Inspection on 21/11/06 for Frintondene

This inspection was carried out on 21st November 2006.

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 28/02/06

Frintondene 15/08/05

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 Key Unannounced Inspection 21st November 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 Frintondene DS0000017825.V320535.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 DS0000017825.V320535.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Frintondene Address 4 Third Avenue Frinton On Sea Essex CO13 9EG 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) 01255 679635 01255 679635 frintondene@hotmail.com Elizabeth Lambert Elizabeth Lambert Care Home 8 Category(ies) of Old age, not falling within any other category registration, with number (8) of places Frintondene DS0000017825.V320535.R01.S.doc Version 5.2 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) 28th February 2006 Date of last inspection 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 a bath or shower, wash hand basin and toilet, with the exception of two single rooms, which have an en-suite wash hand basin and toilet. Communal accommodation comprises of a lounge/dining room at the front of the house. Under the previous regulatory authority, the temporary use of the dining room as a bedroom had been agreed on the basis that this was to cease and return to a dining room by 2007. Fees are £505.00 - £570. 00 per week. Hairdressing and chiropody is included in the fees, with clothing, alcohol and perfumes and creams charged at cost. 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 residents’ accommodation on the ground and first floors, with 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 resident 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 residents like to sit. Frintondene DS0000017825.V320535.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection, covering the key National Minimum Standards, took into consideration all recent records relating to the service, including information sent to the Commission by the Provider. A record of inspection was collated prior and during the inspection process. It also included a site visit to the home on 21/11/06, which lasted 9 hours. At this visit, the inspector was able to speak with all six residents, some in greater depth than others. Elizabeth Lambert, the registered manager was present throughout the inspection. A tour of premises was completed and there was observation of care practice and the sampling of records. Where possible, the site visits focussed on the experience of a sample of two residents, a process known as case tracking. The Commission for Social Care Inspection (CSCI) are trying to improve the way we engage with people who use services so we gain a real understanding of their views and experiences of social care services. We are currently testing a method of working where ‘experts by experience’ are an important part of the inspection team and help inspectors get a picture of what it is like to live in or use a social care service. The term ‘experts by experience’ used in this report describes people whose knowledge about social care services comes directly from using them. Peter Godden-Kent, an expert by experience was present for part of this inspection. He was able to meet with all six residents and a relative visiting the home. The expert by experience was able to speak with three of the residents in depth in private and a further two residents with the inspector at lunchtime. The expert by experience comments are included in this report and are referred to as expert by experience comments. Of the twenty-four National Minimum Standards inspected on this occasion, one was not applicable, sixteen were met and seven were nearly met. Three of the latter are repeat requirements from the last inspection. One requirement is outstanding from 11th March 2005. It is acknowledged that staff and management have worked hard to address the shortfalls identified in previous reports, and overall their efforts have been fruitful. The outstanding requirements relate to risk assessments, complaints and adult protection policies and procedures, dining room accommodation, an occupational therapist (OT) assessment of the premises, completion of management qualifications and provision of lockable storage for residents in their rooms. What the service does well: Frintondene DS0000017825.V320535.R01.S.doc Version 5.2 Page 6 Frintondene continues to present as an attractive, well maintained care home. Decoration and maintenance are ongoing with planned renewal of carpets and furnishings planned and considered. Survey work completed by the Commission praised the home for the care offered. All six residents who had responded said that they were happy living at Frintondene and one resident said that they were glad they had moved to the care home. Relatives who had responded also praised the home speaking of the home as being “home from home” and they were “totally satisfied with every aspect of care at Frintondene.” Healthcare survey work had also identified positive praise from GPs and the district nursing service used by the care home. The ability to make individual choices with regard to social and leisure activities was seen as positive by all residents spoken to. Residents spoke of enjoying listening to the radio, watching the television and reading the paper and completing the crosswords in their own rooms. This was further confirmed by the expert by experience who said “they all felt free to pursue their own interests, and to come and go as they wished. There were no regular organised group activities, but also no desire for them among the residents”. Food, meals and the catering arrangements in the home continue to be well managed, with careful consideration given to sourcing good wholesome food from the locality. From sampling lunch, observation and discussion both the inspector and the expert by experience were impressed with the food served. As stated by the expert by experience – “The quality of catering was praised by all residents – and their praise was well deserved, as was proved by the excellent freshly-cooked lunch of tender and tasty chicken, and a very enjoyable dessert, at which the Inspector and “Expert” were guests.” What has improved since the last inspection? Improvements were noted in the admission initial assessment processes and practice completed by the care home. Greater detail and record keeping showed consideration and thought had been given to the appropriateness of the placement and the plan of the placement. Whilst Frintondene has had no new staff, staff recruitment practice and procedures have been reviewed and would appear to be meet requirements. An effective quality assurance and quality monitoring system has been adopted. The care home has completed a quality assurance audit and whilst these results were very encouraging, the home recognises the need for an ongoing quality assurance monitoring system. Frintondene DS0000017825.V320535.