Inspection on 27/07/06 for Frocester Manor

This inspection was carried out on 27th July 2006.

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 found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Frocester Manor 08/12/05

Frocester Manor 21/07/05

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 Mr Paul Chapman Key Unannounced Inspection 27th July 2006 09:30 Frocester Manor DS0000016443.V303223.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 Frocester Manor DS0000016443.V303223.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. Frocester Manor DS0000016443.V303223.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Frocester Manor Address Frocester Nr Stonehouse Glos GL10 3TF 01453 822342 01453 791781 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) www.hft.org.uk Home Farm Trust Miss Clare Linda Seeley Care Home 43 Category(ies) of Learning disability (43) registration, with number of places Frocester Manor DS0000016443.V303223.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th December 2005 Brief Description of the Service: Frocester Manor is a large manor house situated in substantial grounds in Frocester, nr Stroud. It is owned by The Home Farm Trust and can provide accommodation for up to 43 people with learning difficulties. The accommodation is made up of four buildings across the site (inc. the manor house) and provides people with large communal areas including a wellmaintained 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 facilities in Stroud and other surrounding towns. Frocester Manor DS0000016443.V303223.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector arrived to complete the site visit at 0930 and spent 7 hours at the home. The acting manager was present throughout the inspection and the inspector also discussed some issues with the service manager. All of the units across the site were seen and the inspector spoke to service users and staff from each of these units through the course of the day. Service users that spoke to the inspector throughout the day were very positive about living at the home and the service they received. The CSCI has sent surveys to parents, relatives and other professionals involved in peoples’ lives and their care. At the time of this report being published as a draft document none of the surveys had been returned. Any comments received from them may be taken into consideration by the CSCI in future inspections. The inspector would like to take this opportunity to thank the staff and service users for their time and comments during the site visit. What the service does well: 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. Service users are involved in the recruitment and selection of new staff. 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. Over the past four 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 stated that they enjoyed the various activities they are involved in. Service users met during the inspection discussed holidays they had been on already this year, whilst some spoke of their plans for later this year. It is Frocester Manor DS0000016443.V303223.R01.S.doc Version 5.2 Page 6 clear that the service users lead varied and fulfilling lifestyle, supported by the acting manager and his staff team. The inspector spoke to the service users about how they would go about making a complaint if they were unhappy with something. All of the people spoken with were aware of the complaints procedure and one service user said that when they had made a complaint before “the staff had listened”. The PCP’s examined during the site visit identified peoples’ needs and the goals they wished to achieve. Evidence showed that service users were involved in this process. Staff are provided with a comprehensive policy/procedure to follow when admitting a prospective service user to the home. Following this guidance minimises the risk of service users being admitted to the home whose needs cannot be met. What has improved since the last inspection? 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 Frocester Manor DS0000016443.V303223.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. Frocester Manor DS0000016443.V303223.R01.S.doc Version 5.2 Page 8 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 Frocester Manor DS0000016443.V303223.R01.S.doc Version 5.2 Page 9 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 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. Staff are provided with a comprehensive policy/procedure to follow when admitting a prospective service user to the home. Following this guidance minimises the risk of service users being admitted to the home whose needs cannot be met. EVIDENCE: There have been no new admissions to the home since the previous inspection. The acting manager explained that due to the redevelopment of the site a decision has been made not to admit anyone until they are complete. The inspector examined the HFT admission policy that was available. Elements of this document had been reviewed during 2003/2004. The document was comprehensive and provided staff with the guidance needed to complete a thorough admission process that respected prospective service users rights. Frocester Manor DS0000016443.V303223.R01.S.doc Version 5.2 Page 10 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 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. The PCP’s examined by the inspector identified peoples’ needs and the goals they wished to achieve. Evidence showed that service users were involved in this process. Guidelines provide staff with clear instruction to promote a consistent approach when working with service users. These must be regularly reviewed to ensure that people are not put at risk. Current risk assessments minimise the risks to the service users. The move towards using dedicated computer software should make the decision making process more consistent. EVIDENCE: Across the site the home is split up into five separate units. The inspector visited each unit and examined service users’ files in each of them. Frocester Manor DS0000016443.V303223.R01.S.doc Version 5.2 Page 11 The home has a person centred approach to peoples’ care. The 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. In one of the units the inspector sat with a service user who explained their plan to them. They went through the plan explaining which goals had been achieved and who had supported them. It was clear from the comments made by the service user that they had been involved in developing the plan and this was supported by the fact that some of the plan had been written by them. In one of the