Inspection on 16/07/07 for Frith House

This inspection was carried out on 16th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 28/11/06

Frith House 14/02/06

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 Barbara Ludlow Unannounced Inspection 16th July 2007 20:30 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 Frith House DS0000015978.V339478.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. Frith House DS0000015978.V339478.R01.S.doc Version 5.2 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 80 Category(ies) of Dementia - over 65 years of age (22), Old age, registration, with number not falling within any other category (80) of places Frith House DS0000015978.V339478.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. One named person under the age of 65 years within the registered number of 80 beds Up to three persons between the ages of 55 - 65 years within the registered numbers of 80 beds. Within the maximum registered numbers of 80, the home may accommodate up to 22 service users in the category of DE (E). 28th November 2006 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 80 people over the age of 65 requiring personal care, including 22 persons with dementia care needs. The home is not registered to provide nursing care. 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 older part of the building) - all rooms in the new part of the building have en-suite facilities. There is a separate unit within the home to accommodate up to 22 service users who have dementia. The home has increased its capacity to 80 service users. Frith House offers a respite care service within the registration and has a day care provision for up to ten service users. Social Services have a contract for all the dementia care places to provide a Specialist Dementia Care (SRC) unit. Also contracted are 30 places in the main unit for older persons residential care plus there are 5 ‘step up/step down beds’ used for short term rehabilitative care. There are lounges and sitting areas on both floors. There are dining areas on the ground floor and first floor of the new part of the building. The home has a bar/ lounge where service users may smoke if they wish to do so. The home has a pay phone near the entrance foyer for residents to use. Frith House DS0000015978.V339478.R01.S.doc Version 5.2 Page 5 The home’s current fee range is from £373.00 to £550.00 per week. Additional charges include; newspapers/magazines, hairdressing, mini-bus trips, holidays, chiropody, continence products, toiletries and transport for appointments. Frith House DS0000015978.V339478.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The focus of this inspection visit was to inspect relevant key standards under the Commission’s ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are: - excellent, good, adequate and poor. This inspection commenced at 20.30 in the evening, with the purpose of reviewing the staffing level and care demands during the evening across the whole home. The inspection continued with a visit the next day and was concluded on a second full day at a third visit the following week when the manager had returned from annual holiday. Two inspectors were present on visits one and two, one inspector concluded the inspection on the third visit. Feedback was gathered from service users, relatives and staff over an open inspection period of three weeks. The analysis and feedback is included in the body of the report. A tour of the premises was made during the course of the inspection. The service users in residence, those having respite care and the day care users were seen and spoken with. Staff were observed with service users and were spoken with. Daily life at the home was observed including mealtimes, evening and nighttime care and daytime social activities. The person in charge overnight was seen during the evening visit. The home’s deputy manager was seen on the first full day. The manager supported by the area manager were seen on the second full day. Feedback was given to the manager and deputy at the close of the inspection. What the service does well: Frith House is purpose built, very modern and well updated care home. The decoration and furnishing is of a high standard and very comfortable. The gardens that to date have been completed, provide a pleasant outlook and out door space with seating. The home has a competent management team that are approachable and accessible through their open management style. Training and development of the staff team continues to improve the quality of the service delivery. Frith House DS0000015978.V339478.R01.S.doc Version 5.2 Page 7 The home has a high occupancy rate indicative of its social services contract and popularity in the area. Visiting professionals asked were pleased with the service and care delivered to their clients. Feedback indicated a high rate of service user satisfaction and relative / carer satisfaction. Relatives comments included, 10 out of 10 for everything’, ‘excellent care, and ‘I think it’s about as good as it gets’. What has improved since the last inspection? What they could do better: One garden that is due to be completed was potentially hazardous at the time of the inspection due to the resident nesting seagulls. There is landscaping planned for this garden, in the meantime a risk assessment should be made to assess the safety of this area for staff and service users. The records for service users were examined and where wound care is managed by the community nurses the care homes notes were incomplete. Reference to the care and progress of a wound should be logged on the care plan. Blood sugaring monitoring equipment used by care staff is not sharp safe. Reference to the Medical