Inspection on 04/01/07 for Fritham Lodge

This inspection was carried out on 4th January 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fritham Lodge 01/12/08

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

CARE HOME ADULTS 18-65 Fritham Lodge 36 Shirley Park Road Shirley Southampton Hampshire SO16 4PU Lead Inspector Michael Gough Unannounced Inspection 4 January 2007 09:00 th Fritham Lodge DS0000066517.V323067.R01.S.doc Version 5.2 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 Fritham Lodge DS0000066517.V323067.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 Adults 18-65. 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. Fritham Lodge DS0000066517.V323067.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fritham Lodge Address 36 Shirley Park Road Shirley Southampton Hampshire SO16 4PU 02380 286290 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) Truecare Group Limited Mrs Frances Enid Gillies Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Fritham Lodge DS0000066517.V323067.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection N/A Brief Description of the Service: Fritham Lodge is a residential home providing care and accommodation for up to ten younger adults who have a mental disorder. It is managed by Mrs Francis Gilles on behalf of the providers Truecare Group Limited. The home is situated in a quiet residential area of Shirley and is close to local shops. Accommodation is arranged on two floors providing ten single bedrooms all of which are en-suite and there is also a range of communal facilities and bathrooms. There is an enclosed rear garden, which is laid to lawn. Fees at the home range from £1500 to £2000 per week and are determined on the amount of support required for each individual service user. Fritham Lodge DS0000066517.V323067.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report details the evaluation of the quality of the service provided at Fritham Lodge and takes into account the accumulated evidence of the activity at the home since the home was registered in July 2006 and this is the first inspection visit to the home. Prior to the visit to the home, a pre inspection questionnaire was sent out and also comment cards were sent to service users at the home to gain their views on how they felt that the home was meeting their needs, unfortunately none of these had been received back by the inspector at the time of the visit. The inspection took into account the views of the two service users currently living at the home and further evidence for this report was obtained from reading and inspecting records, touring the home and from observing the interaction between staff and service users. The inspector had the opportunity to speak with 2 service users, and 3 members of staff. The homes manager was not available on the day of the inspection, although the inspector did speak with the manager on the phone. A senior support worker who was on duty assisted the inspector throughout the visit. The home is registered to provide support for 10 service users who have a mental disorder and at the time of the inspection there were 2 service users living at the home. What the service does well: What has improved since the last inspection? This is the first inspection of the home since it was registered in July 2006. Fritham Lodge DS0000066517.V323067.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Fritham Lodge DS0000066517.V323067.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fritham Lodge DS0000066517.V323067.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Effective systems are in place to ensure that service users aspirations and needs are assessed before they move into the home. EVIDENCE: There have been 2 new service users admitted to the home since it opened in July 2006 and the last person to move into the home did so in November 2006. The home has a clear admissions policy and both of the service users had comprehensive assessments in their care plans. The manager of the home carries out her own assessment after obtaining a detailed social service’s assessment and before anyone moves into the home. Both service users spoken with confirmed that the assessment process was thorough and felt confident that the home could meet their needs. Fritham Lodge DS0000066517.V323067.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are clear and effective care planning and risk assessment systems in place to promote service users independence and provide staff with the information they require to meet service users needs. Service users are enabled to make decisions and the staff provide them with support. EVIDENCE: Care plans were seen for both of the service users and these were comprehensive documents that gave staff clear information on what support was required and how and when this should be given. Service users were involved in the care planning process as much as possible and care plans were person centred. Service users spoken to were aware that they had a plan of care that helped staff give them the support they need and told the inspector that they had been involved in making up the care plan with staff. Care Plans seen reflected the aspirations and goals of service users and were written clearly and could be followed easily. Fritham Lodge DS0000066517.V323067.R01.S.doc Version 5.2 Page 10 Recording was noted in various sections of the care plan and there were monthly reviews undertaken with an evaluation of service users progress or lack of it. Service users were actively involved in the decision making process in the home and service users were consulted on all aspects of their lives and their wishes were respected and acted upon. Staff offered support to service users to make informed decisions and both service users had a key to the front door and could come and go as they wished but were asked to inform staff when they were going out and when they were planning to return. Both current service users are able to express their views and wishes to staff who then ensure that their wishes are acted upon. It was very clear by talking with service users and observing the staff interacting with service users that they are able to make their own decisions and Staff respect their wishes and views. Each service users plan seen had risk assessments in place for identified risks to service users and all risk assessment gave information for staff on any support required and how to minimise the risk. Fritham Lodge DS0000066517.V323067.