files examined by the inspector the Person Centred Plan (PCP) was incomplete. Staff explained that this was being completed at the time of this visit, the work completed to date was good using pictures, large text and plain English. Although the PCP was incomplete the staff had helped the service user to develop a ‘memory box’ that contained pictures, etc of their life. The acting manager must ensure that all of the service users have completed PCP’s that are regularly reviewed with the service users. The inspector examined guidelines developed for staff to follow when working with service users. This is a good practice as it enables people to be supported in a consistent manner. Unfortunately some of the guidelines examined were out of date and no longer appropriate. The manager must ensure that all guidelines are reviewed regularly; failure to do this may put both the service user and staff at risk. In discussion with other 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 from the previous report related to the use of monthly summaries detailing the activities of the service users. These are now being completed but the acting manager must monitor the recording as the examples seen by the inspector varied greatly in detail. All of the service users files seen by the inspector contained numerous risk assessments completed by the staff who are trained appropriately. It has been the homes practice that 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. HFT use a programme called Assessnet for completing risk assessments. It is the acting manager’s Frocester Manor DS0000016443.V303223.R01.S.doc Version 5.2 Page 12 aim for all of the risk assessments to be completed using this system. The inspector recommends that this is achieved to provide a consistent approach to risk assessment across the site. The CSCI supplied all of the service users with surveys asking about their care at the home. The response was poor and makes it impossible for the findings to be representative of all of the service users. The majority of the responses received were very positive about the service with service users confirming that their needs are being met. Only one person responded that “sometimes the staff are too busy with other things”. Frocester Manor DS0000016443.V303223.R01.S.doc Version 5.2 Page 13 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 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. 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 Frocester Manor DS0000016443.V303223.R01.S.doc Version 5.2 Page 14 swimming. Service users stated that they enjoyed the various activities they are involved in. Service users that the Inspector met during the inspection discussed 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 lead varied and fulfilling lifestyle, supported by the acting 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 units 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. The inspector spoke to service users in the bungalow with the acting manager present. The inspector asked how they chose the meals/food they ate. Both of the service users said that the staff choose the meals/food. This must be addressed by the manager to ensure that the service users are choosing what they would like to eat. Of the completed surveys received by the CSCI the majority of people appeared satisfied with the amount of activities they are involved in. Only one of the responses stated “I would like more things to do” Frocester Manor DS0000016443.V303223.R01.S.doc Version 5.2 Page 15 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 the following standard(s): 18, 19, 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Personal support guidelines need to be recorded in greater detail to ensure that service users are consistently supported in the manner they wish. Other specialist professionals are used to meet peoples needs where the staff identify they do not have the appropriate skills or knowledge. Medication recording must be reviewed to ensure that service users are not put at risk by medication errors. EVIDENCE: Whilst examining a number of the service users files guidelines relating to how they wished to receive their personal care were seen. Further examination of these documents brought up a number of issues. The main issue was the detail of these guidelines; it was felt that more detail was required to enable staff to meet people’s needs appropriately. The guidelines should detail exactly what support is required. Frocester Manor DS0000016443.V303223.R01.S.doc Version 5.2 Page 16 The service users’ files examined gave numerous examples of where other professionals were involved in meeting peoples needs. In addition to this appointments with Doctors, Dentists, Opticians and Chiropodists were recorded. An issue identified in the previous three inspections relates to the medication administration. Inspection of the records at this visit showed that the same problem still remains. Medication administration sheets continue to have gaps where staff should have signed confirming service users had received their medication. This is a major shortfall as it is an ongoing problem that has never met the regulations. This must be addressed by the acting 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 DS0000016443.V303223.R01.S.doc Version 5.2 Page 17 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 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. The home’s complaints procedure is made available to all the service users. Staff have completed training in the protection and prevention of abuse. This should raise their awareness, allow people to reflect on their practice and further minimise the risks 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 policy file. The Commission for Social Care Inspection have received no complaints. The inspector spoke to the service users about how they would go about making a complaint if they were unhappy with something. All of the people spoken with were aware of the complaints procedure and one service user said that when they had made a complaint before “the staff had listened”. The surveys completed by the service users confirmed that they are aware of the complaints procedure and have access to it. Since the previous inspection the majority of the team have completed in training in adult protection. Frocester Manor DS0000016443.V303223.R01.S.doc Version 5.2 Page 18 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 the following standard(s): 24, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The quality of the accommodation provided at the home has improved greatly