Inspection on 14/02/06 for Frith House

This inspection was carried out on 14th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Frith House 09/04/09

Frith House 16/07/07

Frith House 28/11/06

Frith House 20/07/05

Frith House 16/02/05

Frith House 25/05/04

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

CARE HOMES FOR OLDER PEOPLE Frith House Steart Drive Burnham-on-sea Somerset TA8 1AA Lead Inspector Caroline Baker Unannounced Inspection 08:50 14 February 2006 th 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 Frith House DS0000015978.V277875.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. Frith House DS0000015978.V277875.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Frith House Address Steart Drive Burnham-on-sea Somerset TA8 1AA 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) 01278 782537 01278 782537 Somerset Care Limited Mr Paul Gerard Cullis Care Home 62 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (62) of places Frith House DS0000015978.V277875.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One named person under the age of 65 years within the registered number of 62 beds. Up to three persons between the ages of 55 - 65 years within the registered numbers of 62 beds. 20th July 2005 Date of last inspection Brief Description of the Service: Frith House is situated in a quiet residential area of Burnham-on-Sea, near the sea front and town centre. It is registered with the Commission for Social Care Inspection (CSCI) to provide care for 62 people over the age of 65 requiring personal care, including 30 persons with dementia care needs. Somerset Care Ltd own Frith House; the Registered Manager is Mr Paul Cullis. The home is purpose built and has accommodation on two floors, accessed by a passenger lift. Each bedroom has an emergency call system and a vanity unit (in the old build) - all rooms in the new build have ensuite facilities. The home is currently being refurbished and enhanced to provide accommodation for up to 80 service users. Phase one and two are complete and rooms are in use. There are lounges and sitting areas found on both floors. The home has a pay phone for service user use. There are dining areas on the ground floor and first floors of the new build. The home also provides a bar/lounge where service users may smoke if they wish to do so. Frith House offers a range of activities and also provides day care for up to eight service users. A room is set aside for short stay use. Frith House DS0000015978.V277875.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The last inspection was announced and took place on 20th July 2005. At that inspection no requirements were identified and four good practice recommendations were made. This unannounced inspection took place from 08:50 hours and was conducted by two inspectors Caroline Baker and Jane Poole (16 hrs). At the time of this inspection two recommendations had been actioned. Fifty-one service users were residing at the home including 8 in the Special Rate Care (SRC) unit. Staffing levels appeared adequate to meet the care needs of the current service users. Not all of the National Minimum Standards (NMS) were assessed during this inspection. This report therefore should be read in conjunction with the last inspection report. An assessment of the premises took place where a selection of bedrooms and communal areas were seen. At least twenty-six service users, including five who were case tracked, and three visitors were spoken with. Mr Paul Cullis the registered manager was available throughout the inspection. Throughout the day the inspectors were able to observe interactions between staff and service users. Records relating to the care of the service users, staff and health and safety were examined. The inspectors would like to thank service users and staff for their time and help during the inspection. What the service does well: Frith House provides a well-maintained, secure and comfortable environment, which meets the needs of the current client group. Although building work continues the service users indicated that it had not upset their daily routine. Service users were observed using all communal areas and appeared comfortable and relaxed in their environment. Service users spoken to stated that they liked their bedrooms and were happy and felt safe at the home. Frith House DS0000015978.V277875.R01.S.doc Version 5.1 Page 6 Service users were well attired and looked well cared for on the day of inspection. Service users praised the food. A good choice of wholesome food was given. Flowers were placed on every dining table, which were laid with tablecloths, cutlery, glasses and serviettes. Service users praised the staff. Comments from service users included “they are kind and caring”, “they are patient and respectful” “they allow me my independence”, “they keep it clean”, “we are well fed” and “the managers are brilliant, they notice when you’re not so good”. Visitors consulted praised the care provision at the home. Staffing numbers and the skill mix of staff were sufficient to meet the dependency needs of current service users on the day of inspection. Staff spoken with stated that they felt well supported and happy working at the home. Staff training was well documented and the provision of training for staff was very good. Staff looked and acted in a professional manner. The manager and his two deputies are managing the home effectively through all the changes in the environment ensuring little disruption takes place. What has improved since the last inspection? What they could do better: Individual service users assessed as needing fluid input and output monitored will benefit from records being maintained to ensure their fluid intake is adequate to maintain hydration. Frith House DS0000015978.V277875.R01.S.doc Version 5.1 Page 7 Individual service users assessed, as being at high risk of having nutritional problems will benefit from a plan of care being developed to allow care staff to deliver correct care. Service users will benefit from staff following the homes medication policies to ensure