Inspection on 31/07/06 for Frithwood Nursing Home, The

This inspection was carried out on 31st July 2006.

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

Frithwood Nursing Home, The 03/11/05

Frithwood Nursing Home, The 27/06/05

Frithwood Nursing Home, The 29/09/04

Frithwood Nursing Home, The 06/04/04

Frithwood Nursing Home, The 25/09/03

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

CARE HOMES FOR OLDER PEOPLE Frithwood Nursing Home, The 21 Frithwood Avenue Northwood Middlesex HA6 3LY Lead Inspector Clare Henderson-Roe Key Unannounced Inspection 10:30 31st July 2006 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 Frithwood Nursing Home, The DS0000010931.V293825.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Frithwood Nursing Home, The DS0000010931.V293825.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Frithwood Nursing Home, The Address 21 Frithwood Avenue Northwood Middlesex HA6 3LY 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) 01923 820 955 01923 842 684 MD Homes Carolyn Estabilla Care Home 20 Category(ies) of Physical disability (0), Physical disability over 65 registration, with number years of age (0), Terminally ill (0) of places Frithwood Nursing Home, The DS0000010931.V293825.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Adults over 55 years old in need of general nursing care and Palliative Care Minimum Staffing Notice As agreed on 20/03/06, three named service users with a diagnosis of dementia and one named service user with a mental disorder diagnosis can be accommodated within the home. This is approved for as long as there is no deterioration of the service users that affects the well-being of any other person living at the home. The home must advise CSCI when each service user no longer resides at the home. The rooms used for each service user will revert to the listed categories for the home once the service user no longer resides at the home. 3rd November 2005 Date of last inspection Brief Description of the Service: Frithwood Nursing Home is a converted detached house situated in a residential area of Northwood. It has a well-maintained private garden at the rear of the property. The accommodation consists of fourteen single and three double rooms. There are two bathrooms and two shower rooms plus toilet facilities throughout the home. There is a day room and a dining room for service users to utilise. Local transport facilities are available in the form of buses and Northwood Underground Station. The Registered Manager deals with the care management for the home. The Operations Manager deals with the financial and personnel management of the four homes within MD Homes. The homes fees are £720 per week, subject to assessment. Frithwood Nursing Home, The DS0000010931.V293825.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 7 hours was spent on the inspection process. The Inspector carried out a tour of the home, and service user plans, medication records, staff records, financial records, management records, administration records, maintenance and servicing records were viewed. 5 service users, 3 visitors and 6 staff were spoken with as part of the inspection process. The pre-inspection questionnaire, given to the home at the time of inspection, was also used to inform this report. What the service does well: What has improved since the last inspection? The home has worked hard to meet the requirements from the last inspection, and the care provision plus the related documentation is being maintained to a good standard. Prospective service users are now fully assessed prior to admission to ensure the home are able to meet their needs and that the service users diagnosis comes within the categories of registration for the home. Service user plans are comprehensive and provide a clear picture of the service users needs and how these are to be met. Overall they are kept up to date. Any potential risks to service users are assessed and identified, to include falls and the use of bedrails. Medications are now being well managed in the home, with robust systems in place to monitor this. The activities coordinator is working hard to provide activities in line with service users interests and to meet their needs. The staffing levels in the home were suitable Frithwood Nursing Home, The DS0000010931.V293825.R01.S.doc Version 5.1 Page 6 to meet the needs of the service users. Staff training programmes are in place, to include recognised induction training for any new staff. The training records evidenced that staff had now attended health & safety training. Maintenance and servicing records are now up to date. 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. Frithwood Nursing Home, The DS0000010931.V293825.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Frithwood Nursing Home, The DS0000010931.V293825.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 4. The home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are assessed prior to admission to the home, to ascertain that the home can meet their needs. Staff have received training in specialist topics to include dementia, and are thus able to meet the care needs of service users with such diagnoses. EVIDENCE: Documentation for 3 pre-admission assessments was viewed. These were thorough and provided clear information about the service users needs and how these were being met. Copies of Social Services needs led assessments were also seen for service users referred by Social Services. Since the last inspection a variation to the homes conditions of registration has been agreed by CSCI in respect of 3 named service users with dementia and one with mental health needs accommodated at the home. Staff had received appropriate training and the service users had received specialist healthcare input. The Registered Manager was clear that they must not admit any service users with diagnoses outside the homes conditions of registration. Frithwood Nursing Home, The DS0000010931.V293825.