Inspection on 21/07/05 for Frocester Manor

This inspection was carried out on 21st July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Frocester Manor 27/07/06

Frocester Manor 08/12/05

Frocester Manor 22/02/05

Frocester Manor 30/06/04

Frocester Manor 27/01/04

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

CARE HOME ADULTS 18-65 Frocester Manor Frocester Nr Stonehouse Glos GL10 3TF Lead Inspector Paul Chapman Announced Thursday 21 July 2005 09:30 st 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Frocester Manor D51_D03_S16443_FrocesterManor_V229565_210705_Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Frocester Manor Address Frocester Nr Stonehouse Glos GL10 3TF 01453 822342 01453 791781 Clare.seeley@hft.Org.uk Jeff.Squires@hft.Org.uk Mr Barry Armstrong, Home Farm Trust 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) Mr Jeffrey Squire Care Home - Personal Care 43 Category(ies) of Learning Disability (43) registration, with number of places Frocester Manor D51_D03_S16443_FrocesterManor_V229565_210705_Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: n/a Date of last inspection 22/02/05 Brief Description of the Service: Frocester Manor is a large manor house situated in substaintial grounds in Frocester, nr Stroud. It is owned by The Home Farm Trust and can provide accomodation for up to 43 people with learning difficulties. The accomodation is made up of four buildings across the site (inc. the manor house) and provides people with large communal areas including a well maintained garden. All of the people have individual bedrooms, and some have small flats with cooking facilities. The home has access to a number of vehicles that allows people to make use of facilties in Stroud and other surrounding towns. Frocester Manor D51_D03_S16443_FrocesterManor_V229565_210705_Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over 6 hours on a day in July 2005. All of the buildings across the site were inspected during the day. Service users and staff were spoken with whilst the assistant service manager was with the inspector throughout the day. Records seen during the day included risk assessments, Person Centred Plans, personal files and staff training records. What the service does well: What has improved since the last inspection? The quality of the furnishings and fittings continues to improve across the site. Staff training records are well organised. Frocester Manor D51_D03_S16443_FrocesterManor_V229565_210705_Stage4.doc Version 1.30 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. Frocester Manor D51_D03_S16443_FrocesterManor_V229565_210705_Stage4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Frocester Manor D51_D03_S16443_FrocesterManor_V229565_210705_Stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: None of these standards were inspected on this occasion. Previous inspections of these standards have shown them to meet the criteria of the standards and regulations. Frocester Manor D51_D03_S16443_FrocesterManor_V229565_210705_Stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, 9, 10 Development of PCP’s for all of the service users will identify more of their needs and enable staff to plan how to meet them. Risk assessments encourage and support people living at the home to challenge and deal with problem areas in their lives. EVIDENCE: The home has an identified member of staff who takes the lead in the development of Person Centred Plans (PCP’s). Currently the staff are in the process of developing PCP’s with all of the service users. The completed documents examined by the inspector were well designed making good use of photos and symbols to support service users with communication difficulties. The plans identify important people in their lives, places they like, health needs, activities, likes and dislikes, dreams and fears and other items. In addition to this each person has a personal file that contains all other relevant information like financial details and records of medical appointments. All documents are stored securely. Frocester Manor D51_D03_S16443_FrocesterManor_V229565_210705_Stage4.doc Version 1.30 Page 10 In discussion with service users they stated that they were involved in developing their PCP’s and that staff supported them to maintain contact with their families and friends where it was required. Friends and family are welcome to visit. A recommendation that came from discussion with the manager and a staff member was to look at the use of monthly summaries of the service users activities completed by key workers (all service users have key workers) or team leaders. All service users have numerous risk assessments completed by staff that are trained appropriately. Once the assessments have been written the assistant service manager reads and approves them or returns them to staff for revision. All risk assessments were reviewed regularly. Frocester Manor D51_D03_S16443_FrocesterManor_V229565_210705_Stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15, 17 Staff support service users to lead active and varied lifestyles. Activities that have been identified in their PCP’s are completed and therefore meet service users wishes. EVIDENCE: The home has been part of the local community for in excess of thirty years and continues to have a good relationship with the neighbours. Service users stated they feel they are part of the local community. A range of opportunities are available, including attending the day centre on site, or day services in the community and Colleges in Stroud. A range of personalised activities are accessed by each home. All service users activities are recorded in their personal files and daily notes. Leisure activities that take place off site included: horse riding, attending various local social clubs, bowling, going to pubs, eating