they receive their prescribed medication at the correct time and have the correct amount. Service users will benefit from staff answering call bells more swiftly. This will aid in the prevention of falls and ensure their health care needs are met promptly. Service users will be protected and benefit from more robust recruitment procedures. Individual service users assessed as requiring bedrails will benefit from any risk of entrapment being eliminated. Good practice recommendations were issued in regard to: • • • • • the length of time service users waiting for their meals changing the current ethos of some service users that feel that staff are ‘too busy’ or ‘rushed’ so they are worried about asking for help auditing staff recruitment files to ensure they contain the documents required by legislation the checking of bedrails and the provision of call bell pendants for service users unable to reach a call bell in the communal areas. Although issues were identified at this inspection that compromise the high standard of care delivery the inspectors were satisfied that the registered person will take action to comply with any requirements made within the given timescales. 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. Frith House DS0000015978.V277875.R01.S.doc Version 5.1 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 Frith House DS0000015978.V277875.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1; 2; and 3. NMS 6 does not apply. Service users are provided with the information they need to enable them to make an informed choice about moving to the home. The home was able to demonstrate that service users are fully assessed prior to admission to ensure their needs can be met. The home was able to demonstrate it can provide a service whereby service users can stay to recover from a hospital stay, prior to going home. EVIDENCE: The home displays a current Statement of Purpose in the entrance hall of the home for service users and visitors to access. All service users are given a copy of a Service User Guide as part of their contract. Evidence was seen in five of the care plans sampled that pre-admission assessments had been gained to ensure the home could meet the individual service users needs. The SRC ‘initial assessments’ audited were comprehensive and well written. Frith House DS0000015978.V277875.R01.S.doc Version 5.1 Page 10 Each service user case tracked had a contract, which reflected additional charges, for example: hairdressing, toiletries, and newspapers. Although NMS 6 is not applicable to this service the inspector felt that the following, warranted mentioning, under this standard. Since the last inspection the home has included in the block contract with social services the home, four ‘step up, step down’ beds. The purpose of these beds is to reduce unnecessary admissions to hospital or residential care (step up) and to facilitate early discharge from hospital of patients who are clinically ready to transfer, but are needing a further period of rehabilitation (step down). People using the contracted beds will have received a multidisciplinary assessment, which clearly identifies their individual care needs and recognises that the step up step down bed is a means to achieving the agreed outcome. The usual placement is for 6 weeks. At the time of this inspection two of the beds were occupied and the service users were well on the way to going home having had support from the home and the rehabilitation team for 6 weeks to maximise their independence, following previous hospitalisation. The inspector consulted with one of the service users using the scheme. They indicated that they had enjoyed their stay at Frith House and stated that the staff team had promoted their independence. Frith House DS0000015978.V277875.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8; 9 and 10. Each service user had an individual plan of care. The home’s care planning system demonstrated that care plans were kept under review, however not always updated. Service users have access to health care professionals expertise to meet their individual needs. Service users were overall protected, by the homes procedures in regard to the receipt, administration, recording and disposal of medications, however minor shortfalls were identified. The home’s procedures in regard to self-medication were in line with the homes policy. Service users were treated with kindness and respect. EVIDENCE: The care plans (NMS 7) for individual service users case tracked were not fully assessed at this inspection. The home was undergoing a ‘pilot’ computerised care planning system, which was installed end of November 2005. Evidence was seen that staff have been working hard to develop the system and use it to its full potential. Frith House DS0000015978.V277875.R01.S.doc Version 5.1 Page 12 Hard copies of the service users individual risk assessments were available and were assessed. Five service users were case tracked as part of the inspection process, and the individual service users were met. One service user was poorly and was nursed in bed at the time of this inspection. Evidence of regular oral care and turning to minimise the risk of pressure ulcers were seen. The service user looked well cared for and comfortable. As discussed at inspection fluid balance and food charts should be implemented also, to determine fluid balance and nutritional intake. From the records assessed it was difficult to see how much fluid or nutrition intake the service user had had over the past five days. Evidence of pressure relief risk assessments were seen in the five plans examined. Pressure relieving equipment appeared to be being used appropriately. Falls risks assessments were maintained. Evidence was seen that service users have access to health care professionals. A podiatrist was seen visiting the home and treating service users on the day of inspection. Evidence of nutritional screening was noted however as discussed when the service user is found to be ‘high’ risk a care need should be flagged up and a plan developed. Specialist care needs plans