Inspection on 20/07/05 for Frith House

This inspection was carried out on 20th July 2005.

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

The inspector 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 14/02/06

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 Announced 20th July 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Frith House D53-D02 S15978 Frith House V231857 200705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Frith House Address Steart Drive, Burnham-on-Sea, Somerset, TA8 1AA Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01278 782537 01278 782537 Somerset Care Ltd Mr Paul Gerard Cullis Care home 53 Category(ies) of Old age (53) registration, with number of places Frith House D53-D02 S15978 Frith House V231857 200705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: One named person under the age of 65 years within the registered number of 53 beds. Date of last inspection 16th February 2005 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 53 people over the age of 65 requiring personal 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 old build) – all rooms in the new build have ensuite facilities. The home is currently being refurbished and enhanced to provide accomodation for up to 80 service users. Phase one is 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 floor 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 D53-D02 S15978 Frith House V231857 200705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The last inspection was unannounced and took place on 16th February 2005. At that inspection five requirements were identified and three recommendations were made. This announced inspection took place from 09:00 and was conducted by two inspectors Caroline Baker and Barbara Ludlow (10.5hrs). At the time of this inspection requirements identified had been complied with and two recommendations had been actioned. Forty-four service users were residing at the home and one was in hospital. Staffing levels exceeded minimum levels to meet the care needs of the current service users. An assessment of the premises took place where a selection of bedrooms and communal areas were seen. At least fifteen service users were spoken with and four visitors. Paul Cullis the registered manager and his deputy, were available throughout the inspection. Throughout the day the inspectors were able to observe interactions between staff and service users and one was able to join service users for lunch. 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 new bedrooms and were happy and felt safe at the home. Frith House D53-D02 S15978 Frith House V231857 200705 Stage 4.doc Version 1.30 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. Fresh flowers were placed on every dining table, which were laid with tablecloths, cutlery, glasses and serviettes, and staff served residents in an unhurried and dignified manner allowing choice at all times. Service users praised the staff. Some comments received via comment cards and speaking with service users included: “A very caring home”, “this should be named “The Ritz” and “my care is excellent”. Visitors were made welcome and indicated their satisfaction at the provision of care at the home. Positive comments were received via a comment card sent to a GP who visits 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 deputy are managing the home very 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: The inspection identified the following good practice recommendations: o Updating care plans in regard to wound care o Recording service users weight on admission and then on a monthly basis o Recording actions to take if service users found to be at a high risk of falling o Following policy guidelines in regard to self-medication o Auditing staff recruitment files to ensure all documents are in place in line with current legislation o Checking the fitting of bedrails on a monthly basis to prevent any risk of harm to service users using them. Frith House D53-D02 S15978 Frith House V231857 200705 Stage 4.doc Version 1.30 Page 7 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 D53-D02 S15978 Frith House V231857 200705 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Frith House D53-D02 S15978 Frith House V231857 200705 Stage 4.doc Version 1.30 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 standard(s) 1, 3, 4, 5, and 6 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 would be able to introduce prospective service users to the home prior to admission. 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. Service users spoken with at inspection confirmed this. Frith House D53-D02 S15978 Frith House V231857 200705 Stage 4.doc Version 1.30 Page 10 Evidence was seen in the most recently admitted service users care plans sampled that pre-admission assessments had been gained to ensure the home could meet their needs. Service users are able to visit the home at any time prior to admission. A day service can be provided to give them a flavour of the home. The home also provides day care for up to eight service users. Five day care service users were at the home on the day of the inspection. Those spoken with praised the day care provision at the home. At least two of the service users living at the home had been day care users in the past. The manager informed the inspectors that the Change Agency Team (CAT) scheme was ending and a new scheme named ‘step up, step down’ was commencing. Both schemes are nurse supported. The scheme allows for persons who do not need to remain in hospital but are not ready to go home to have an interim period at the home to fully recover. Although not classed as ‘intermediate care’ service users are given support to maximise their independence to return home. One service user under the scheme was met at inspection and told the inspector how much better they had felt since admission and were looking forward to returning home. Frith House D53-D02 S15978 Frith House V231857 200705 Stage 4.doc Version 1.30 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 standard(s) 7, 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. Evidence was seen that service users agreed with their written care plan. Service users have access to health care professionals expertise to meet their individual needs. Service users were protected by the homes procedures in regard to the receipt, administration, recording and disposal of medications. The home’s procedures in regard to self-medication were not fully in line with the homes policy. Service users were treated with kindness and respect. EVIDENCE: Six care plans were examined as part of the case tracking process and the individual service users were met by one of the