005 09:30 Frindsbury House DS0000028882.V254793.R01.S.doc Version 5.0 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 Frindsbury House DS0000028882.V254793.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 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. Frindsbury House DS0000028882.V254793.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Frindsbury House Address 42 Hollywood Lane Frindsbury Rochester Kent ME3 8AL 01634 719942 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) The Mortimer Society Elizabeth Joan Knight Care Home 16 Category(ies) of Learning disability (16) registration, with number of places Frindsbury House DS0000028882.V254793.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Sixteen (16) People with Learning Disabilities between 18 & 65 years of age. 13th June 2005 Date of last inspection Brief Description of the Service: Frindsbury House is a residential home for Young adults with Learning Disabilities, the home is owned by ‘The Mortimer Society’ and has been established for a number of years. All the residents at the home are male and the staff team reflects this with a high majority of male carers. Frindsbury House is a large detached property, with an extensive garden area to the rear, there is also a garden area and driveway at the front of the premises. Accommodation is offered over 2 floors; all the bedrooms at the home offer single occupancy with a washbasin. Downstairs there is a lounge, with a large conservatory area adjacent and a separate dining room. In addition there is an identified ‘quiet’ lounge within the home. There are additional buildings situated within the rear garden, offering facilities for residents on site, which include an Art room/ Workshop and an Occupational Therapy kitchen; there is also a separate room within these buildings set aside for the use of staff. The home is located within a residential area, within easy reach of Strood town centre and general facilities within the Medway towns. Frindsbury House DS0000028882.V254793.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Announced Inspection at Frindsbury House took place on 6th November 2005 by one inspector Lucy Ansell. The Inspector agreed and explained the inspection process with the Registered Manager and discussed the ethos and values of the home. Time was spent reviewing a sample of written policies and procedures, looking at care plans and records kept within the home. A tour of premises and discussions with two residents were undertaken. The focus of the inspection was to assess Frindsbury House in accordance to the National Minimum Standards for Young Adults and principally on residents’ views of the home. In some instances the judgement of compliance was based solely on verbal responses given by those spoken with. Some Standards were not inspected in full and the last report should be read in conjunction to obtain a full picture. What the service does well: What has improved since the last inspection? The home has employed a maintenance man who has completed an assessment of the building and surrounding areas, and who has written up an action plan of refurbishment, replacement and redecoration. He is also a trainer in fire safety and has written new fire policies and completed training with all staff. Frindsbury House DS0000028882.V254793.R01.S.doc Version 5.0 Page 6 The home has rewritten all the residents care plans based on a personcentered approach. The manager has moved her office to ensure more confidentiality for residents and families using the visitors’ room. The home has also increased its staffing levels to ensure the needs of all residents are met. 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. Frindsbury House DS0000028882.V254793.R01.S.doc Version 5.0 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 Frindsbury House DS0000028882.V254793.R01.S.doc Version 5.0 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 the following standard(s): 2,5 Residents are confident the home can meet their needs and are provided with a good statement of terms and conditions. EVIDENCE: Residents are provided with a statement of terms and conditions when moving into the home. Evidence was seen of the home’s contract in the resident’s files, these were very detailed and contained all the required information. Residents are usually admitted following a full assessment by the homes senior management and trail visits being completed. A care manager referred the newest admission last month as an emergency placement. The manager was able to explain the pre-assessment process and how it was staged over a week. This included assessment at his last placement, trial visit with the family as well as the resident, and to see that the service could meet their needs. Normally the home would like more trial visits so the resident could also stay the night and more thorough assessments could be completed. This new resident appears to have settled well. Frindsbury House DS0000028882.V254793.R01.S.doc Version 5.0 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 the following standard(s): 6, 7,8, Residents can be confident that their individual needs and choices are well met by the plans of care. Residents can be confident that they will be consulted and participate in all aspect of life in the home. EVIDENCE: The new care plans were seen these are now compact versions of the old care plans, which hold only necessary information. These were very detailed documents that contained, individual plans for daily living, action and support plans and health needs. The monthly and six monthly reviews need to be added in a format which keep them up to date and the risk assessments need rewriting to ensure consistency with the new plans. The home now uses archive files to hold the old reviews, yearly assessments and any non-vital medical information. The information held by the home is excellent and shows the staff have a complete knowledge and understanding of the residents needs. The home’s change to a person centred model ensures its care plans reflect the homes practice of residents being consulted on all decisions and participating fully in the home. The home’s daily writes up are Frindsbury House DS0000028882.V254793.R01.S.doc Version 5.0 Page 10 detailed and comprehensive with the times and signatures of the respective staff. The care plans viewed included information about the preferred life style of the individual service users. There were detailed descriptions of guidance on how to care for the resident, and clear evidence of making informed decisions. Where service users’ rights to