Inspection on 15/08/05 for Frintondene

This inspection was carried out on 15th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Frintondene 16/10/07

Frintondene 21/11/06

Frintondene 28/02/06

Frintondene 19/01/05

Frintondene 27/07/04

Frintondene 18/11/03

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

CARE HOMES FOR OLDER PEOPLE Frintondene 4 Third Avenue Frinton On Sea Essex CO13 9EG Lead Inspector Pauline Dean Unannounced 15 August 2005 th 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 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. Frintondene I56_I05_S17825 _Frintondene_V224537_UI150805_Stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Frintondene Address 4 Third Avenue Frinton On Sea Essex CO13 9EG 01255 679635 01255 679635 frintondene@hotmail.com Mrs Elizabeth Lambert 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) Mrs Elizabeth Lambert Care Home (CRH) 8 Category(ies) of Old age, not falling within any other category registration, with number (8) of places Frintondene I56_I05_S17825 _Frintondene_V224537_UI150805_Stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 8 persons). Date of last inspection 20th January 2005 Brief Description of the Service: Frintondene is a family run residential care home for eight older people. There is one twin bedroom and the remaining are single bedrooms. All have en-suite facilities of either a bath or shower, wash hand basin and toilet, with the exception of one single room which has an en-suite wash hand basin and toilet. The property is situated in a quiet residential road, close to the seafront at Frinton on Sea. It is a three-storey, detached house with service user accommodation on the ground and first floors and the second floor being a staff flat. A passenger lift is installed to operate between the residential floors and there are other aids and adaptations suitable to the needs of the service user group the home is registered to accommodate. The home does not have a rear garden, but there is a paved area at the front where some service users like to sit. Frintondene I56_I05_S17825 _Frintondene_V224537_UI150805_Stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over one day in August 2005. This was the first inspection of the inspection year 2005 to 2006. Throughout the day there was discussion with the registered provider/registered manager, Mrs Elizabeth Lambert. One relative, who was visiting, and four residents were interviewed during the inspection. Care staff and catering staff on duty assisted the Inspector during this inspection. There were seven residents on the day of inspection. A tour of the premises was conducted and both resident and staff records were sampled and inspected at this inspection. Policies and procedures were also sampled and inspected. Twenty-three of the thirty-eight standards were inspected; of these fifteen were met, with seven standards almost met. One standard was not applicable. This is an improvement from the last inspection and it is anticipated that the remaining shortfalls will receive early attention to ensure compliance. What the service does well: When asked what they felt the service did well Mrs Lambert said that Frintondene was able to offer a “high level of care, treating people as individuals, particularly as we are small”. Mrs Lambert said that the home had an established, small family staff group and therefore was able to offer “continuity of care”. She said that the home has “few rules”, and residents are aware that relatives and friends may visit as they wish and are made very welcome. All four residents spoken with, and the one relative visiting the home, confirmed this. Catering within the home was highlighted by residents as being well managed. Choice and variety was said to be very good, with preferences, likes and dislikes considered. Frintondene I56_I05_S17825 _Frintondene_V224537_UI150805_Stage4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Frintondene I56_I05_S17825 _Frintondene_V224537_UI150805_Stage4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Frintondene I56_I05_S17825 _Frintondene_V224537_UI150805_Stage4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 and 6. Clear detailed information is provided to prospective residents and their relatives to enable them to make a choice as to whether they wish to be admitted to the home. Documentation did not ensure that residents move into the home with their needs assessed and being assured that they will be met. Intermediate care is not offered at Frintondene. EVIDENCE: Following discussion at the inspection, further review and revision was needed to the Statement of Purpose document. Prior to writing this report the revised Statement of Purpose was received and it was found to meet requirements. The Service Users’ Guide was also reviewed at the inspection and this was found to meet requirements. Admission paperwork for the most recent admission to the home was sampled and inspected. Current paperwork used is unclear as to the time of completion, for whilst it was entitled ‘Observation Upon Admission’, Mrs Lambert said that some