inspectors. Individual care needs plans contained detailed actions to be taken by care staff to assist with or deliver the care. Frith House D53-D02 S15978 Frith House V231857 200705 Stage 4.doc Version 1.30 Page 12 Four of the care plans reflected current individual care needs. Two required updating to reflect current wound care needs that the District Nurse (DN) gave support with. Generic, falls, pressure sore, nutritional and manual handling risk assessments were in place. Evidence of visits from health care professionals had been recorded. As discussed at inspection action to be taken when a service user is deemed ‘high risk’ of falling should always be reflected and all service users should be weighed on admission and monthly thereafter to determine their nutritional, manual handling and pressure sore risk status. The homes receipt, administration, recording and disposal of medication procedures were examined. Overall a high standard of practice was seen. The recording of the frequency of administration of an injection given by the DN was not reflected, and the medication administration record (MAR) stated ‘as directed by the doctor’. As discussed this should be reviewed and the dates recorded when administered to prevent any potential mistakes. Self-medication is actively encouraged at the home and two of the service users case tracked were self-medicating. Both had lockable spaces to store their medication. According to the homes self-medication policy MAR sheets should be stored with the medication in the individual service users room and weekly compliance checks should be carried out. As discussed at inspection the procedures at the home should be in line with the policy or the policy reviewed to reflect the homes procedures. Service users were treated and addressed appropriately by staff throughout the day of the inspection. Care plans reflected preferred names. 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. Service users spoken to indicated that the staff always treated them with respect. All service users indicated through comment cards received, and speaking with them that they felt well cared for, liked living at the home, that the staff treated them well and that their privacy was respected Frith House D53-D02 S15978 Frith House V231857 200705 Stage 4.doc Version 1.30 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, and 15. 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. 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. Trips are organised on a regular basis. Service users are offered an annual holiday to Weymouth. Three had taken advantage of this. Photographs were displayed of events service users had attended. 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. Frith House D53-D02 S15978 Frith House V231857 200705 Stage 4.doc Version 1.30 Page 14 Service users spoken to at inspection and through comment cards received indicated that they were happy with the activities provided. On the day of inspection one inspector joined some of the service users for a game of dominos. The atmosphere was happy at the home with service users either joining in with the activities provided or reading, chatting or watching TV. During the afternoon service users were given an opportunity to have a manicure. 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. It was evident through comments received from service users that they had a choice of daily living. The inspector was able to join service users for lunch. It was pleasing to note that service users had been given a choice of meal. Menus were displayed on tables and at lunchtime there were three choices of main meal. On the day of inspection it was a choice of breaded cod, veggie grills or omelette. There was a choice of dessert. The food was well presented and tasty. All service users spoken to stated that the food was always good. The menu was also displayed on a notice board. Weekly menus looked balanced and nutritious. Everyone in the dining room appeared to enjoy meals. The atmosphere was happy, unhurried and dignified. Hot and drinks were available throughout the day. daily well their cold Frith House D53-D02 S15978 Frith House V231857 200705 Stage 4.doc Version 1.30 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17 and 18. A complaints procedure is made available to service users to allow them to raise any concerns. Service users were given the opportunity to exercise their rights. Appropriate steps were being taken to reduce the risk of harm or abuse to service users. 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 had not received any complaints since the last inspection. The CSCI had not received any against the home. 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. Three of the four recruitment files sampled evidenced this. All service users are registered to vote either by post or by being taken to the local polling station. Frith House D53-D02 S15978 Frith House V231857 200705 Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25, 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: An assessment of the premises took place through the case tracking process, which involved sampling at least twelve bedrooms ten of which were in phase one of the new build. Communal areas were sampled including the activities room, lounges, and conservatory and dining area. Following completion of phase one of the new build and since the last inspection the home currently provides: o o o o o Two new assisted bathrooms with hi-lo baths Twenty eight showers (including en-suites) Two new adapted toilet facilities plus two WC’s in new bathrooms Twenty six en-suite facilities Twenty six new bedrooms D53-D02 S15978 Frith House V231857 200705 Stage 4.doc Version 1.30 Page 17 Frith House o Two small kitchenettes for service user use o A new reception and main entrance area o And more communal space. Service users are encouraged to personalise their rooms and staff ensure that the privacy and dignity of service users is respected. This was evident at inspection. All service users had accessible locks on their bedroom doors. Service users spoken with informed the inspectors that they were happy with their rooms. There were sufficient toilet and bathing facilities to accommodate the service user group. The home was equipped with handrails along all corridors to promote independence. Corridors were wide and accessible by wheelchairs. There were ramps to facilitate easy access to the grounds, which are also being developed and enhanced. Many service users were seen using walking aids and appeared confident when using them. A company Occupational Therapist can give the home advice and support. Rooms sampled during the inspection had large windows overlooking the grounds. Emergency lighting was available throughout the home and was checked on a monthly basis. 