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Frintondene DS0000017825.V320535.R01.S.doc Version 5.2 Page 8 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 Frintondene DS0000017825.V320535.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Documentation ensures that residents move into the home knowing that their needs will be met. Frintondene care home does not offer intermediate care. EVIDENCE: On the day of the site visit there were six residents at Frintondene. Two of the residents had been admitted to the home since the last inspection. Care planning documentation was sampled and case tracking took place for the two most recent admissions to the home. Frintondene DS0000017825.V320535.R01.S.doc Version 5.2 Page 10 Documents seen evidenced that a detailed full initial assessment process had been followed and all aspects of care had been considered. For one resident an Inquiry Form had been completed on the initial telephone enquiry and for both residents there was evidence of a Client Personal Profile being completed both before and on admission to the home. All residents at Frintondene are self-funding and therefore did not have a care management assessment completed by health or social services. Their admission depended upon the assessment processes completed by the registered manager, who clearly had a good understanding of the skills and experience held in the home by care staff. Following the site visit and prior to writing this report, the Commission conducted a survey of the views of residents. All six residents had responded. Three residents confirmed that they had been involved in making a choice as to whether they wished to live at Frintondene. One said that they had visited the home with their relative, another said that they had been visited by the manager when they were in hospital, whilst their family had visited the home and a third said that their family had visited the home several times prior to their admission to Frintondene. Copies of both the Statement of Purpose and the Service Users’ Guide had been given to them before they moved into Frintondene. These documents had been reviewed and revised in June 2006 and it could be seen that the service is able to meet the assessed needs of prospective residents as detailed in these documents. Frintondene does not offer intermediate care. Frintondene DS0000017825.V320535.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning documents fully detailed the action to be taken and by whom and regular reviews of care plans took place. Risk assessments with regard to clinical practice need to be reviewed and revised. Medication, administration, storage and record keeping offered protection to residents. Residents are treated with respect and dignity and are actively supported to maintain control of their care and health needs, as appropriate. EVIDENCE: Frintondene DS0000017825.V320535.R01.S.doc Version 5.2 Page 12 A plan of care had been developed for the two residents involved in this case tracking exercise. These covered all aspects of care with some risk assessments linked to cover issues such as mobility, toileting, washing, bathing, dressing and pressure sore prevention. One exception to this is the use and management of bedsides for a resident. The registered manager was advised of the need to review the management of this care in line with relevant clinical guidelines produced by professional bodies concerned with older people. Risk assessments need to be created to ensure that full consideration is given to the welfare of the resident. Daily records are kept for each resident and monthly reviews were seen to be in place to update any changing needs and current health, personal and social care objectives are actioned. As stated previously, following the site visit and prior to writing this report, the Commission had conducted a survey of residents’ views. All six residents had responded. Comments such as “I am happy, well and love being here”. “I am glad I moved here”. “I feel safe” and “I am very happy here, staff are kind and patient” were found in this survey work. In addition comment cards were sent to relatives and visitors to the home and seven comment cards were completed and returned. Again there were positive comments regarding the care home. Comments such as “home from home,” “totally satisfied with every aspect of care at Frintondene” and “the atmosphere from a visitor’s perception is congenial” were found in these comment cards. The expert by experience said “They were united and emphatic in their praise of the quality of care they were receiving and of the attitude of all staff”. Within the daily records, health care issues were referred to. The registered manager said that currently residents do not need the services of the district nursing service, although GPs are called and frequently visit the home as needed. A chiropodist who is used by the majority of the residents visits the home every four weeks and both hearing and eyesight tests are arranged with a local service as required. Residents may visit their practice or have a home visit. Dental treatment is provided as is needed and once again home visits or visits to the practice can be arranged. Comment cards were sent to local GP surgeries used by the residents and two GPs had replied. One GP said, “In my opinion, Frintondene is an excellent care home.” Health and Social Care