sampled were, on one hand very detailed with actions to take should a problem occur, however another seen for example in regard to diabetes, times of blood sugar monitoring and problems to look out for were unclear and needed further development. The manager and deputy agreed with the shortfalls noted and agreed to take action to develop the care plans further. The homes receipt, administration, recording and disposal of medication procedures were examined. Overall a good standard of practice was seen, however shortfalls were noted on five occasions where hand transcribed Paracetamol did not reflect the maximum dose. And on one occasion Paracetamol had not been administered where it clearly stated give 2 tablets at each meal. Self-medication was actively encouraged at the home and it was clear from the MAR sheets that four of the service users were self-medicating. Lockable spaces to store medication were available in all of the rooms assessed. The homes self-medication policy was being followed. Service users were seen to be treated and addressed appropriately by staff. Service users can lock their bedroom doors from the inside if they wish for extra privacy, and staff would be able to access the rooms from outside in an emergency. Staff were seen and heard to knock on doors before entering service users rooms. Frith House DS0000015978.V277875.R01.S.doc Version 5.1 Page 13 Service users spoken to indicated that the staff always treated them with respect. They indicated that they felt well cared for, liked living at the home, that the staff treated them with kindness and that their privacy was respected. Frith House DS0000015978.V277875.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12; 13; 14 and 15 Service users benefit from a range of activities provided by the home to suit their individual choices and needs. The home is open to visitors at any time and encourages service users to access the local community. Service users individual choices and needs dictate the routine of the home, however mealtimes are set. Service users are offered a choice of nutritious well-balanced menus promoting their health and well being. EVIDENCE: Activities such as, reminiscence, flexercise, music, films, quizzes, bingo, dominos, and crafts, are offered to all service users on a weekly basis. The home has access to a mini bus with a dedicated driver. Each service user had an individual record of social activities they had joined in with evidencing that all service users have a chance to join in. On the day of inspection service users were seen enjoying a ‘Valentines’ tea party with musical entertainment provided. Service users spoken with all Frith House DS0000015978.V277875.R01.S.doc Version 5.1 Page 15 indicated that they enjoyed the activities o offer at the home but were missing the activity co-ordinator who was on leave. Provision had been made to cover the activity hours. The home has a visitor’s book, which indicated many visitors to the home at varying times. Service users told the inspector that their families and friends were made welcome at the home. Visitors spoken to confirmed this and told the inspector that they were happy with the provision of care at the home. Service users benefit from a range of dining areas. The majority use the largest dining room near the conservatory. Menus were displayed on tables in dining areas throughout the home, including the SRC unit, and at lunchtime there were three choices of main meal. There was a choice of dessert. All service users spoken to stated that the food was always good. The daily menu was also displayed on a notice board. Weekly menus looked well balanced and nutritious. Everyone in the dining room appeared to enjoy their meals. Hot and cold drinks were available throughout the day. Some of the service users consulted raised issues over the wait for their meal at lunchtime and told the inspectors that they had been told they had to be in the dining room at a set time, as meals were not served until everyone was sitting. The inspectors observed that one service user had been sat at the table for at least 45 minutes before lunches commenced. The inspector’s findings regarding lunchtime were discussed during feedback with the registered manager, and his deputy. It was agreed that a survey would be distributed to obtain the individual views of service users in regard to times of waiting at mealtimes. Frith House DS0000015978.V277875.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. A complaints procedure is made available to service users to allow them to raise any concerns. Systems were in place to ensure service users were protected, however staff recruitment shortfalls potentially put service users at risk of harm. EVIDENCE: The complaints procedure is found within the statement of purpose, and Service Users Guide, which is given to each service user. It is displayed on the home notice board and is named ‘Seeking Your Views’. All service users spoken to said they had no complaints and would know whom to talk to if they did. A complaints record is kept and the home received one anonymous letter of complaint via the CSCI since the last inspection. Appropriate action was taken and detailed investigation notes had been recorded. One area of the complaint was upheld in regard to a carpet being malodorous, due to a constant spillage problem, and action had been taken; the carpet had been replaced. Staff, before commencing employment at the home are subject to a POVAFirst check as part of an enhanced CRB disclosure for the protection of vulnerable service users at the home. Only two of the four recruitment files sampled evidenced this, which potentially put service users at risk of harm. An Immediate Requirement Notice was issued. Frith House DS0000015978.V277875.R01.S.doc Version 5.1 Page 17 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; 24 and 26. Service users live in a homely, well-maintained, clean environment where they can enjoy the privacy of their own bedrooms or socialise in a variety of communal areas. EVIDENCE: As part of the case tracking process individual