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit through opportunities to take part in appropriate activities, access the community, maintain relationships and participate in the planning of meals. Service users rights and responsibilities are recognised in the daily routines of the home. EVIDENCE: Service users take part in a range of appropriate activities. For example one service users currently attends college 3 times per week for maths and office skills. He is looking for employment and has an interview next week. Another service user is being supported to look for employment and care plans contained sections on developing skills in education and also in seeking employment. Fritham Lodge DS0000066517.V323067.R01.S.doc Version 5.2 Page 12 Service users are supported to access the local community and one service users spoken with said that he likes to go out into the town and uses local pubs and also visits the local chip shop. Family links and friendships are encouraged and service users are supported to maintain contact with family and friends. Visitors to the home are welcome at any time and there is a clear visiting policy. There are appropriate policies and procedures in place with regards to sexuality/sexual relationships. Service users are encouraged to have responsibilities for helping with the daily routines of the home and staff support service users as required and staff were observed interacting with service users in a friendly and respectful manner. Service users confirmed that they had their own house and room keys and there are no restrictions on service users who are free to come and go as they please but are asked to keep staff informed when the go out and when they intend to return. Service users are able to move about the communal areas freely and can choose whether to be alone or in company. Food menus are devised on a week-by-week basis with service users involved in planning the menu. Alternative meals are available if requested and drinks and snacks are freely available. At present staff prepare the meals at the home but the kitchen has 3 cookers so that service users can be as independent as their skills allow and staff can support service users with cooking if required. Service users spoken to were very happy with the meals provided and said that the food was good. Fritham Lodge DS0000066517.V323067.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive personal and healthcare support to meet their individual needs and service users are generally protected by the home’s medication policies and procedures. EVIDENCE: Support needs are well documented in care plans. The home has a mix of both male and female staff and there is a policy on staff members giving crossgender personal care. Those care plans seen gave comprehensive guidance for staff providing support to service users, although most support was verbal prompting and encouragement. Conversations with service users confirmed that they were well supported by the staff team. Health needs including mental health were documented and through reading care plans there was evidence that service users health needs were being monitored and met. Records showed when health appointments were booked and attended and when health professionals visited service users at the home. One service user who is diabetic had regular appointments at a diabetic clinic and eye and foot care needs were monitored. Service users are registered Fritham Lodge DS0000066517.V323067.R01.S.doc Version 5.2 Page 14 with different doctors and specialist support was also documented and available. Service users support needs with regard to medication is detailed in their personal care plans. The home uses a monitored dose system for medication at the home and currently there is only a small amount of medicines kept in the home and these were stored appropriately. A sample of the administration records was checked and was up-to-date. Records showed that staff received training in relation to medication. There are currently no service users who fully manage their own medication, however one service user does administer his own insulin injection and this was individually recorded and a risk assessment was in place. Also the service user monitors his own blood glucose levels 3 times per day and staff records the outcomes. The inspector discussed this with the senior support worker on duty who was aware of what action to take should blood glucose levels fall outside the normal range, however there was no written information for staff on what action they should take and clear information must be provided for staff with regard to blood glucose levels. Fritham Lodge DS0000066517.V323067.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are protected by a simple, clear and accessible complaints procedure and are protected by the home’s policies and procedures for responding to any form of abuse. EVIDENCE: The home has a corporate complaints procedure, which includes details of who would investigate complaints together with timescales. The complaints procedure also gave details of how to contact the Commission for Social Care Inspection and there had been no complaints since the home was registered in July 2006. Service users spoken with knew about the complaints procedure and knew how they could make a complaint. The home has a copy of the Hampshire Adult Protection procedure, a whistle blowing policy and a copy of the department of health guidelines “No Secrets.” A laminated copy of what action staff should take in the event of any concern is on the notice board in the office. Staff receive training with regard to protection of vulnerable adults (POVA) as part of their induction and as further training updates. The members of staff on duty were aware of their responsibilities in this area. Fritham Lodge DS0000066517.V323067.