make decisions are limited, the home usually recorded reasons on the care plans and in risk assessments. The care plans are still in the early stages and there are several adjustments that need to be made or added to ensure the care plans are service user friendly. Care plans need photos of the residents. The files would also benefit from clearer action plans, which are specific and achievable. Also the language used could sometimes be construed as inappropriate and could cause offence. The home also needs to consider whether they should have a confidential section at the back for areas of concern, and they also need to look at the format they will use to record all reviews. A service user spoken to during the inspection spoke of an environment in which they are encouraged and enabled to make decisions. He was offered support and guidance that enhanced his independence by staff working along side him promoting his rights. This was evidenced by the many activities he is able to undertake by himself. Frindsbury House DS0000028882.V254793.R01.S.doc Version 5.0 Page 11 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 the following standard(s): Not inspected exceeded the standards on the last inspection and no change seen. EVIDENCE: Frindsbury House DS0000028882.V254793.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 19, 21 Residents can be confident that their personal and health care needs will be well met. Residents benefit from their wishes on death and dying being respected. EVIDENCE: The health needs of residents are well met with evidence of good multidisciplinary working taking place on a regular basis. The home promotes and maintains residents health through supporting and facilitating medical appointments as required. The Manager stated that all service users are registered with a GP of their choice. There was also clear evidence of medication reviews happening and optician and dentist appointments. Evidence was seen of the wishes of residents on death and dying being well recorded and respected, as the resident would wish. Frindsbury House DS0000028882.V254793.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 22,23 Residents are protected from abuse and benefit from having access to a clear complaints procedure. EVIDENCE: The home has a clear step-by-step complaints procedure that meets the requirement of the regulations. The residents know the complaints procedure and were able to tell me quite clearly whom they would tell if they had any concerns, but the home has received no complaints since the last inspection. The home is confident that the policy is in language simple enough to be understood by virtually all the residents. The home is using the Kent and Medways new Adult protection policy as well as having their own guidelines. Staff spoken to were clear on the procedures to follow and the manager of their sister home is the staff’s trainer on Adult Protection. The home will also continue to send all staff to an outside agencies course on adult protection so they can have a wider view on the subject. Frindsbury House DS0000028882.V254793.R01.S.doc Version 5.0 Page 14 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 the following standard(s): 27,28,29,30 Residents benefit from living in a safe, well maintained, clean and homely environment in which the standard of décor, furnishings and fittings are high. EVIDENCE: The home has two bathrooms with toilets upstairs as well as a separate toilet with a shower. Downstairs there is a wet room and two further toilets. All bathrooms and toilets are lockable from the inside and are situated close to bedrooms and communal areas. All the rooms have an alarm cord fitted. The home is in a very beautiful location with views across the countryside from most windows. The Home has a comfortable feel and is spacious and well maintained. The Home is well decorated and the furniture is to a high standard in the communal areas, which make the Home, appear warm and comfortable, It was also evident to the inspector that the colours and furnishing were appropriate for the male service user group. There is also plenty of space, with a smoking and non-smoking lounge and a quiet area if required. There is also an Activity room and life skills kitchen situated at the rear of the property. All residents are involved in redecoration and this is apparent in their rooms that were personalised to their own tastes. Frindsbury House DS0000028882.V254793.R01.S.doc Version 5.0 Page 15 The premises were clean, hygienic and free from offensive odours. The manager has also moved her office from the front of the building to the rear and this ensures more confidentiality for residents and families using the visitors’ room, which is sited, next to what used to be the managers office. There is a laundry area sited to the rear of the home, which was seen by the inspector. Soiled articles are not carried through areas where food is stored, prepared, cooked or eaten. Where necessary, soiled linen bags are used to take washing to the laundries, which are equipped with an industrial quality machine that wash at the required temperatures, as well as a domestic machine and tumble dryer. Hand washing facilities are prominently sited with towels available. Policies and procedures are in place for infection control, disposal of clinical waste. Protective clothing is available if required. Frindsbury House DS0000028882.V254793.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,34,35,36 The residents benefit from being cared for by a staff team who are well supported and supervised. The residents benefit from being cared for by an effective staff team who are appropriately trained. EVIDENCE: All staff members have a job description. It was evident through discussion and observation, that they understand the aims of the home and are committed to achieving them. They are aware of their respective roles and how these support the goals set out in the service users’ plans. Staff rotas were seen and evidenced that staffing was suitable to provide appropriate shift cover. The home does not use agency staff and has its own bank of care staff to call on. The home has recently increased the staff from four on shift to now have five staff on shift. The home also employs a Cook, Handyman, activity co-ordinator and several domestic staff for cleaning and laundry. All staff are given a copy of the General Social Care Councils Code of Practice and staff handbook during their induction a good practice recommendation would be for staff to sign to say they have received and understood. Frindsbury House