Inspection on 28/02/06 for Frintondene

This inspection was carried out on 28th February 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 21/11/06

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 Unannounced Inspection 28th February 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Frintondene DS0000017825.V284670.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Frintondene DS0000017825.V284670.R01.S.doc Version 5.1 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 Mrs Elizabeth Lambert Mrs Elizabeth Lambert Care Home 8 Category(ies) of Old age, not falling within any other category registration, with number (8) of places Frintondene DS0000017825.V284670.R01.S.doc Version 5.1 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) 15th August 2005 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 either 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. This currently remains empty and is to be re-decorated and returned as a dining room. 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, 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 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 DS0000017825.V284670.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over one day in February 2006. This was the second inspection of the inspection year 2005 – 2006. Throughout the day there was discussion with Mrs Elizabeth Lambert, Registered Manager. During this inspection, the inspector was able to speak with six residents and one relative visiting the care home. Eight residents are living at Frintondene. A tour of the premises was conducted and both residents’ and staff records were sampled and inspected at this inspection. Policies and procedures were also sampled and inspected. Eleven of the thirty-eight standards were inspected, of these five were met, with six nearly met. Over the two inspections of the inspection year 2005 – 2006, all of the key standards were inspected, with several of the standards inspected on both occasions. What the service does well: What has improved since the last inspection? Frintondene DS0000017825.V284670.R01.S.doc Version 5.1 Page 6 A gradual improvement was found in the care planning documentation held in the home. Work has been undertaken on the assessment processes and paperwork held in the home. Self-medicating arrangements have been reviewed and revised and these now meet requirements. A programme of maintenance and decoration has now been developed and an ongoing programme can now be seen to evidence work planned and completed. Staff training is ongoing, with the requirement of 50 of care staff with National Vocational Qualifications (NVQ) level 2 or equivalent in care now met and a planned basic training programme. 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 DS0000017825.V284670.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Frintondene DS0000017825.V284670.R01.S.doc Version 5.1 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 the following standard(s): 2 & 3. Residents are provided with a contract at the point of moving into the home and they are therefore fully aware of the terms and conditions of their stay at Frintondene. Documentation did not fully ensure that residents move into the home with their needs assessed and being assured that they will be met. EVIDENCE: Contracts/statements of terms and conditions were sampled and inspected. Both of the contracts seen detailed requirements as the National Minimum Standards – Standard 2. Copies were seen to be signed by the resident and are held by them and their relatives, with the home holding a copy. Documentation for the most recent admission was sampled and inspected. As at the last inspection, the paperwork used consisted of a Client Personal Profile and an Observation Upon Admission. From these assessments a resident’s plan of care is developed. A second admission process sampled had similar paperwork, but had not included a pre-admission assessment completed by the registered manager. Mrs Lambert acknowledged that this was an omission and Frintondene DS0000017825.V284670.R01.S.doc Version 5.1 Page 9 prior to writing this report has sent to the Commission a Service User Inquiry Form and a Service User Assessment form, which is to be completed before admission to the care home. Frintondene DS0000017825.V284670.R01.S.doc Version 5.1 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 the following standard(s): 9. Medication administration and storage are well managed, helping to ensure residents’ health care needs are met. EVIDENCE: Seven out of the eight residents at Frintondene are on medication. One resident is self-medicating. Risk assessments have now been completed and a lockable space for the storage of this medication has been found. The management, administration and storage of Controlled Drugs continue as at the last inspection. Both the storage and record keeping in the Controlled Drug register was found to meet requirements. A further two medication administration records for two residents were sampled and inspected and these were found to be in good order. Mrs Lambert said that Medication Handling training is planned as a refresher course for staff in October 2006. Frintondene DS0000017825.V284670.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these Standards were inspected in full at this inspection. EVIDENCE: The Key Standards relating to the ‘Daily Life and Social Activities’ were not considered in full at this inspection. They were inspected at the last inspection. However, during this inspection, residents were seen to be occupied within their rooms. Two residents spoke of enjoying doing a crossword each day in the daily paper and a third said that they enjoyed listening to music and watching the television in their room. A fourth resident said that, when they are able, they like to go out for a walk. A relative visiting confirmed this and said that they enjoy a meal out when they are able. Frintondene DS0000017825.V284670.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these Standards were inspected in full at this inspection. EVIDENCE: The Key Standards relating to the ‘Complaints and Protection’ were not considered in full at this inspection. They were inspected at the last inspection. Residents spoken to during this inspection said that the felt able to raise any concerns with the registered manager – Mrs Lambert. No complaints or Protection of Vulnerable Adults (POVA) issues have arisen since the last inspection. Frintondene DS0000017825.V284670.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 22. 