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service user plans are well completed and maintained up to date, thus giving a good picture of the service users needs and how these are to be met. Medications are being well managed at the home, thus safeguarding service users. Staff care for the service users in a gentle and courteous manner, thus respecting their privacy and dignity. EVIDENCE: The Inspector sampled service user plans. Those viewed were comprehensive and work had been done to personalise them to reflect the individual needs of each service user and how these are to be met. There was evidence of input from service users families. Risk assessments for falls had been updated following any falls, and all related documentation had been completed. Risk assessments were also in place for any other identified areas of risk. The service user plans had been updated monthly and whenever a service users condition changed, with the exception of one care plan that required updating to reflect a change in medication regime. Apart from this finding, all the documentation viewed was up to date. Frithwood Nursing Home, The DS0000010931.V293825.R01.S.doc Version 5.1 Page 10 There were no service users with wounds or pressure sores at the time of inspection. Pressure relieving equipment was seen in use in the home. Assessments for pressure sore risk had been carried out. Moving & handling, dependency, nutritional and continence assessments had been carried out. Where problems had been identified care plans had been formulated. Monthly observation charts are in place, to include weight checks. If there are any concerns about a service users weight, then the frequency of weight checks is increased to weekly and the service user referred to the GP. Where bedrails are in use, risk assessments to identify the appropriateness of their use plus written consent to their use were in place. In one service user plan viewed, the service users family had provided information about the service users life history, which was interesting and informative for the staff. A photograph of the service user is available in each service user plan. A record of input from the GP and other healthcare professionals is maintained in each service user plan. The Inspector sampled the medication records. Liquid medications had been dated when opened. Medication receipts and disposals had been recorded and signed for. All administration of medications to include creams and nutritional supplements had been signed for. Any allergies are recorded on the medication administration record (MAR) chart. For one service user there were printed instructions on the MAR chart ‘use as directed by your doctor’, although the Registered Manager had corrected each section to accurately reflect the administration regime. In one instance a medication dosage had changed midcycle and the label on the medication box needed amending to reflect this. The MAR chart had been altered accordingly. The Registered Manager said that she would speak with the GP and the dispensing pharmacist to ensure the administration instructions are printed in full for all medications. Controlled drugs are correctly stored and recorded in the home. The home disposes of medications in line with current legislation. Medications are stored securely in the home, and the need to ensure medication for disposal is always securely stored was discussed and addressed at the time of inspection. The home uses single use lancets for blood glucose monitoring. Fridge temperatures were within safe limits. There is a list of approved homely remedy medications signed by the GP and all administration of homely remedies is recorded in a separate book. The homes medication policies and procedures had been updated to include the current disposal regime. Overall medications are being well managed in the home, with comprehensive records being maintained. Care plans had been formulated for any newly identified needs. Staff were seen caring for service users in a gentle and courteous manner, and the Inspector observed good interaction between service users and staff. Service users and visitors spoken with expressed their satisfaction with the home. Service users were appropriately dressed and clothing is labelled for each service user. Service users can bring in personal possessions in line with health & safety. The atmosphere in the home was homely and contented and service users looked well cared for. Frithwood Nursing Home, The DS0000010931.V293825.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activities co-ordinator is working to provide a programme of activities to meet the service users interests. The home has an open visiting policy, thus encouraging service users to maintain contact with family and friends. Advocacy arrangements are in place, thus ensuring the service users rights and opinions are heard and respected. The food provision in the home is good, offering variety and choice, to meet the service users needs. EVIDENCE: M D Homes employ an activities co-ordinator who sets up activities programmes for each of their 4 homes. The Inspector spoke with the activities co-ordinator and it was clear that she is working hard to introduce and implement a full activities programme and also access input from local community groups to include schools and churches in the area. A variety of activities had been arranged and these are reflected in the homes Activities Programme. The activities co-ordinator said that for service users who do not wish or are unable to join in with group activities, she spends one-to-one time with them to encourage them to maintain their interests. Records of each service users involvement in the activities programme are kept and the activities co-ordinator said that she is also spending time ascertaining service users individual interests. The activities co-ordinator is also looking to set up a Frithwood Nursing Home, The DS0000010931.V293825.R01.S.doc Version 5.1 Page 12 day centre at one of the homes that has the facilities to accommodate it and this would be available for service users from all of the homes in the group. The home has an open visiting policy and visiting is encouraged. Visitors spoken with said that they are always made welcome at the home and can visit whenever they wish. The home has information on display for Hillingdon Re-Think Advocacy services and also information on the advocacy service for Hillingdon Hospital in case of any related concerns. Relatives spoken with said that they are kept up to date with any issues. The food provision in the home is good. There is a daily menu offering a choice of meals, and service users choices are recorded. If service users wish to have an alternative this is provided. Drinks and snacks are available throughout the 24 hour period. Staff were seen assisting service users with their meals in a pleasant manner. The kitchen was clean and tidy and the records were up to date. Useful information to include service users birthdays and dietary information was on display. There was a good stock of fresh, frozen and dried foodstuffs available. Frithwood Nursing Home, The DS0000010931.V293825.