service users rooms and some of the communal areas were seen. All rooms assessed were warm and homely with equipment such as profiling beds for those service users with manual handling needs. All rooms had locks fitted and lockable storage spaces. All rooms are single with en-suite shower rooms. The majority of service users consulted with indicated that they were satisfied with their rooms. One service user preferred to be downstairs and the manager agreed to discuss this with them and reassure them that a ground floor room would be available when Phase 3 of the new build is completed. Health and safety records were assessed which evidenced that the home is well maintained and complies with the requirements of the local Fire Service and Environmental Health department. The home is being further developed Frith House DS0000015978.V277875.R01.S.doc Version 5.1 Page 18 and refurbished to include bedrooms in the old build, the main dining room, conservatory, kitchen, staff facilities and laundry. The gardens looked well stocked and nicely maintained. The deputy manager told the inspectors that grab rails are being considered for outside to enable and promote independence; this will be beneficial to service users. Rooms sampled during the inspection had large windows overlooking the grounds. Emergency lighting was available throughout the home and was checked in-house on a weekly basis according to records seen. There are thermostatic controls on the hot water outlet taps in all areas. Records of bath temperatures had been maintained. On the day of inspection the home was free of any offensive odours. All areas were clean and well maintained. The laundry facilities were not assessed. There were hand-washing facilities throughout the home for staff with an adequate supply of paper hand towels and liquid soap. Gloves and aprons were seen for staff use. Frith House DS0000015978.V277875.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27; 29 and 30. The numbers and skill mix of staff appeared appropriate to meet the needs of current service users, however some service users indicated that the home was short of staff and that the staff were too busy to help. The safety of service users was compromised by the time it took to answer call bells. Staff morale was good. Shortfalls were discovered in the home’s staff recruitment procedures potentially putting service users at risk of abuse. EVIDENCE: Duty rotas were recorded and reflected the staff on duty at the time of the inspection. Copies were given to the inspectors as part of the inspection process. At the time of this inspection 51 service users were residing at the home. The home appeared adequately staffed at the time of the inspection. Staff training at the home is on a rolling programme and includes, for example, dementia awareness training, abuse awareness, risk assessing, NVQ 2 and 3 in care and health and safety training which includes: • • • Manual handling Infection control First Aid DS0000015978.V277875.R01.S.doc Version 5.1 Page 20 Frith House • • Basis and Advanced Food Hygiene And Fire Awareness training. Staff appeared relaxed and happy on the day of inspection. The majority of service users spoken to complimented the staff group, on their kindness and caring natures. Some service users told inspectors that they felt staff were ‘too busy’ or ‘rushed’ therefore were reluctant to ring their bells for help. One service user felt they were a ‘nuisance’ when staff were hoisting them and talking amongst themselves. It was concerning that on at least three occasions during the inspection staff were noted to be taking up to five minutes to answer call bells. One service user was overheard to say to a visitor that overnight they feel they cannot ring for help as the staff are too rushed. These concerns were brought to the attention of the manager who agreed that this ethos of staff being ‘too busy’ to help must stop. It was also agreed that a member of staff should be allocated to walk the floors on a regular basis, to ensure service users in their rooms or in the communal sitting areas are safe and comfortable. A member of staff was not seen on one floor, for at least an hour and a half. Four staff recruitment files were examined and the findings were as follows: • • two of the staff had commenced employment before a POVAFirst check had been gained, according to the records and one file did not have an application form or current references available. An Immediate Requirement notice was issued in this regard. Regular auditing of staff files is recommended as at the last inspection to ensure that all documents are available in line with current legislation, for the safety and protection of the service users. Frith House DS0000015978.V277875.R01.S.doc Version 5.1 Page 21 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 and 38 The registered manager and his deputies effectively manage the home. The home is committed to staff training. Quality assurance systems were in place to ensure the home is run in the best interest of the service users. The systems in place for ensuring the health and safety of service users and staff were good. EVIDENCE: Mr Paul Cullis and his deputies continue to effectively manage the home. This was evident from comments received from service users, staff, relatives and health care professionals. Service users and staff spoke highly of the manager. A further deputy manager has been appointed since the last inspection to Frith House DS0000015978.V277875.R01.S.doc Version 5.1 Page 22 manage the SRC unit. This gives a firm structure to the management of the home and adds further support for the manager. The home has gone through a period of change over the past 18 months with the new build, and since November 2005 the computerised care planning systems being implemented as a ‘pilot’. This has involved a lot of hard work including a settling in period for service users moving into the new build and/or the SRC unit, new staff being employed, re-structuring the staff groups and to implement a brand new care planning system and ensure all staff are able