Devices Agency (MHRA) guidance from June 2006 is recommended. Care plans recording personal care and bathing did not mention any preference or choice being offered of carer, either male or female. Frith House DS0000015978.V339478.R01.S.doc Version 5.2 Page 8 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. Frith House DS0000015978.V339478.R01.S.doc Version 5.2 Page 9 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.V339478.R01.S.doc Version 5.2 Page 10 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): 2,3 Quality in this outcome area is good. Contracts for the costs of the service are clear. The homes manager or deputy undertake pre admission assessment, this ensures that prospective service user’s care needs can be met at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Visits to the home are welcomed and time can be spent at the home to see if the home might suit the individual’s needs. Mr Cullis the manager explained to the inspectors how he or his deputy manager would visit potential service user to make a pre admission assessment. This assessment would determine if the persons care needs could be met at the home before acceptance of their admission to the home. A Frith House DS0000015978.V339478.R01.S.doc Version 5.2 Page 11 brochure about the home would be taken for the prospective service user at this time. The service user guide is placed in each bedroom for each service user to refer to after their admission. This was a goal for improvement stated in the home Annual Quality Assurance Assessment and achievement of this was evidenced. Care plans were sampled at the inspection and the pre admission documentation was seen. There was good evidence of thorough assessment of needs and the gathering of information from the community professionals involved with the assessment of need for care and support. One service user asked said they had visited Frith House to ‘look around ‘ and their daughter had also been to look around before a decision was made to move in to the home. One service user who has been in residence for a while commented that the home was ‘still as good’ as when they decided to move in some years ago. Relatives reported that they were very pleased with the care, one commented that staff are ‘always professional and attentive’, another that residents are ‘well looked after’. One relative felt the home had taken the burden of care from them as their relative was having ‘ a good quality of life’. Contracts were sampled for service users receiving residential care, step up / down care and respite care. All costs were clear. The contract states that the first four weeks of residence are considered to be a trial period for both parties. Extra charges are made for chiropody and hairdressing trips out and holidays. Transport for appointments is also an extra cost. Newspapers can be ordered at cost. Toiletries and other small items can be purchased from the home’s shop. Day care is not a registered service but is offered at the home. Two day care service users were seen. Both were very complimentary about the service. Frith House DS0000015978.V339478.R01.S.doc Version 5.2 Page 12 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): 7,8,9,10 Quality in this outcome area is good. Care plans are in place for all service users, personal and health care needs are met and there is good support from the community health care services. Medications management was satisfactory. Service users are treated respectfully. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans were sampled these demonstrated pre admission assessment and information gathering from community professionals to inform the process. The care plans have been computerised. A print off page is held to for the signature of the service users to indicate their agreement to the care planning detail. Care plans are written sensitively and in a person centred manner. Lots of relevant details and contacts were recorded. Frith House DS0000015978.V339478.R01.S.doc Version 5.2 Page 13 All service users are registered with a local General Practitioner. Health care needs are monitored and any nursing or medical health care input is provided from the community health services such as the community nurses, local doctors surgery and the Somerset Partnership for Community Mental Health Care. One Community Psychiatric Nurse visiting the home took time to speak with the inspector. Very positive feedback was heard about the dementia care unit and the care of the service users in residence there. Professional allied to health care such as chiropody services attend Frith House, there are charges made for this service. One incident had occurred involving a service user who sustained an injury and was taken to hospital. The visiting professionals and the care records supported that the service user had received a good level of care whilst resident at Frith House. Where wound care is provided to a service user by the community nurses a record should be made within the care plan to evidence progress of the wound. The home is reliant upon the nurses to record the progress and treatment but their records would be removed when a wound has healed leaving no audit trail in the care records. Reference to wound care information recording in the care plan is required at this inspection. The management of diabetes is recorded and staff have been trained to care for named service users requiring insulin or blood sugar level monitoring. The monitoring of blood sugar levels must be with equipment that is determined to be sharp safe for care staff to use safely to reduce the risk of needle stick injury. The Medical Devices Agency (MHRA) has issued notifications for care homes to be guided by. A requirement is made for the manager to address this after this inspection. Service users are treated respectfully. One service user commented that staff ‘always knock’ before entering their bedroom and this was observed. Staff were reported to be kind and considerate. Two ladies spoken with both commented independently that they were not offered a choice of carer, male or female for bathing and personal care delivery. One person said they ‘were embarrassed at first’ but had got used to it and had no objections now. An important part in maintaining the dignity of service users is the offering of a choice and an explanation so that a positive choice can be made and this information should be recorded and acted upon. Frith House DS0000015978.V339478.