out, theatre, cinema, shopping and swimming. Service users stated that they enjoyed the various activities they are involved in. Service users that the Inspector met during the inspection discussed Frocester Manor D51_D03_S16443_FrocesterManor_V229565_210705_Stage4.doc Version 1.30 Page 12 holidays they had been on already this year, whilst some spoke of their plans for later this year. It is clear that the service users in the homes lead a varied and fulfilling lifestyle, supported by the Manager and his staff team. A number of the service users attend the local church, and staff support some where it is appropriate. Any of the service users are free to attend church whenever they wish. Across the different homes on the site menus were seen to provide service users with a varied and nutritious diet. In conversation with service users they stated that snacks and drinks were available and that they choose what meals are prepared. Frocester Manor D51_D03_S16443_FrocesterManor_V229565_210705_Stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20 Medication recording must be reviewed to ensure that service users are not put at risk by medication errors. EVIDENCE: An issue identified in the previous two inspections relates to the medication administration. The Assistant Services Manager has given the responsibility for its management to one of the senior staff. Inspection of the records at this visit showed that the same problem still exists. Medication administration sheets had only been started eight days before this inspection and three gaps where staff should have signed confirming service users had received their medication were found. This is a major shortfall as it is an ongoing problem that has never met the regulations. This must be addressed by the manager to ensure that it does not happen again in the future. The majority of the staff team have completed medication training at a local college and examination of the other areas of medication administration showed it to be managed correctly. Frocester Manor D51_D03_S16443_FrocesterManor_V229565_210705_Stage4.doc Version 1.30 Page 14 Frocester Manor D51_D03_S16443_FrocesterManor_V229565_210705_Stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 23 The home’s complaints procedure is made available to all the service users. Staff must complete training in the protection and prevention of abuse to raise their awareness and minimise risk to the service users. EVIDENCE: The home has a complaints policy that the inspector has examined at previous inspections. The management team of the home have dealt with previous complaints appropriately, following the procedure detailed in the home’s procedure. The Commission for Social Care Inspection have received no complaints. As identified later in this report there is a need for staff to complete training in the protection and prevention from abuse and the training co-ordinator. The inspector spoke to the registered manager about an investigation completed at the beginning of this year. Some training needs were identified on reflection of the process and these will be addressed in the future. Frocester Manor D51_D03_S16443_FrocesterManor_V229565_210705_Stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29, 30 The quality of the accommodation provided at the home has improved greatly over the past three years. The environment is homely and comfortably furnished. There is an ongoing maintenance and refurbishment programme in place making sure that the home continues to meet the needs of the people living there. EVIDENCE: Over the past three years the standard of the accommodation at Frocester Manor has improved substantially. All of the units are now more personalised, especially the manor house. This is a credit to the assistant service manager and her staff team. Service users spoken to during the visit stated that they liked their bedrooms and when they were decorated they were able to choose the colours. Looking across the whole site some minor issues were identified which were: C & S’s bathroom – ceiling must be painted. Frocester Manor D51_D03_S16443_FrocesterManor_V229565_210705_Stage4.doc Version 1.30 Page 17 S’s flat – the fridge must be replaced. Purple bathroom – floor covering must be replaced as it is damaged. J’s front room – two bolts should be fitted to the left hand door that does not open. The current bolt is worn which means the doors do not close securely. S & T’s flat – Bathroom ceiling must be painted and the carpet on the stairs must be replaced as it is worn. Across the site there are various adaptations to maintain people’s independence and the manager stated that a new assisted bath is due to be fitted. The majority of the accommodation across the site was clean and hygienic although it is recommended that the upstairs landing in the lodge be cleaned. The majority of the service users bedrooms were seen, and were decorated to a high standard and personalised by the people who lived in them. Frocester Manor D51_D03_S16443_FrocesterManor_V229565_210705_Stage4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 34, 35 The recruitment procedure allows service users to make a valued contribution in the appointment of staff. Comprehensive induction of new staff ensures that service users are not put at risk. The training programme ensures that established staff’s training is always up to date. EVIDENCE: All staff have job descriptions and contracts of employment. Service users are involved in the recruitment and selection of new staff. The manager stated that each person receives training in an interview skills group where they discuss questions, methodology, confidentiality and practice techniques. As part of the recruitment process the service users show prospective staff around the home and a group of them have a discussion with