Professionals were also surveyed and two replies were received. A nurse practitioner spoke of the home as being “very caring, always contact me if concerned.” Frintondene DS0000017825.V320535.R01.S.doc Version 5.2 Page 13 Medication administration, storage and record keeping was sampled and inspected for the two residents who were part of the case tracking exercise. This was well managed and found to be in good order. All residents were on medication, although no controlled drugs were being administered. One resident was self-medicating with the home ordering and obtaining their medication. Records were seen of the auditing processes as medication entered the home and as medication left the home or was disposed of. The registered manager said that homely remedies are used as needed, but in recent months this had not been necessary for GPs would visit and prescribe as required. At the last inspection, the inspector had been told that medication training (a refresher course) was planned for October 2006. The registered manager said that this had not taken place, but it was planned for early next year. From speaking to residents on the site visit and from the survey work completed by the Commission the inspector was told that residents do feel that they are treated with respect. Five of the six responses returned to Commission for Social Care Inspection (CSCI) had stated that there are never any arranged activities in the home and three residents had said that they did not wish to take part in such activity. It was said that living in a small home “there is not really any scope for any organised activities, but a small home has advantages that outweigh this.” It was clear that residents preferred to occupy themselves in their rooms. When asked if they felt that their privacy was respected, two residents said that they felt this was, for care staff would always knock and wait to be asked to enter their rooms. During the site visit, the inspector observed this practice as they went about the home. Three residents have their own telephone in their room, whilst a fourth resident has a mobile telephone. The expert by experience said, “Overall, the atmosphere of Frintondene was one of genuine care and concern for residents’ welfare and preferences, with which residents were well content”. Frintondene DS0000017825.V320535.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs and preferences were taken into account in the organisation of daily schedules. Residents were supported to maintain contact with family and friends. Residents were able to exercise choice and control over their lives. Mealtimes were a positive experience for residents. EVIDENCE: As stated previously in this report, the right to make choices was respected by the care home. Residents are able to make choices with regard to the social and leisure activities they pursue. Whilst group activities are not offered or Frintondene DS0000017825.V320535.R01.S.doc Version 5.2 Page 15 wished for, both residents spoken to in depth, confirmed that they wished to follow their own individual activities. Crosswords and word puzzles were popular with both residents and it was said that care staff and management get involved in these activities. Within care plans there was evidence of residents’ interests and how they are given an opportunity to participate in these. An example of this was the storage and maintenance of a mobility scooter, which enabled the resident to continue to access the locality. The resident concerned was most appreciative of this and said “this gives me freedom to go to the shops at any time.” The expert by experience said “they all felt free to pursue their own interests, and to come and go as they wished. There were no regular organised group activities, but also no desire for them among the residents”. He continues that “Television and radio were not obtrusive; residents could have their own sets in their own rooms as they wished, without having to suffer others’ choices of programmes”. Residents spoken to at the inspection said that visitors were able to visit as they wished. They spoke of being able to visit their relatives, as they were able in their own homes. On the day of the site visit, a relative visited the home, taking their relative out for lunch. Management and staff confirmed that visitors may visit residents as they wished, either in private in their room or in the lounge/dining room. With prior notice, meals are available and refreshments are always offered. Relatives who had taken part in the Commission’s survey work had praised the home speaking of the home as being “home from home” and they were “totally satisfied with every aspect of care at Frintondene.” The registered manager said that all six residents handle their own financial affairs, either with the assistance of a solicitor or family. Frintondene prides itself on home cooking. Lunch is the main meal of the day, with normally at least two choices offered. Fish and a roast lunch are available twice a week. The cook said that she and the registered manager plan the menu week by week. This enables them to take advantage of seasonal fresh fruit and vegetables. Shopping is done weekly on-line through a major supermarket, with additional fruit, vegetables and potatoes purchased at a local greengrocer. Fresh fish is purchased from a local fishmonger. On the day of the site visit, ample food supplies were seen within food cupboards, fridges and freezers. Frintondene DS0000017825.V320535.R01.S.doc Version 5.2 Page 16 The registered manager said that three care staff have recently attended a refresher Basic Food Hygiene course. The inspector and expert by experience were able to have lunch with the residents. This was very pleasant. The food was served piping hot in the lounge/dining room. It was evident that all enjoyed the meal, for all residents expressed their gratitude to the cook. Within the survey work completed by the Commission positive comments regarding meals were made – “Meals are enjoyable and adequate – sometimes a little more than adequate. Moreover, they are arranged so that we have a well-balanced diet – no excess saturated fats or sugar and plenty of vegetables.” A second resident said that “They are superb, I eat very well,” whilst a third said “lovely food, served well. I have put on weight” and a fourth resident said that “The meals are very good here, and we have lots of vegetables and fruit, which is excellent.” The expert by experience also praised the catering within the home. He said, “The quality of catering was praised by all residents – and their praise was well deserved, as was proved by the excellent freshly-cooked lunch of tender and tasty chicken, and a very enjoyable dessert, at which the inspector and the expert by experience were guests. Residents commented that the food was always of this quality, and said that if they wanted a meal at a different time, for any reason, this was never a problem”. Frintondene DS0000017825.V320535.