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 and since the last inspection the kitchen had been re-fitted. Radiator covers have now been fitted on areas accessed by the residents. In addition, the care home now has a programme of routine maintenance and renewal of the fabric and decoration of the home. Records were seen of work planned and work completed. As at the last inspection, Mrs Lambert was advised of the need to progress a detailed assessment of the premises and facilities to ensure that residents have the specialist equipment they require to maximise their independence. Mrs Lambert said that an occupational therapist visit had been conducted for one of the residents, but that she recognised that she needs to pursue an OT Frintondene DS0000017825.V284670.R01.S.doc Version 5.1 Page 14 assessment for Frintondene. Prior to writing this report, Mrs Lambert confirmed that a visit had been arranged. Frintondene DS0000017825.V284670.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 & 30. 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: The Frintondene staff group is an established team with all being family members. Staff recruitment records were sampled and inspected. Of the two sampled, an omission was noted on one file, namely no photograph. The second sampled file was completed in July 2005 for an existing carer to cover for the post of a cook/carer. With an established family staff group there has been no new staff in post. The inspector was therefore unable to inspect the staff training programme on Induction and Foundation training. Basic training needs were said to be considered. Whilst it was acknowledged that there has been no basic training since the last inspection, training in Manual Handling, First Aid, Medication Handling, Food Hygiene and Health and Safety is planned for October 2006. These are seen as refresher courses for all of the care home’s staff. Frintondene DS0000017825.V284670.R01.S.doc Version 5.1 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. The home is run and managed well; the registered manager is seeking to increase her knowledge and understanding by obtaining the required qualification. 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. Residents’ financial interests are safeguarded through written records of all transactions. The health and safety of residents and staff is protected through the renewal and updating of health and safety certifications. EVIDENCE: Frintondene DS0000017825.V284670.R01.S.doc Version 5.1 Page 17 The need to obtain a NVQ level 4 qualification in care and management was considered with Mrs Lambert. She said that she had a meeting arranged with a training provider and would be looking to start this training in the immediate future. Details and confirmation of this placement are required within the inspection report Action Plan. As at the last inspection the need to develop an effective quality assurance and quality monitoring system was discussed with Mrs Lambert. A Quality Assurance Audit Tool had been completed in October 2005. A detailed report of this exercise was shared with the Commission. Following this the care home needs to adopt an annual development plan for the home, based on a systematic cycle of planning – action – review, reflecting aims and outcomes for the residents. The results of this completed work need to be circulated amongst the resident group, prospective residents, relatives and staff. Mrs Lambert said that the home does not hold or manage any personal money of the residents. Some residents have secure facilities for safe-keeping of money and valuables; others have signed a disclaimer stating that they do not wish to have such a facilities. Mrs Lambert was advised of the need to review these arrangements, detailing the risk assessment completed and the arrangements in place in their care plans. Health and safety certification was sampled and found to be in good order. The Portable Appliance Testing (PAT) was completed August 2005 and Fire Extinguishers and Blankets were inspected June 2006. Both the passenger lift and wheelchairs were inspected in January 2006 and the bath hoist inspected in October 2005. A gas safety and maintenance check were completed February 2006 and all of the above were found to meet requirements. Frintondene DS0000017825.V284670.R01.S.doc Version 5.1 Page 18 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 3 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X 2 X X X X STAFFING Standard No Score 27 X 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X X 3 Frintondene DS0000017825.V284670.R01.S.doc Version 5.1 Page 19 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 OP3 Timescale for action 12, 13, 15 The registered manager must 28/04/06 ensure that new residents are admitted only on the basis of a full assessment undertaken prior to moving into the care home. (This is a repeat requirement. Previous timescale of 07/10/05 was not met.) 23 The registered person must 28/04/06 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 from the last two inspections. Previous timescales of 11/03/05 and 07/10/05 were not met.) The registered person must 28/04/06 review and revise staff recruitment documentation in line with Care Homes Regulations 2001, Regulation 17, Schedule 4 and Regulation 19, Schedule 2. (This is a repeat requirement from the last two inspections. Previous timescales of 11/03/05 and 07/10/05 were not met.) DS0000017825.V284670.R01.S.doc Version 5.1 Page 20 Regulation Requirement 2. OP22 3. OP29 17,Sch4.1 9, Sch2 Frintondene 4. OP31 5. OP33 6. OP35 The registered manager must be 28/04/06 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. Confirmation of a placement on the above training is required within the Action Plan. 21, 24 The registered person must 28/04/06 develop an effective quality assurance and quality monitoring system, based on seeking the views of residents, to measure the homes’ success in meeting aims, objectives and it’s statement of purpose. These views need to be shared with the residents and used in the annual deveopment plan. 16, 17, 19 The registered manager must 28/04/06 ensure that safeguards are in place to protect the interest of the residents with regard to holding personal money and valuables. 18, 19 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Frintondene DS0000017825.V284670.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex 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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