them. Staff sit in on this process and take notes. After the group discussion service users meet with the staff on the interview panel to discuss their findings. This is excellent practice that allows the service users to have a valuable input into the recruitment of staff. Frocester Manor D51_D03_S16443_FrocesterManor_V229565_210705_Stage4.doc Version 1.30 Page 19 All new staff receive a comprehensive induction when they start at the home, and one staff member has responsibility for supporting them through this process. All elements of the induction process are signed by both parties to confirm the element has been completed and understood. In addition to this new staff complete the mandatory training required by the regulations. This induction process is excellent as it ensures that new staff have the skills required to start supporting people with learning disabilities. A major improvement seen at this inspection was in the staff training records and the method of organising future training. Certificates of previous training are well organised for all staff, and the system in place allows the training coordinator to easily identify when refresher courses are required. At the time of this inspection 15 staff had completed a minimum of NVQ level two, with another 12 staff completing theirs at the time. A shortfall identified by the inspector related to the staff receiving training in protection and prevention from abuse. This had also been highlighted by the training co-ordinator who was in the process of organising training for the future. Frocester Manor D51_D03_S16443_FrocesterManor_V229565_210705_Stage4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 41, 42 Comprehensive health and safety monitoring ensures that risks to services users are minimised. Records are well organised by staff which allows quick and easy access to service users files. Regular service user meetings ensure that peoples’ views are heard. EVIDENCE: Currently the assistant service manager is in the process of becoming the registered manager of the home. She has considerable experience in working in this field and is appropriately qualified. Observations during the inspection showed her to have a good relationship with her staff and the service users. Over the past three years the CSCI have recognised that the service continues to develop and improve and this is reflected in the reports produced from the CSCI inspections. Frocester Manor D51_D03_S16443_FrocesterManor_V229565_210705_Stage4.doc Version 1.30 Page 21 Service users across the site have regular meetings where they are able to express their views. Regular health and safety meetings are held with representatives from each home in attendance. These meetings are held every two to three months and allows staff to bring issues to the attention of the health and safety representative on site. To support this process an annual health and safety audit is completed by qualified health and safety consultant. Evidence of this audit was available for inspection. When completing the inspection across the site evidence was seen of regular health and safety checks, other relevant health and safety regulations being adhered to: Portable appliance testing had been completed in February 2005. Fire equipment had been serviced in May 2005. Fridge/freezer temperatures were recorded twice a day. A food probe was used in the main kitchen. One shortfall identified was in the Lodge where a fire drill must be completed and the emergency lighting tested. The records seen during the inspection were well organised and stored securely. Frocester Manor D51_D03_S16443_FrocesterManor_V229565_210705_Stage4.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 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 x 3 Standard No 31 32 33 34 35 36 Score 3 3 3 4 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Frocester Manor Score x x 1 x Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 3 3 x D51_D03_S16443_FrocesterManor_V229565_210705_Stage4.doc Version 1.30 Page 23 yes 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 20 Regulation 13(2) Requirement The manager must ensure that medication administration is managed correctly. Requirement of the previousn inspection. The manager must ensure that all staff receive training in Protection and Prevention from abuse. The manager must ensure that the doors in Js front room are fitted with two bolts to secure the door properly. The manager must ensure that the fridge in Ss flat is replaced. The manager must ensure that the ceiling in C & Ss bathroom is repainted. The manager must ensure that the floor covering in the purple bathroom is replaced. The manager must ensure that the bathroom ceiling in S & Ts bathroom is repainted and the carpet on the stairs leading to it is replaced. The manager must ensure that fire drills and emergency lighting tests are completed in The Lodge. Timescale for action 09/09/05 2. 23 13(6) 16/12/05 3. 24 13(4)a 30/09/05 4. 5. 6. 7. 24 27 27 27 23(2)c 23(2)d 23(2)d 13(4)a, 23(2)b, d 30/09/05 04/11/05 04/11/05 04/11/05 8. 42 23(4) 09/09/05 Frocester Manor D51_D03_S16443_FrocesterManor_V229565_210705_Stage4.doc Version 1.30 Page 24 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 6 Good Practice Recommendations The manager should consider the use of monthly summaries completed by peoples keyworkers or staff that work with them. Frocester Manor D51_D03_S16443_FrocesterManor_V229565_210705_Stage4.doc Version 1.30 Page 25 Commission for Social Care Inspection 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester GL3 4AB 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 Frocester Manor D51_D03_S16443_FrocesterManor_V229565_210705_Stage4.doc Version 1.30 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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