DS0000028882.V254793.R01.S.doc Version 5.0 Page 17 The home’s staff are well supported and there is close liaison with external support services including Consultant Psychiatrists, Psychologists, Community Psychiatric Nurses, GP’s and the Community Learning Disability Team. As already indicated there is an experienced and well-trained staff team who show clear evidence of commitment to the service and to identifying and meeting service users needs. In addition to the ongoing induction and foundation training programmes in which all staff participates, eight staff members have successfully completed NVQ training level 2,3 and nine further staff are working towards completing this. The manager has completed Registered managers award level 4. The standard will therefore be met in this regard. There is a strong commitment to training from the home and the training matrix indicated a rolling program with a huge range being offered to ensure all staff stayed current. The home was advised for all auxiliary staff to complete adult protection training and to ensure the training matrix covers all required areas and is easy to follow. The home always evaluates the quality and content of any training offered through evaluation and feedback from staff and managers and this is a excellent practice. A number of staff files were sampled, which included all types of staff, who had been at the home for varying lengths of time. The files seen did contain all the correct information. Evidence was seen of actual photos of staff; rather than relying on a blurred copy of the passport photo, which had been happening. The reference request now asks managers to confirm dates that an employee worked for the said firm. Good practice recommendation is made to have a checklist as a front sheet to record dates when asking for any references or CRBs and then consequently when received. All staff had completed CRB disclosures. All staff receive supervision and support formally bi-monthly. This includes: the homes aims and philosophy, work with individual clients, support and professional guidance and training and development needs. The senior staff also have five minute supervision after any incident to discuss this and then sign it off, a record is stored securely of all supervision. A good practice recommendation is made for a date to be set for the next one at the end of the session. The supervisors are looking at completing a supervisory course to enhance their skills. Frindsbury House DS0000028882.V254793.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39, 40-43 The residents benefit from a well run home with good transparent leadership and they can be confident that their views are listened to. The residents’ best interests and rights are safeguarded by the home’s policies and procedures. The residents’ health, safety and welfare are promoted and protected by the home. EVIDENCE: The manager is experienced and competent to run the home as has many years experience with clients with learning difficulties. She has completed the NVQ 4 and RMA but need to ensure periodic training is undertaken to maintain and update her skills and knowledge. The residents benefit from the management approach of the home and an open and inclusive atmosphere is created. The processes of managing and running the home are open and transparent Frindsbury House DS0000028882.V254793.R01.S.doc Version 5.0 Page 19 The home felt welcoming, relaxed and centred on the Service Users needs and aspirations. Regular discussions about activities and planning of daily routines continue to be supported and facilitated by staff. Regular team meetings, supervision and house meetings ensure everyone is aware of what is happening. The home does have a quality assurance and monitoring system in place and regularly surveys the residents. The home produces the results and outcomes for all interested parties to see. This is also incorporated into the quarterly newsletter that the two homes produce. The home received positive comments from family and health and social care professionals all praising the service and care received. The home does have all the policies and procedures required, and yearly updates and reviews them. The policies seen had been dated with the reviews and signed. The records required by regulation for the protection of residents and for the effective and efficient running of the home are all maintained and up to date. The manager ensures as far as is possible the health, safety and welfare of the residents. The home’s moving and handling training is up to date as is the home’s fire safety equipment, procedures and testing. The home has safe storage for hazardous substances and COSHH sheets have been obtained. The home has fitted a valve to regulate the water temperatures, and risk assessments for the property have been carried out. The home is financially viable and finances are spent on improvements as are needed. Insurance cover for the home was seen. Lines of accountability are clear and well evidenced. Frindsbury House DS0000028882.V254793.R01.S.doc Version 5.0 Page 20 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 x 3 x x 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 x x Standard No 24 25 26 27 28 29 30 STAFFING Score 4 x x 3 4 x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score 3 3 x 4 3 3 CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Frindsbury House Score 3 x x 3 Standard No 37 38 39 40 41 42 43 Score 4 x 3 3 3 3 3 DS0000028882.V254793.R01.S.doc Version 5.0 Page 21 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 2 3 Standard YA6 YA9 YA23 Regulation 15(1) Requirement Timescale for action 30/12/05 30/12/05 30/03/06 The home to ensure all action plans are specific and achievable. 13 4(a)(b) The home to ensure all risk assessments are congruent with current care plans. 13(6) The home to ensure all auxiliary staff are trained in adult protection. 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 YA34 YA35 YA35 Good Practice Recommendations A good practice recommendations was made to include a checklist on staff files to record when paperwork sent and received. In the induction process staff need to sign that the code of practice and policies and procedures have been read and understood. The homes training matrix needs to be revamped to include all relevant training schedules. Frindsbury House DS0000028882.V254793.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Frindsbury House DS0000028882.V254793.R01.S.doc Version 5.0 Page 23 - 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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