to use it. Considering the amount of work, which is also on going, the manager continues to ensure that a high standard of care provision continues at the home. The inspectors were satisfied that shortfalls identified during the inspection would be acted upon, within the given timescales. The home has Quality Assurance (QA) monitoring systems in place. Relatives meetings are held on a regular basis and there had been a recent residents meeting however the minutes were not available at the time of this inspection. The last staff meeting was held on 17/01/06. The deputy manager told inspectors that approx 8 service users attended. There is a training plan in place for staff to include NVQ training in care to levels 2 and/or 3 and specialist training, for example in mental health awareness. The company carried out an annual QA audit on 10/01/06. The area manager carries out monthly visits to the home under Regulation 26, the last being on 30/01/06. All service histories were current. The fire records were examined; the home had conducted weekly fire and emergency light checks, the last being on 08/02/06. A fire drill was implemented on 23/06/05. Records indicated that staff attended regular fire training. The emergency lighting and fire equipment was last serviced on the 24/01/06. Gas servicing was up to date. PAT testing was up to date – done in January 2006. There were a total of 90 accidents recorded since the last inspection 78 being falls. This is higher than at the last inspection. Accidents had been audited, however as discussed if times were reflected on the summary sheets then the manager would be able to see at a glance if there were any patterns emerging. The home has informed the CSCI of any deaths or serious incidents. One service user, nursed in bed, had bedrails fitted. There was a significant gap where the bedrails fitted the bed even though bumpers were fitted. It was required that the manager undertake an immediate risk assessment to decide whether the risk of falling out of bed was greater than the risk of entrapment. It was also agreed that hourly checks be implemented given the frailty of the service user. Frith House DS0000015978.V277875.R01.S.doc Version 5.1 Page 23 As recommended at the last inspection and in regard to the findings at this inspection where one set of bedrails in use appeared to be a potential entrapment risk, bedrails should be checked on an individual basis to ensure they are fitted correctly, and records kept to prevent any risk of harm to service users. The way service users summon help from staff from the conservatory and other communal areas was discussed. It is recommended that the provision of call bell pendants be considered for these areas. The kitchen was clean and well organised and records were up to date. Frith House DS0000015978.V277875.R01.S.doc Version 5.1 Page 24 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 3 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 2 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 Standard No Score 16 3 17 X 18 2 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 X 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 2 Frith House DS0000015978.V277875.R01.S.doc Version 5.1 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP8 Regulation 12(1) Timescale for action To promote and make proper 28/02/06 provision for the health and welfare of service users, the registered person must ensure that any nutritional risk assessed as ‘high’ must have a plan of care developed. Also when a care plan states that fluid input and output to be monitored the registered person must ensure records are maintained in this regard, to ensure adequate fluid intake. The registered person must 28/02/06 ensure that all staff follow the homes medication policies, record maximum doses to be given, in particular regard to analgesia and give medication as stated on the prescription label. The registered person must 28/02/06 ensure systems are in place for monitoring the amount of time call bells are answered and take action to ensure that service users are not waiting for care provision. DS0000015978.V277875.R01.S.doc Version 5.1 Page 26 Requirement 2 OP9 13(2) 17(1)[a] 3 OP27 13(4)[c] Frith House 4 OP29 17(2) 19 The registered person must 14/02/06 ensure safeguards are in place to protect service users at all times by ensuring the fitness of persons before their commencement of employment, in line with company recruitment policies. An Immediate Requirment notice was issed. The registered person must 14/02/06 ensure that a risk assessment is recorded for the use of bedrails on the identified hospital bed to ensure the risk of entrapment is eliminated. An Immediate Requirment notice was issed. 5 OP38 13(4) 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 OP15 OP27 Good Practice Recommendations An audit should be carried out to ascertain all service users views on any waiting time at meal times. It is strongly recommended that staffing is structured in a way that enables a member of staff to walk the floors on at least hourly to ensure service users in their rooms and/or in the sitting areas are safe and comfortable. And reassurance should be given to service users who feel unable to use their call bells or ask for help, due to an ethos developing of the staff being ‘too busy’. 3 OP29 Staff recruitment files should be audited on a regular basis to ensure documents required by Schedule 2 are available for the protection of vulnerable adults. Frith House DS0000015978.V277875.R01.S.doc Version 5.1 Page 27 4 OP38 Checks of bed rails should be maintained the frequency, depending on individual need, ensuring they are well fitted, to protect service users from a risk of harm. The provision of call bell pendants should be considered to enable service users in the conservatory and other communal areas to summon help when required. 5 OP38 Frith House DS0000015978.V277875.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Frith House DS0000015978.V277875.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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