of the information had been completed prior to Frintondene I56_I05_S17825 _Frintondene_V224537_UI150805_Stage4.doc Version 1.40 Page 9 admission, on visiting the home. needs to be developed. From this needs assessment a care plan Frintondene does not offer intermediate care. Frintondene I56_I05_S17825 _Frintondene_V224537_UI150805_Stage4.doc Version 1.40 Page 10 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 standard(s) 7, 8, 9 and 10. Residents’ health care needs are consistently met within the home and records provided evidence of this. Overall, medication administration and storage are well managed ensuring residents’ health care needs are met. The only exception being the need to implement risk assessments and secure storage for self-medication by a resident. Care practices ensure that residents are treated with respect and their right to privacy is upheld. EVIDENCE: Three care plans were sampled and inspected in full. Others were reviewed in part. Of those sampled, all were found to detail health, personal and social care needs and detail of action to be taken by care staff, to ensure that these needs are met, was noted. Care plans were seen to be reviewed monthly and updates were made to reflect changing needs. All four residents spoken with were aware of their care plan and confirmed that they were involved in the reviews. From discussion with management and residents the inspector was informed that all residents have their own GPs from two local surgeries. Other health care professionals are accessed in the community or by arranged visits to Frintondene. An example of this was dental and chiropody visits and visits by Frintondene I56_I05_S17825 _Frintondene_V224537_UI150805_Stage4.doc Version 1.40 Page 11 the opticians. In addition, Frintondene currently has visits from the diabetic nurse for one of the residents. Residents spoken with confirmed input from health care professionals and spoke of ways in which the home assists them with this. Six out of the seven residents in the care home are on medication. One resident has a Controlled Drug and this is stored in a metal cupboard and receipt, administration and disposal of the Controlled Drug is recorded in the Controlled Drug register. One resident is self-medicating. No risk assessment had been completed and the home had not provided a lockable space in which to store this medication. These matters were raised with Mrs Lambert at the inspection and immediate action was to be taken. All other medication administration, disposal and record keeping sampled was found to be in good order. Residents and a relative spoken with were complimentary regarding the way in which personal care and health care needs were being met. They said that they felt that staff treated them in an appropriate way, respecting their privacy and dignity. Frintondene I56_I05_S17825 _Frintondene_V224537_UI150805_Stage4.doc Version 1.40 Page 12 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 standard(s) 12, 13, 14 and 15. The daily routine and activites in the home were flexible and optional, with residents being encouraged to choose and be independent. Visiting arrangements were open and relaxed, with links to the local community encouraged. Frintondene provides varied, good quality homecooked food in sufficent quantities and residents are provided with a well balanced diet to suit their individual needs. EVIDENCE: Residents’ spoken with confirmed that they are able exercise their choice in relation to leisure and social activities. As at previous inspections, the residents of Frintondene continue to make a positive choice to be self-contained and not take part in communal activities or meetings. They continue to prefer to remain in their rooms, undertaking their own activities or meeting up with each other in their rooms. Details of individual activities were noted in care plans. Two residents said that they enjoy trips to a local theatre and arrangements and assistance had been given to enable them to independently attend performances. Mealtimes were also seen to be flexible, with residents able to have their meals in their room or in the lounge/dining area. On the day of the Frintondene I56_I05_S17825 _Frintondene_V224537_UI150805_Stage4.doc Version 1.40 Page 13 inspection one resident chose to have their meal in their room and catering Another resident went out for lunch with their staff accommodated this. relative. All four residents spoken with confirmed that they are able to see visitors in private and that they are able to choose when they wish to see them. The relative visiting the home that day also confirmed this. From speaking with two recent admissions to the home the inspector understands that they had been able to bring in personal possessions, the extent of which had been agreed prior to and on admission. The inspector was also informed that they were enabled and encouraged to handle their own financial affairs for as long as they wish and for as long as they are able and have the capacity to do so. At Frintondene menus are planned weekly, with two choices offered at lunchtime. In