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear complaints procedures in place to address any concerns raised by service users and their visitors. The system in place for protection of vulnerable adults is robust, thus safeguarding service users. EVIDENCE: The home has a clear complaints procedure with timescales for action. There have been no complaints since the last inspection. Relatives spoken with said that they are kept informed of their loved ones condition and if they have any concerns these are addressed promptly. The home follows the Hillingdon Safeguarding Adults procedures, and the homes own POVA procedures dovetail with this documentation. Staff spoken with said that they would report any concerns, and were clear on the procedures to follow. Policies for the management of aggression are in place, and staff have received training in dementia care. Frithwood Nursing Home, The DS0000010931.V293825.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 24, 25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are areas of the home are in need of redecoration and refurbishment, and thus there are some shortfalls in the accommodation provision for service users. Work has been done to upgrade the bath and shower provision, thus providing service users with suitable facilities to meet their needs. The heating system is not fully functional and the alternative heating provision could pose a risk to service users when in use. Clear infection control procedures are in place and being adhered to, thus safeguarding service users. EVIDENCE: The Inspector carried out a tour of the home. The exterior of the premises requires redecoration, as do several of the rooms and corridor areas. Following the inspection the Operations Manager has forwarded some information regarding redecoration, but this does not include a full up to date programme of redecoration and refurbishment for the whole home. A new carpet had been laid on the ground floor corridor and the reception area, which looked very welcoming. Work has been done to ascertain the cause of the area of Frithwood Nursing Home, The DS0000010931.V293825.R01.S.doc Version 5.1 Page 15 subsidence in the driveway, and action has been taken to highlight this area so that people coming to the home are aware of it. The Operations Manager said that this would be dealt with as part of the overall work being planned for an extension to the home. The lock on one bathroom on the first floor was damaged and in need of replacement. The rear garden is well maintained and is accessible to service users and their visitors. Since the last inspection one of the out of use bathrooms has been converted into an assisted shower, and with this addition the bath and shower provision in the home is suitable to meet the needs of the service users. The beds throughout the home are adjustable, some manually and some are electronic profiling beds. One service user chooses to have a divan bed. There is a call bell system in place throughout the home, and staff answer bells promptly. Some of the bedrooms carpets were marked and needed cleaning, and others required replacement. Several of the wardrobe doors were swinging open and the Registered Manager said that there was one key only available for all the wardrobes. The wardrobe acts as each service users secure facility, and identical locks do not provide this security. Action must be taken to ensure that all wardrobe doors shut properly and that there is a secure space in each bedroom with an individual lock and key provided for the service user. The hot water temperature records evidenced that where the water temperature is above 43˚centigrade, action is now being taken to adjust the safety mixer valve accordingly. In bedrooms 1, 2 and 3 additional heating appliances were seen, and did not appear to have low surface temperature controls. It is acknowledged that these were not in use during the hot weather. The heating within the home has been an issue in the past and action must be taken as a priority to address this and ensure the heating system is in full working order prior to the autumn. A timescale of 01/09/06 was agreed at the time of inspection for completion of this work. The laundry room was very warm and there was no ventilation available except for opening the exterior door. Action needs to be taken to address this. The laundry room was clean and tidy and individual baskets are provided for each service users’ clean clothing. There are two washing machines, one of which has a sluice programme for soiled items. There are two tumble dryers. Protective clothing to include gloves and aprons were available, plus antiseptic hand wash is also available. The home was clean and tidy throughout, with the exception of the aforementioned carpets. Health & safety documentation includes clear infection control procedures. Frithwood Nursing Home, The DS0000010931.V293825.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was appropriately staffed to meet the needs of the service users. Staff have received appropriate training to provide them with the skills and knowledge needed to meet the needs of the service users, thus maintaining good standards of care. Robust recruitment and vetting procedures are in place, thus safeguarding service users. EVIDENCE: At the time of inspection the home was being staffed to meet the needs of the service users. The staffing rosters identify that staffing levels are maintained and that cover is provided for any absences. The home has supervised practice students who mainly work in a supernumerary capacity, shadowing the registered nurse on duty. Kitchen, maintenance and domestic staff are employed in appropriate numbers to meet the needs of the home. The majority of the care staff employed at the home are staff who have trained as nurses in their own country, and are awaiting, or have commenced supervised placement training to gain registration as a nurse in this country. Information provided by the home states that 98 of the care staff are qualified to NVQ level 2 in care or the equivalent. The induction programme used by the home is in line with Skills for Care core standards, and the Registration Training programme for supervised practice nurses is approved by the Nursing & Midwifery Council and Thames Valley University. Staff have Frithwood Nursing Home, The DS0000010931.V293825.R01.S.doc Version 5.1 Page 17 received training in several topics relevant to the service user group accommodated at the home, to include dementia care training. The Inspector viewed 3 sets of staff employment records. These were comprehensive and clear, and contained the information required under the Care Homes Regulations 2001. Frithwood Nursing Home, The DS0000010931.V293825.