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall, residents were well treated and listened to, with complaints and adult protection procedures in place. EVIDENCE: Some review and revision of the home’s complaints procedure is necessary for clarification is required as to the role of Commission for Social Care Inspection (CSCI). It should be noted that the Commission is not a ‘complaints agency’ and does not have statutory powers to investigate complaints. The Commission will use their powers of inspection to undertake enquiry so that we can make a judgement as to whether the provider is complying with the regulations. The adult protection policy within the home needs to be reviewed and revised. It was dated as having been revised in March 2005. The registered manager was advised of the need to review and revise this document to incorporate local authority guidance on adult protection, abuse and the Protection of Vulnerable Adults (POVA) referral process. In addition the home needs to Frintondene DS0000017825.V320535.R01.S.doc Version 5.2 Page 18 clearly detail in a policy the adult protection arrangements used in their staff recruitment processes. Frintondene DS0000017825.V320535.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall, the home provides a safe, well-maintained environment that is accessible to residents, homely and meets individual needs. EVIDENCE: At the site visit, Frintondene was found to be clean, well maintained and homely. A monthly planned maintenance programme ensures that work is highlighted and prioritised and actioned. Rooms are decorated on becoming vacant. This was confirmed in a survey completed, for they said “My room is lovely and was decorated for me before I came in.” A second resident said Frintondene DS0000017825.V320535.R01.S.doc Version 5.2 Page 20 that there “room is always clean and tidy” and all said that the home was always fresh and clean. Following a new admission to Frintondene, the former separate dining room has been re-instated as a ground floor bedroom. This option was offered by the previous regulatory authority, with a view to cease in 2007. The registered manager should therefore give some thought as to the planning and placement of this resident in the very near future to free up this room and recreate a separate dining room and lounge. By creating these two rooms, the provision of communal areas would be greatly enlarged, offering a more comfortable seating arrangement in the lounge. This was further endorsed by the expert by experience, for they spoke of “The present combined dining room and lounge does not seem to have such a warm and cosy atmosphere as could be possible in a separate lounge.” Whilst it is acknowledged that Frintondene has very little outside space at the rear of the building, residents are able to seat out in the front garden. This garden has a paved driveway and forecourt with flower and shrub beds either side of the garden. As at the last three inspections, Elizabeth Lambert was advised of the need to progress a detailed assessment of the premises and facilities. She said that she continued to experience problems in obtaining a detailed occupational therapy (OT) assessment of the home and equipment and facilities. The registered manager was advised that it may be appropriate to look for alternative professionals e.g. a Chartered Physiotherapist rather than an OT. The in-house utility and laundry room is located towards the rear of the building on the ground floor. Frintondene has one washer and one dryer. The washer has a variety of programmes, with washing programmes in excess of 65° C. Hot water temperatures are checked and recorded and these were found to be around 44° C. The registered manager said that should temperatures deviate from around 43° C, a plumber is called in. Frintondene DS0000017825.V320535.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff were roistered in sufficient numbers to keep residents safe and address their basic needs. The home has an experienced and dedicated staff team and residents are protected by the home’s recruitment practices and training programme. EVIDENCE: With a reduction to six residents, staffing levels were found to be met. The ratio of care staff to residents was calculated using the Residential Forum Guidance. The inspector was told that staffing hours include both catering and cleaning duties and these hours were in excess of those calculated using the Department of Health guidance. There are six care staff in total at Frintondene. Three of the six care staff have completed a National Vocational Qualification (NVQ) level 2 in care. Frintondene DS0000017825.V320535.R01.S.doc Version 5.2 Page 22 Staff recruitment records were sampled and inspected. Of the two sampled, appropriate recruitment practices were seen to have been followed. The registered manager said that recruitment practices have been reviewed and revised to ensure that requirements as detailed in Care Homes Regulations 18 and 19 and Schedule 2 are complied with. With an established family staff group there has been no new staff in post. The inspector was therefore unable to inspect the staff Induction and Foundation training. However, ongoing basic training courses have taken place since the last inspection. Fire Extinguisher training, Basic Food Hygiene and Manual Handling training has been completed in 2006. This was evidenced from speaking to care staff and through supervision records. The registered manager said that three care staff are to attend a Basic First Aid course in December 2006. Frintondene DS0000017825.V320535.