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): 12,13,14,15 Quality in this outcome area is good. Life at Frith House is spent how the service users choose to spend their time. There are activities coordinators providing a range of events for service users to participate in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a range of social activities for the service users to participate in and dedicated activities staff and an activities room. The home is taking part in a piece of research around activities in care homes, which involves staff visiting the home from Exeter University. One person commented on the fact you could ‘spend your time as you wish’ and this person had made a positive choice to ‘do nothing’. Bedrooms are comfortable and can be personalised and service users seemed to enjoy their private space. Frith House DS0000015978.V339478.R01.S.doc Version 5.2 Page 15 Service users spoke of enjoying the company of other service users and of they’re being a ‘good crowd’ at the home. Communal areas are comfortable and are very well used on the ground floor. The home has a payphone on the ground floor close to the shop and reception area. Service users were seen waiting for incoming calls from relatives. One relative commented on the written feedback that a payphone on each floor of the home would be an improvement. Day care service users share the communal rooms with residential service users. On the first full day visit this was causing some distress for one service user who was displaced from their usual seat in a small lounge. Another residential service user took positive action and vacated her seat to defuse the tension. Care must be taken to ensure day care / residential care service user are satisfied with the shared use of the communal space. Service users had friends and there was supportive camaraderie between small groups choosing to sit together in the lounges and at meal times. Meal times were observed in four areas, both floors in the SRC unit, the small dining room and the large dining room. The SRC unit staff have undertaken training and have learned from the dementia care mapping exercise. The meal times were very social occasions. Service users served their own vegetables from serving dishes and enjoyed a well organised mealtime experience. It was relaxed and the staff interactions were rewarded with attentive interaction and responses. This was commendable and a notable improvement from the last inspection. The small dining room was less well managed and lessons should be taken from the SRC unit. There were no menus on the table, no vegetables were offered in dishes and the interactions between staff and service users were minimal and task orientated only. The large dining room is well used. Service users congregated early and chatted whilst waiting to be served. Menus were available. Drinks were served first and then the meals table by table, which appeared to work well. Service users complained that the same tables are always served last and this can result in the food being less than hot. The logistics of lunchtime in this large room with a large number to serve at one time is challenging for the catering and serving staff; overall the service and experience was good. The meal looked appetising and was nicely presented. Service users commented that the ‘food is good’, they are offered ‘a choice’ at mealtimes and ‘food is very nice’. Frith House DS0000015978.V339478.R01.S.doc Version 5.2 Page 16 The home catering team also prepare food for two external day centre luncheon clubs for 10 to 12 persons each week. Frith House DS0000015978.V339478.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): 16,18 Quality in this outcome area is good. The home has a company complaints policy and procedure. The recruitment of staff is of a standard that will protect the service users from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has policies and procedures for dealing with any complaints; the service user guide available in each bedroom explains the process. The home has recruitment policies and procedures to protect service users from harm. The recruitment of staff was sampled and evidence of good practice was seen. New recruits had application forms with work history, two references held on file, criminal record bureau (CRB) checks and POVA First checks. Staff spoken with were happy working at the home and confirmed feeling able to raise any concerns with the senior staff team. Staff are valued by the service users and almost all offered very positive comments including ‘staff are very good’, ‘friendly staff’, one said that ‘some Frith House DS0000015978.V339478.R01.S.doc Version 5.2 Page 18 can’t be bothered to speak to you’ but also said that generally all are very helpful. The manager confirmed that service users civil rights are upheld and they would be registered to vote when resident at the home. Frith House DS0000015978.V339478.