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 adequate for the number of service users. There was a sluicing facility on the washing machines and access to an outside drying space. There were hand-washing facilities throughout the home with an adequate supply of paper hand towels and liquid soap. Gloves and aprons were seen for staff use. The home was compliant with the local fire department and environmental health department. Frith House D53-D02 S15978 Frith House V231857 200705 Stage 4.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30. The numbers and skill mix of staff were appropriate to meet the needs of current service users. Staff morale was good. Minor 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 sent to the inspector as part of the inspection process. Service users and staff spoken to at inspection commented on how they felt the home was adequately staffed. The homes own relief staff were used to cover any shortfalls. At the time of this inspection 44 service users were residing at the home. The home appeared more than adequately staffed at the time of the inspection. Staff training at the home is on a rolling programme and includes, for example, mental health awareness training, abuse awareness, risk assessing, NVQ 2 and 3 in care and health and safety training which includes: • • Manual handling Infection control D53-D02 S15978 Frith House V231857 200705 Stage 4.doc Version 1.30 Page 19 Frith House • • • First Aid Basic and Advanced Food Hygiene And Fire Awareness training. 53 of staff had gained an NVQ in care, which exceeds the standard. Staff interviewed during the inspection confirmed the training they had received. Staff appeared relaxed and happy on the day of inspection and told the inspectors that they enjoyed working at the home. Service users complimented the staff group. Four staff recruitment files were examined and some of the individual staff met at inspection. Although robust systems were in place for the protection of vulnerable adults the following were identified: o o o o o One POVAFirst check was not seen References were missing although ticked received in one file Copies of passports for two overseas staff were not seen One contract was not signed and one was not dated And medical details were not seen in one file. Following a discussion with the manager it was evident that the references had been applied for and received but had somehow been mislaid. Action was taken during the inspection to find them and the inspector asked to be kept informed of the outcome. Regular auditing of staff files is recommended to ensure that all documents are available in line with current legislation. Frith House D53-D02 S15978 Frith House V231857 200705 Stage 4.doc Version 1.30 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 34, 35, 36, 37, and 38. The registered manager and his deputy effectively manage the home. The home is committed to staff training. The systems in place for ensuring the health and safety of service users and staff were good. EVIDENCE: Mr Paul Cullis and his deputy 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. Mr Cullis is responsible for the implementation of company policy in respect of all care home services and management of staff and all tasks in line with the Care Standards Act 2000. Frith House D53-D02 S15978 Frith House V231857 200705 Stage 4.doc Version 1.30 Page 21 It was evident having spoken to staff and service users on the day of inspection, that the manager communicates a clear sense of direction, and leads the staff in a way that they understand. The inspectors recognise and commend the managers for the way they continued to manage the home during the refurbishment and different phases of new build, which because of this, has caused little disruption to the service users. Evidence of residents/relatives meetings were seen. Minutes were recorded. Service users spoken to confirmed attending meetings and indicated that actions were taken on issues raised. Service users and visitors were made aware of the inspection by a poster being displayed on the main notice board. Service user surveys were due to be distributed and will be followed up at the next inspection. The CSCI sent comment cards to at least 20 service users and had received 19 at the time of this inspection. All were very positive about the provision of care at the home. Staff had formal supervision and records were seen. The remaining records seen at inspection were up to date and in line with current legislation. All service histories were current. The fire records were examined; the home had conducted weekly fire and emergency light checks and was done during the inspection. A fire drill was implemented on 23/06/05. The emergency lighting and fire equipment was last serviced on the 23/05/05. Gas servicing was up to date. PAT testing was up to date. Records indicated that staff attended regular fire training and one or two had not yet received it this year. There were a total of 72 accidents recorded since the last inspection these were audited by the company at head office. COSHH records were maintained. There have been ten deaths at the home in the past 12 months. The home has informed the CSCI of any serious incidents. Bedrails should be checked and records kept on a monthly basis to ensure they are well fitted to prevent any risk of harm to service users. The kitchen was clean and well organised and records were up to date. Frith House D53-D02 S15978 Frith House V231857 200705 Stage 4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 x 3 3 3 3 3 Frith House D53-D02 S15978 Frith House V231857 200705 Stage 4.doc Version 1.30 Page 23 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 Regulation Requirement Timescale for action 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 OP8 Good Practice Recommendations Wound care needs records should be current in line with the District Nurses records. Service users should be weighed on admission and monthly thereafter. Actions should be recorded where service users are found to be at high risk of falls. Self-medication policy guidelines should be followed or reviewed 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 Bed rails should be checked and records kept, to ensure they are well fitted, on a monthly basis to protect service users from a risk of harm. 2. 3. 4. OP9 OP29 OP38 Frith House D53-D02 S15978 Frith House V231857 200705 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection 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 D53-D02 S15978 Frith House V231857 200705 Stage 4.doc Version 1.30 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!