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a competent and experienced manager to run the home. The home has developed a quality assurance and quality monitoring system to help ensure that the home is run in the best interests of the residents. Overall, residents’ financial interests were safeguarded through invoicing residents for additional expenditure. Consideration must be given to the provision of secure, lockable storage facilities. Safe working practices are promoted through ongoing training and compliance with health and safety certifications. Frintondene DS0000017825.V320535.R01.S.doc Version 5.2 Page 24 EVIDENCE: The registered manager said that she is currently working on her Registered Manager’s Award and is planning to move on to the National Vocational Qualification (NVQ) Level 4 in care. She said that she hopes to complete this training in September 2007. It was evident from discussion with management and care staff and observation on the day of the site visit, that the home has a good staff team with care staff taking full responsibility for their actions when caring for the residents. Regular supervision sessions documented discussion on staff training opportunities, care practice and efficiency and timing. Following the last inspection an effective quality assurance and quality monitoring system has been adopted. Questionnaires were sent out to residents and their relatives. These covered topics such as catering and food, personal care and support, daily living and premises and management. In addition in June 2006, local GPs surgeries and District Nursing team had been surveyed. Comments such as “clean and peaceful” and the “best home in the area” were seen. A quality assurance audit was completed late June 2006 and this information has been added to the revised copy of the Frintondene Users’ Guide. It was recognised that whilst the results were very encouraging, the need for an ongoing quality assurance system was promoted. The registered manager said that the home does not hold money for the current resident group. She said that all residents have declined the use of a lockable facility for the safekeeping of money and valuables. Whilst it is recognised that residents do not have to use these facilities, the care home must review current practice and ensure that secure facilities are available for all residents within their rooms. Health and safety certification was sampled and found to be in good order. Emergency Lighting, Fire Extinguishers and Fire Alarms had been serviced and upgraded in June/July 2006. Fire drill records completed and held monthly were seen and a Fire Risk Assessment had been completed in August 2006. The Portable Appliance Testing (PAT) was completed in August 2006 and a National Inspection Council for Electrical Installation Contracting (NICEIC) Electrical Installation report was completed in April 2006. This was valid for three years. Servicing certificates were also seen for a static bath hoist, wheelchairs and a passenger lift. These were completed in July 2006. Frintondene DS0000017825.V320535.R01.S.doc Version 5.2 Page 25 As detailed earlier in this report, Frintondene has an ongoing basic training programme and courses such as Fire Extinguisher training; Basic Food Hygiene and Manual Handling training have been completed in 2006. A Basic First Aid course is to be held in December 2006 when three care staff are to attend. Frintondene DS0000017825.V320535.R01.S.doc Version 5.2 Page 26 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X 2 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 X X 3 Frintondene DS0000017825.V320535.R01.S.doc Version 5.2 Page 27 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 OP7 Regulation 13(4)(b) (c), 15 Schedule 3, Requirement Timescale for action 16/01/07 2. OP16 22, Schedule 4 The registered person must ensure that service user’s plan meets relevant clinical guidelines produced by the relevant professional bodies concerned with the care of older people, and includes a risk assessment, with particular attention to prevention of falls and the use of bedsides. The registered person must 16/01/07 ensure that there is a clear and effective complaints procedure, which includes the stages of, and time scales, for the process, and that residents know how to complain. 16/01/07 3. OP18 12, 13, 21 The registered person must ensure that residents are protected from abuse, neglect and self-harm. This is with regard to the adult protection policy and procedure. 16, 23 The registered person must ensure that an assessment of the premises and facilities has been made by a suitably DS0000017825.V320535.R01.S.doc 4. OP22 16/01/07 Frintondene Version 5.2 Page 28 qualified person e.g. occupational therapist. (This is a repeat requirement from the last three inspections. Previous timescales of 11/03/05, 07/10/05 and 28/04/06 were not met.) 5. OP31 18, 19 The registered manager must be 30/09/07 qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. The required qualification is a NVQ level 4 in care and management. (This is a repeat requirement from the last inspection. Previous timescale of 28/04/06 was not met.) 6. OP35 16, 17, 19 The registered manager must ensure that safeguards are in place to protect the interest of the residents with regard to holding personal money and valuables. (This is a repeat requirement from the last inspection. Previous timescale of 28/04/06 was not met.) 16/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Frintondene Refer to Good Practice Recommendations DS0000017825.V320535.R01.S.doc Version 5.2 Page 29 1 Standard OP19 The registered person should review current arrangements with regard to the use of the dining room as a single bedroom. This option was offered by the previous regulatory authority, with a view to cease in 2007. Frintondene DS0000017825.V320535.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Frintondene DS0000017825.V320535.R01.S.doc Version 5.2 Page 31 - 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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