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): 19,20,21,22,23,24,25,26 Quality in this outcome area is excellent. Frith house has been purposefully modernised and extended. It has been built to a high standard to meet the needs of the service users in residence. The home is kept very clean and well maintained and infection control is of a good standard. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Frith House has undergone a major building and refurbishment to modernise and bring the premises up to a high standard; this work with the exception of a garden area is now complete. Frith House DS0000015978.V339478.R01.S.doc Version 5.2 Page 20 The home is registered with CSCI to provide personal care for up to a maximum of 80 service users. Within the maximum numbers of 80, the home has a specialised dementia unit, which can accommodate up to 22 service users. The home has allocated step up /step down and respite care places in one area of the home. The main dining room has been extended and refurbished and the kitchen, laundry and staff facilities have been improved. The home is purpose built and is arranged over two floors. Shaft lifts give access to the first floor in both the residential area and the SRC unit. Call bells and grab rails are conveniently sited throughout the home. The dementia unit has been designed using the latest research in respect of the environmental needs of people who have a dementia. To ensure the safety of service users, upstairs windows have been restricted and wardrobes secured to the wall. Hot water outlets are fitted with thermostatic valves to reduce the risk of scalding. There are assisted bathing facilities, raised toilets and mobile hoists available throughout the home to assist service users. All newly built bedrooms meet with the national minimum standards for size and have been fitted with an en-suite toilet with level access shower. Eighteen of the existing bedrooms have also been extended to provide this provision. All bedrooms are for single occupancy and a number were viewed at this inspection. Bedrooms appeared comfortable and service users are encouraged to personalise their rooms. All service users asked at this inspection said they were happy with their bedrooms. All bedrooms are fitted with a lock and service users are provided with a key. Locks can be over-ridden by staff in the case of an emergency. Bedrooms are also fitted with lockable storage. The home has a number of lounge areas and those on the ground floor are well used. Day care use can unwittingly intrude on the residential service users who may have become settled into using one particular lounge and chair in that lounge. The day care numbers are currently restricted to six per day. This should be managed sensitively and reviewed if problems occur. There is also a small lounge which is fitted with a bar area, service users are permitted to smoke this designated area. The home also has a hairdressing salon, small shop and activities room. Frith House DS0000015978.V339478.R01.S.doc Version 5.2 Page 21 All areas seen at this inspection were warm, clean and free from malodours. Staff have access to appropriate protective clothing. The facilities for staff hand washing and the management of infection control at the home was very good. There is a well equipped treatment room and cool medication storage room. Frith House DS0000015978.V339478.R01.S.doc Version 5.2 Page 22 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): 27,28,29,30 Quality in this outcome area is adequate. Care staffing numbers have been maintained. Recruitment is ongoing and there is a growing staff team. Regular agency staff are used to meet the needs of the service users as capacity occupancy has been reached, following the completion of extension of the premises. Staff have received training to carry out their roles competently and have received regular supervision. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff were seen during the three visits to the home. At the first visit made during the evening the staff working on the Dementia care (SRC) unit were seen. Service users were still up and about and staff dedicated their time to the well being of the service users. Persons who wanted to stay up later remained in the lounges with staff supervision. Staff explained to the inspectors what their duties at night are. Caring for service users was first and foremost. But night care work included cleaning communal areas, toilets and attending to the laundry. Staff in the main part of Frith House DS0000015978.V339478.R01.S.doc Version 5.2 Page 23 the home also clean the kitchen, dining room, lay breakfast tables and trays. The reception and some communal areas are vacuum cleaned during the night. It was felt to be inappropriate to vacuum clean the SRC unit lounges during the night as the bedrooms are in close proximity and service users once settled could then be disturbed by the noise. The inspector was informed that vacuuming communal areas at night would cease. The SRC unit has only three staff at night and this means the person working on their own must be relieved to leave the unit to take washing to the laundry. It is essential that staff are clear that the floors of the dementia care unit are never left unattended especially at night. Not all staff spoken with clearly understood this. An incident had occurred on the dementia care unit, which has been investigated. Regular senior care support has been implemented to ensure inexperienced or agency staff have senior staff who are familiar with the service users in residence and their care plans. Hourly nighttime checks are now carried out and are recorded. This is a satisfactory response. On the residential wing service users were seen up and about after 10pm, staff were busy with the