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager has the qualifications and experience to manage the home, and does so effectively. Systems for quality assurance are in place, thus providing an ongoing process of system and practice review. Service users monies are well managed, thus safeguarding service users interests. Systems for the management of health and safety throughout the home are good, thus safeguarding service users, staff and visitors. EVIDENCE: The Registered Manager is a first level registered nurse and has completed the Registered Managers Award, NVQ level 4. She is experienced in acute and nonacute nursing, and has undertaken in dementia care and palliative care. Staff spoken with said that the home is well managed and that there is good teamwork. Frithwood Nursing Home, The DS0000010931.V293825.R01.S.doc Version 5.1 Page 19 The home has a monitoring system in place for Quality Assurance, to cover each standard in the National Minimum Standards for Older People, and this is reviewed annually. Quarterly audits of all the homes within the group take place. Monthly audits of the medications take place at the time of delivery, plus the dispensing pharmacist carries out 6 monthly inspections. Relatives meetings take place and minutes are taken. The Registered Manager said that she would ensure notification of relatives meetings is prominently displayed in order to inform all visiting relatives. Service users can speak with the Registered Manager or any of the staff if they have any issues to discuss. Regulation 26 unannounced visits made by or on behalf of the Responsible Individual are carried out and a copy of the report forwarded to the CSCI. The home manages personal monies for 3 service users, all of whom have named bank accounts. The home pays out initially for any expenditure, and periodically this expenditure is totalled up and the money paid from the service users account to meet this. Clear computerised records of income and expenditure are maintained. Receipts for all expenditure are retained. Staff meet each morning to have handover and also to discuss any relevant topics. Individual staff supervision is carried out every 2 months and records of this are kept. Staff spoken with said that they are well supported by the Registered Manager and Operations Manager and enjoy working at the home. Servicing and maintenance records were sampled, and those viewed were up to date. The fire log evidenced regular fire drills and fire safety training. The fire risk assessment had been reviewed in November 2005. Risk assessments for safe working practices to include those for the kitchen and laundry areas are in place and reviewed monthly. The staff training records evidence that staff have undergone training in health & safety to include fire safety, moving & handling & infection control. Staff handling food had undertaken food hygiene training. There are plans to build an extension to the home, and some areas of maintenance required to include work on a cracked wall are being planned in with this proposed work. Within the last year any areas of concern have been inspected by a structural engineer, and deemed safe. Work is also being done to ensure that any structural problems being caused by the environment are appropriately addressed. Frithwood Nursing Home, The DS0000010931.V293825.R01.S.doc Version 5.1 Page 20 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 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X 3 X 2 2 2 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 X 3 X 3 3 X 3 Frithwood Nursing Home, The DS0000010931.V293825.R01.S.doc Version 5.1 Page 21 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 Requirement When there is a change in the service users condition or treatment the service user plan must be updated to reflect this. An environmental audit for redecoration and refurbishment purposes must be carried out and the redecoration and refurbishment programme updated with timescales to include all areas in need of work. With the exception of those areas being incorporated in the planned extension, the work must be completed no later than 01/12/06. Confirmation of completion must be forwarded to CSCI. The damaged bathroom lock must be replaced. An audit of the carpet provision must be carried out. Where identified carpets must be replaced. All carpets must be maintained in a clean condition. Action must be taken to ensure the wardrobe doors shut properly. Service users must be provided with an individual DS0000010931.V293825.R01.S.doc Timescale for action 01/09/06 2. OP19 23(b)&(d) 01/12/06 3. 4. OP19 OP24 12, 13(4) 16(2)(C) 23(2)(d) 08/09/06 01/10/06 5. OP24 23(2)(b) (n) 01/10/06 Frithwood Nursing Home, The Version 5.1 Page 22 6. OP25 13(4) 7. 8. OP25 OP26 23(2)(p) 13(4) lockable space and have the option to keep the key if they so wish. All heating in the home must guarded or have guaranteed low surface temperatures. This includes any temporary heating devices. The heating system must be in full working order in the home. The laundry room must be reviewed in respect of the lack of ventilation and action taken to ensure the room is adequately ventilated in a safe manner at all times. 01/09/06 31/10/06 31/10/06 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 Frithwood Nursing Home, The DS0000010931.V293825.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection West London Area Office 11th Floor West Wing 26-28 Hammersmith Grove Hammersmith London W6 7SE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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