addition, choices are offered at both the breakfast and teatime meals. Nutrition records confirmed this. Food is purchased weekly at local supermarkets and greengrocers. Fresh fish is offered normally at least once or twice a week and this is purchased locally. Specialist diets, such as for diabetics, are managed within the planned menus of the home. All four residents spoken with at this inspection spoke positively regarding the meals served in the home. They said that they were able to choose what they would like and presentation and variety was very good. Frintondene I56_I05_S17825 _Frintondene_V224537_UI150805_Stage4.doc Version 1.40 Page 14 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 standard(s) 16 and 18. The home’s complaints procedure is made available to residents and their representatives to enable them to progress any complaints as they wish. Policies and procedures, and appropriate practices are in place to help ensure that resdients are protected from abuse. EVIDENCE: The home’s complaints procedure is to be found in the Statement of Purpose and meets requirements. Copies of this procedure were available in the home and two residents and a relative spoke of raising complaints with the registered manager, which had been resolved. The home’s adult protection procedure has been reviewed and revised since the last inspection. Reference can be found to local authority guidance and the need to complete the Protection of Vulnerable Adults (POVA) checks for employees. In addition to the above, the home’s whistle-blowing procedure has also been reviewed and revised. Frintondene I56_I05_S17825 _Frintondene_V224537_UI150805_Stage4.doc Version 1.40 Page 15 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 standard(s) 19, 22, 25 and 26. The home provides a safe, well-maintained environment that is accessible to residents, homely and meets individual needs. EVIDENCE: A tour of the premises was conducted on the day of inspection. Frintondene was found to be in good order, both internally and externally. There was evidence of ongoing maintenance, renewal and repair. The home, however, does not have a programme of routine maintenance and renewal for the fabric and decoration of the premises. A Fire Service inspection had taken place since the last inspection and recommendations were complied with. Mrs Lambert said that a qualified occupational therapist had visited the home. She was advised of the need to review and progress a detailed assessment of the premises and facilities to ensure that residents have the specialist equipment they require to maximise their independence. Frintondene I56_I05_S17825 _Frintondene_V224537_UI150805_Stage4.doc Version 1.40 Page 16 Interim risk assessments have been completed for all unguarded hot water pipe work and radiators. The installation of pipe work and radiator guards is planned and Mrs Lambert said that this will completed by December 2005. Hot water temperature checks are recorded monthly and these were found to be around 44 degrees centigrade. Frintondene offers an in-house laundry service, with day and night care staff undertaking these duties. As at the last inspection, the home has one washer and one dryer. Confirmation of whether the services and facilities comply with the Water Supply (Water Fittings) Regulations 1999 was not considered at this inspection. It will be reviewed at future inspections. Frintondene I56_I05_S17825 _Frintondene_V224537_UI150805_Stage4.doc Version 1.40 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 and 29. Staffing levels and skills are appropriate to the needs of the residents. Staff recruitment processes were found to have omissions and shortfalls, which failed to support and protect residents. Staff are trained and competent to do their work through a comprehensive induction training process. EVIDENCE: A staff deployment rota for the week was produced on the day of inspection. Whilst it is acknowledged that thought has been given to the Residential Forum guidance, it was unclear as to how current staffing levels had been reviewed and considered with the recent admissions to the home. Following this inspection and before completion of the inspection report calculations were submitted using the Residential Forum Guidance. The hours noted on a week’s rota were seen to meet requirements as calculated using the guidance. Staff recruitment records were sampled and inspected. Of the two sampled omissions were noted i.e. no photograph, no references and no contract for their present role was found on the file for one staff member, and for a second staff member, no application form, with employment history or references, was found. Whilst it is acknowledged that all staff currently working in the home are members of the manager’s family, the need to review staff recruitment records was highlighted. The need to introduce a new application form with consideration for requirements as listed under the Care Homes Regulations 2001, Regulation 7, 9, 19 – Schedule 2 is required. Frintondene I56_I05_S17825 _Frintondene_V224537_UI150805_Stage4.doc Version 1.40 Page 18 Following