kitchen duties and laying the breakfast tables. The senior staff was dispensing medication at this time. The inspectors felt that at this time of night the care staff should be spending more time with the service users helping them to settle rather than carrying out tasks that could be done quietly in the middle of the night. This was fed back to the manager and the area manager at the time of the inspection. Staff recruitment was sampled and was found to be satisfactory. Criminal Record Bureau checks and POVA First checks were in place. The home has recruited activities staff, this is an improvement. There is separate domestic, catering and maintenance staff. Frith House DS0000015978.V339478.R01.S.doc Version 5.2 Page 24 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): 31,32,33,53,38 Quality in this outcome area is good. Mr Paul Cullis is an experienced and well respected care home manager. The home is run with the best interests of the service users being paramount at all times. Health and safety matters are well managed and responsibly monitored. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager is Mr Paul Cullis and has been involved in the care of older people for over 30 years. Mr Cullis has worked at the home in various roles for the past 16 years. Frith House DS0000015978.V339478.R01.S.doc Version 5.2 Page 25 Mr Cullis has achieved appropriate management qualifications and is also an NVQ assessor. Mr Cullis holds a certificate in managing health and safety (IOSH) Mr Cullis promotes an open and inclusive style of management and has now had three of his ‘open surgeries’ for service users and relatives to meet with him and the number attending is increasing. The home has an effective deputy manager and has regional support from the area manager for company, Somerset Care Limited. Regulation 26 visits are completed each month for the home. The views of service users and other stakeholders are sought on a regular basis as part of the company quality assurance programme. The Annual Quality Assurance Assessment (AQAA) for CSCI had been fully completed by Mr Cullis and his deputy prior to this inspection. Regular meetings are held for service users, staff and visitors and minutes are maintained. Mr Cullis was pleased that since the home first carried out the dementia mapping initiative more staff have attended the meetings. Some staff have attended in their own time to hear how what the exercise had revealed and what changes to practise could be made. The home has a wide range of policies and procedures, which are reviewed annually by the company. The registered manager ensures that all staff receive formal supervision at least 6 times a year. Records sampled confirmed this. All staff receive an annual appraisals. The records for service user’s personal monies held on their behalf were checked. All transactions were balanced and the monies were seen to be securely held and access is restricted. The balance of the individual amounts of money held were not checked. FIRE SAFETY EQUIPMENT – Weekly fire alarm tests had been carried out, emergency lighting had been checked. The alarm system had been serviced on 23rd February 2007 EQUIPMENT SERVICING – Records examined confirmed that the home’s passenger lift was serviced on 13th July 2007. The home has a ‘rolling’ contract with an external company to ensure that all equipment for the transporting /moving of service users is serviced every 6 months. GAS SAFETY – The home has an up to date annual landlords gas safety certificate dated 20th April 2007. Frith House DS0000015978.V339478.R01.S.doc Version 5.2 Page 26 ACCIDENTS - Accidents are appropriately recorded and analysed monthly by the registered manager. One concern was raised from the regulation 37 notifications sent to CSCI this has been reviewed as part of this inspection. The manager is reminded that regulation 37 notifications need to be made in the event of a service user dying in hospital. Frith House DS0000015978.V339478.R01.S.doc Version 5.2 Page 27 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 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 3 3 3 3 3 4 4 3 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 3 3 3 X 3 3 3 3 Frith House DS0000015978.V339478.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? NO 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 17 (1)(a) Schedule 3 (3)(n) Requirement The registered person shall ensure that the home promotes and makes proper provision for the health & welfare of service users: - Care plans must clearly evidence any wound care management. Timescale for action 24/09/07 2. OP26 13(3) Blood sugar monitoring by care 24/09/07 staff must be sharp safe. Guidance from the MHRA must be followed. To reduce the risk of needle stick injury to staff. 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. Refer to Standard OP10 Good Practice Recommendations Service users should be consulted and their preference for personal care / bathing assistance, should be recorded. This would demonstrate the promotion of choice and of dignified intimate personal care. DS0000015978.V339478.R01.S.doc Version 5.2 Page 29 Frith House 2. OP27 3. OP27 It is recommended that the registered person gives consideration to the employment/deployment of additional support during meal times so that meals can be served hot and in timely manner to all service users. The registered person should ensure that care staff on the dementia unit are allocated to each floor in appropriate numbers at all times. Frith House DS0000015978.V339478.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Frith House DS0000015978.V339478.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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