over the past four 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 four 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. Since the previous inspection the planned modernisation of the site has started. This is a major programme of work to convert different areas of the home across the site to meet the current and future needs of the service Frocester Manor DS0000016443.V303223.R01.S.doc Version 5.2 Page 19 users. The inspector spoke to the service manager about this and it was agreed that they will keep the CSCI informed of the progress. Service users spoken to during the visit stated that they liked their bedrooms. The majority of the requirements from the previous inspection have been addressed. Looking across the whole site some minor issues were identified which were: Purple bathroom – floor covering must be replaced as it is damaged. The manager explained that this has not been done due to the bath being replaced (this was due to be replaced the week after this inspection). Once this has been done the floor covering will be replaced. 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. This has been a requirement of the previous 4 inspections and must be addressed. The accommodation seen by the inspector across the site was clean and hygienic. A number of the service users’ bedrooms were seen, they were seen to be decorated to a high standard and personalised by the people who lived in them. Frocester Manor DS0000016443.V303223.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. 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. 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. EVIDENCE: All staff have job descriptions and contracts of employment. At a previous inspection the inspector has spoken with the service users about their involvement in the recruitment procedure. 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 DS0000016443.V303223.R01.S.doc Version 5.2 Page 21 The inspector examined recruitment records for a number of the new staff that have started since the previous inspection. Two shortfalls were found, one person’s identification had not been verified, and there was no CRB for another. The service manager has sent a copy of the CRB disclosure to the CSCI since the inspection. The acting manager must ensure that all recruitment is managed effectively and meets the criteria of these regulations. 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. The service manager stated that the induction process has now been extended to 3 days instead of 2 and the 3rd day is for all new staff to complete abuse awareness training. At the time of this inspection 22 staff had completed a minimum of NVQ level 2 with others either completing, due to start theirs. Since the previous inspection 13 of the staff team have completed training in adult protection. It is the service manager’s intention that those who have not completed as yet will do during this financial year. Frocester Manor DS0000016443.V303223.R01.S.doc Version 5.2 Page 22 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 at least once during a 12 month period. 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. Regular health and safety meetings help to minimise the risks to the service users. Regular checks of equipment across the site by staff and outside professionals minimises risk to service users EVIDENCE: Currently the registered manager is on maternity leave and a team leader from one of the organisation’s other homes is acting manager. Service users across the site have regular meetings where they are able to express their views. Frocester Manor DS0000016443.V303223.R01.S.doc Version 5.2 Page 23 Regular health and safety meetings are held with representatives from each unit 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 2006. Fire equipment had been serviced in May 2006. Fire Officer visited in June 2006. Fire safety checks completed by the staff were checked and the inspector found that these were not being completed regularly. The acting manager must ensure that this is addressed and that all equipment is checked in line with the regulations. Electrical wiring certificate issued July 2006. Fridge/freezer temperatures were recorded twice a day. A food probe was used in the main kitchen. One of the team leaders spoke to the inspector about a Health and Safety file that has been developed for each of the units. These files are due to be implemented in July/August and the inspector will examine them at the next inspection. The records seen during the inspection were well organised and stored securely. Frocester Manor DS0000016443.V303223.R01.S.doc Version 5.2 Page 24 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 3 X 3 X X 3 X Frocester Manor DS0000016443.V303223.R01.S.doc Version 5.2 Page 25 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 YA6 Regulation 15 Requirement The manager must: Ensure that all guidelines for staff working with service users are up to date by regularly reviewing them. All of the service users must have completed person centred plans. The manager must ensure that guidelines for the service users requiring support from staff to complete their personal care are detailed and up to date. The manager must ensure that when staff give medication to the service users that the medication sheets are signed confirming that. The manager must ensure that the doors in Js front room are fitted with two bolts to secure the door properly. Carried forward from the previous inspection. The manager must ensure that the floor covering in the purple bathroom is replaced. Carried DS0000016443.V303223.R01.S.doc Timescale for action 29/09/06 2. YA18 15 29/09/06 3. YA20 13(2) 01/09/06 4. YA24 13(4) a 08/09/06 5. YA27 23(2) d 15/09/06 Frocester Manor Version 5.2 Page 26 forward from the previous inspection. 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. 2. 3. 4. Refer to Standard YA6 YA9 YA17 YA34 Good Practice Recommendations The manager should ensure that the monthly reports completed by the staff are consistently recorded. The manager should ensure that risk assessments are all reviewed/renewed using the new methodology. The manager needs to clarify who is responsible for choosing the meals/food in the bungalow. The manager should ensure that recruitment records are maintained. Frocester Manor DS0000016443.V303223.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Gloucester Office Unit 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 DS0000016443.V303223.R01.S.doc Version 5.2 Page 28 - 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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