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a well-maintained environment and service users have access to comfortable indoor and outdoor facilities and the home was clean, pleasant and hygienic. EVIDENCE: The inspector toured the building with a member of staff and found that communal areas were bright and airy. The main lounge/dining area was large and contained a large TV, hi-fi equipment and comfortable seating for up to ten people. The dining area had 2 dining tables and comfortable dining chairs. There is also a smaller, quiet lounge with a computer, TV and DVD. The home benefits from an enclosed rear garden with lawn and shrubs. Service users own rooms are situated on both the ground and first floors and all were well furnished and those occupied had been personalised by the individual. Service users spoken with were very happy with the home and said that there was lots of space and they were both very happy with their own rooms. Fritham Lodge DS0000066517.V323067.R01.S.doc Version 5.2 Page 17 The home has a separate laundry room, away from areas where food is prepared, stored, cooked or eaten. There is a tumble drier and washing machine, which is able to wash clothing at appropriate temperatures and staff at the home support service users with their laundry if required. Fritham Lodge DS0000066517.V323067.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are protected by the homes staff recruitment procedure and service users benefit from being supported by well trained and qualified staff. EVIDENCE: There is a mix of both male and female staff at the home and all staff are encouraged and supported to undertake NVQ training. The members of staff on duty demonstrated through discussion a good understanding of their role and responsibilities and issues relating to service users. The inspector spoke with both service users at the home and they indicated that staff did a good job of supporting them. One service user offered particular praise for staff who was supporting him to manage his diabetes effectively and he said he now felt in control. On the day of the inspection the homes manager was not available, therefore it was not possible to view recruitment records at this visit, as records were kept locked away for confidentiality reasons. The inspector did speak with the homes manager on the phone who confirmed that all staff had undertaken Fritham Lodge DS0000066517.V323067.R01.S.doc Version 5.2 Page 19 suitable recruitment checks and advised the inspectors that recruitment records were available for inspection at any time. The home has a training log that was available for inspection and this showed that there is structured induction training for staff linked to NVQ awards and a further training programme to ensure that staff have the skills to meet service users needs. Records showed that staff had training in health and safety, first aid, manual handling, fire safety and infection control. Other training included self-harm awareness, schizophrenia, counselling skills, diabetes training, adult protection and medication. Training certificates were held on individual staff member’s files with copies in the training log and staff spoken to confirm that they receive regular training to help them meet the needs of service users. Fritham Lodge DS0000066517.V323067.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home that seeks their views and promotes the health, safety and welfare of service users and staff. EVIDENCE: The homes registered manager was not available during the visit, however the recent registration process confirmed that the manager had suitable qualifications and also had the skills required to effectively manage the home. The home has only been in operation for a few months and has not carried out any quality assurance surveys, however service users stated that they were consulted regularly and that their views were taken into consideration. Staff confirmed that there are regular staff meetings where they can express their views. The Truecare organisation has a quality assurance policy and procedure in place, which will be implemented by the home in due course. Fritham Lodge DS0000066517.V323067.R01.S.doc Version 5.2 Page 21 The home has a health and safety file which contained records of checks and tests carried out on gas and electrical systems and appliances, fire safety equipment and water quality. The homes fire safety logbook showed that staff had fire drills and checks had been maintained on alarms, fire door closers, emergency lighting and extinguishers Fritham Lodge DS0000066517.V323067.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Fritham Lodge DS0000066517.V323067.R01.S.doc Version 5.2 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 YA20 Regulation 13(2) Timescale for action The home must ensure that clear 28/02/07 information is provided for staff with regard to what action they should take should a service users blood glucose levels fall outside their normal range. Requirement RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Fritham Lodge DS0000066517.V323067.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Fritham Lodge DS0000066517.V323067.R01.S.doc Version 5.2 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. 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