this inspection and prior to writing this report, a copy of the Croner’s Care Standard – A Management Guide –‘Application for Employment’ form has been sent. Within this document there was a sheet entitled ‘Summary’. This would appear to be misplaced within this document and could be used for interview purposes, rather than as part of the application form. The inspector advises an immediate review of all staff recruitment documentation to ensure that the requirements under the Care Homes Regulations 2001 are met. There have been no new staff since the last inspection. Four care staff have completed the National Vocational Qualification (NVQ) level 2 training in care. Three of these staff continues to work at the care home and therefore Frintondene is meeting the minimum ratio of 50 trained members of care staff by 2005. Frintondene I56_I05_S17825 _Frintondene_V224537_UI150805_Stage4.doc Version 1.40 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 37 and 38. The need to introduce an effective quality assurance and quality monitoring system is required to help ensure that the home is run in the best interests of the residents. Records held to protect residents were well-maintained, up-todate and stored safely. The health and safety of residents and staff is protected through the renewal and updating of health and safety certifications. EVIDENCE: As at the last inspection the need to develop an effective quality assurance and quality monitoring system was discussed with Mrs Lambert. Advice has been given as to how this could be progressed and immediate consideration should be given to this to meet requirements. Records, required for the protection of residents, sampled and inspected at this inspection included staff rotas, staff recruitment records, residents’ assessments, care plans and daily care records, and nutrition records and menus. Comments have already been made regarding this record keeping under the relevant standard. Frintondene I56_I05_S17825 _Frintondene_V224537_UI150805_Stage4.doc Version 1.40 Page 20 Health and safety certification was sampled and found to be in good order. The Portable Appliance Testing (PAT) was said to have been completed. Mrs Lambert said that the home is awaiting the report. A gas safety certificate dated 23.03.05 was seen, but there was no gas maintenance certificate found. Mrs Lambert said she would follow this up. Whilst basic and a variety of training courses have been progressed in 2004, further training courses and training needs have been identified by the home and further training courses as part of staff refresher training are required. Frintondene I56_I05_S17825 _Frintondene_V224537_UI150805_Stage4.doc Version 1.40 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 x x 2 x x 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 2 x x x 3 2 Frintondene I56_I05_S17825 _Frintondene_V224537_UI150805_Stage4.doc Version 1.40 Page 22 Yes 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 3 Regulation Requirement Timescale for action 07/10/05 2. 9 3. 22 4. 29 5. 38 12, 13, 15 The registered manager must review and revise current documentation and record keeping detailing a needs assessment prior to admission to the care home. 13 The registered manager must ensure that following assessment and the provision of a lockable space, residents are able to take responsibility for their own medication if they wish within a risk management framework. 23 The registered person must ensure that an assessment of the premises and facilities has been made by a suitably qualified person, e.g. occupational therapist. (This is a repeat requirement. Previous timescale of 11/03/05 not met.) 17, The registered person must Schedule review and revise staff 4. recruitment documentation in 19, line with Care Homes Schedule Regulations 2001, Regulation 17, Schedule 4 and Regulation 19, 2 Schedule 2. (This is a repeat requirement. Previous timescale of 11/03/05 not met.) 16, 17, The registered manager must I56_I05_S17825 _Frintondene_V224537_UI150805_Stage4.doc 07/10/05 07/10/05 07/10/05 07/10/05 Page 23 Frintondene Version 1.40 26, 37 ensure, so far as is reasonably practicable, the health, safety and welfare of residents and staff, as detailed within the National Minimum Standards for Care Homes for Older People – Standard 38. (This is a repeat requirement. Previous timescale of 11/03/05 not met.) 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. Refer to Standard 19 33 Good Practice Recommendations The registered manager should develop a programme of routine maintainance and renewal of the fabric and decoration of the premises with records kept. The registered manager should ensure that the home has an effective quality assurance and quality monitoring system in place to ensure that the best interests of residents are met. Frintondene I56_I05_S17825 _Frintondene_V224537_UI150805_Stage4.doc Version 1.40 Page 24 Commission for Social Care Inspection 1st Floor Fairfax House Causton Road Colchester CO1 1RJ 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. 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