Inspection on 08/12/05 for Frocester Manor

This inspection was carried out on 8th December 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Frocester Manor 27/07/06

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 Unannounced Inspection 8th December 2005 09:40 Frocester Manor DS0000016443.V275904.R01.S.doc Version 5.1 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.V275904.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 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.V275904.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Frocester Manor Address Frocester Nr Stonehouse Glos GL10 3TF 01453 822342 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) Home Farm Trust Mr Jeffrey Squire Care Home 43 Category(ies) of Learning disability (43) registration, with number of places Frocester Manor DS0000016443.V275904.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st July 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.V275904.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was completed over 2.5 hours on a day in December 2005. The inspector was supported throughout the inspection by one of the home’s unit managers. The main focus of the inspection was to identify the home’s progress towards meeting the requirements of the previous inspection report. In addition to this the inspector also assessed a number of the core standards that were not addressed at the announced inspection. A tour of the premises was completed and records examined by the inspector included Person Centred Plans, medication and service users’ personal profiles. It is recommended that for a more comprehensive overview of the service provided at the home that this report should be read in conjunction with the report from the announced inspection completed on 21/07/05. The inspector would like to take this opportunity to thank the staff and service users for their co-operation and time during this inspection. What the service does well: What has improved since the last inspection? What they could do better: Medication changes must be recorded thoroughly/correctly as identified in the body of the report. Frocester Manor DS0000016443.V275904.R01.S.doc Version 5.1 Page 6 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 DS0000016443.V275904.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Frocester Manor DS0000016443.V275904.R01.S.doc Version 5.1 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 the following standard(s): EVIDENCE: None of these standards were inspected on this occasion. Frocester Manor DS0000016443.V275904.R01.S.doc Version 5.1 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 the following standard(s): 6 Monthly summaries enable the staff team to easily identify what activities service users have been completing. EVIDENCE: At the previous inspection all of the standards were inspected. One recommendation was made to the manager, in that they should consider the use of monthly summaries completed by key workers that identify the activities completed by the service users. The inspector saw evidence that these are now being completed. Frocester Manor DS0000016443.V275904.R01.S.doc Version 5.1 Page 10 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): PCP’s are developed with the service users whose rights to choice are respected by the staff supporting them to develop the PCP. EVIDENCE: At the previous inspection standards 11, 12, 13, 14, 15 and 17 were assessed with no shortfalls being identified. At this inspection the inspector examined 3 of the service users’ person Centred Plans (PCP’s) to identify whether their rights to choice were being respected. The PCP’s seen by the inspector had been developed with the service users who had clearly highlighted the goals they wished to achieve. This standard was not fully inspected and the inspector will look at it more closely at the next inspection. Frocester Manor DS0000016443.V275904.R01.S.doc Version 5.1 Page 11 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): 20 Medication administration has improved since the previous inspection but the shortfall identified means that risks to the service users remain. EVIDENCE: A requirement of the previous inspection report was for the manager to ensure that the medication administration was managed correctly. A major issue of the previous inspection was the number of gaps where staff should have signed to confirm that service users had received their medication. The records examined by the inspector at this inspection showed a major improvement with no gaps over a period of 4 weeks. A shortfall identified on this occasion was where staff had hand written medication changes on the administration sheets. These changes were not signed by the staff member whom had written them up, and there was no record of who had requested the medication change. This was brought to the attention of the unit manager supporting the inspector. It is a requirement of this report that any future medication changes identify who has instructed the change and that the staff member writing up the change on the medication sheet signs it. Frocester Manor DS0000016443.V275904.R01.S.doc Version 5.1 Page 12 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): 23 Completion of adult protection training by the staff team will support the home’s policies and procedures for adult protection and further minimise potential risks to the service users. EVIDENCE: A requirement of the previous inspection was that all staff must receive training in adult protection. The unit manager supporting the inspector was also responsible for training and stated that 2 courses had been booked. Initially 2 staff members from each team across the site will attend the course, these staff have been chosen as they key work service users who are more vulnerable than others across the site. Other staff members will complete the course over the coming months. Frocester Manor DS0000016443.V275904.R01.S.doc Version 5.1 Page 13 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, 27, 30 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: At the previous inspection the inspector completed a tour of the site visiting all of the units and the majority of the service users bedrooms. As part of this inspection the inspector visited the areas of the site where requirements had been made in the previous report. The previous inspection report required that following areas were addressed: Two bolts were to be fitted to the French windows leading to the fire exit from “J’s” flat. The reason for this being that currently they do not shut securely and could cause the service user to be put at risk. This has not been addressed as yet and becomes a requirement of this inspection report. The fridge in “S’s” flat was to be replaced, as it was rusty. The fridge has been removed and staff explained that it has not been replaced, as the service user Frocester Manor DS0000016443.V275904.R01.S.doc Version 5.1 Page 14 did not use the fridge. (At the previous inspection the inspector saw that the fridge was not in use). The ceiling in “C&S’s” bathroom was repainted, as it was water damaged. This has been addressed. The floor covering in the “purple bathroom” must be replaced. The registered manager explained that this had not been done as they were planning to replace the bath and the flooring would be replaced at that point. The manager stated that they hoped this would be completed by the end of January ‘06. “S&T’s” bathroom ceiling must be repainted, and the carpet on the stairs leading to it replaced. Both of these areas were seen to have been addressed. At the time of this inspection the areas of the home seen by the inspector were clean, tidy and there were no offensive odours. Frocester Manor DS0000016443.V275904.R01.S.doc Version 5.1 Page 15 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): EVIDENCE: None of these standards were inspected on this occasion. At the previous inspection standards 31, 32, 34 and 35 were assessed with no shortfalls identified. Frocester Manor DS0000016443.V275904.R01.S.doc Version 5.1 Page 16 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): Potential risk to the service users are lessened by the home completing the required fire safety checks. EVIDENCE: None of these standards were fully assessed on this occasion, at the previous inspection standards 37, 38, 41, 42 At the previous inspection the inspector identified that the unit called “The Lodge” needed to complete fire drills and emergency lighting tests more frequently. Examination of their records on this occasion showed that this was now being done correctly. Frocester Manor DS0000016443.V275904.R01.S.doc Version 5.1 Page 17 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 X 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 X 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X X X X X X 3 X Frocester Manor DS0000016443.V275904.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement The manager must ensure that any changes to the medication sheets are signed by the staff making the change. Also, that the name of the professional prescribing the change is recorded on the sheet. 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 floor covering in the purple bathroom is replaced. Timescale for action 03/03/06 2. YA24 13(4) a 03/03/06 3. YA27 23(2) d 31/03/06 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 Frocester Manor DS0000016443.V275904.R01.S.doc Version 5.1 Page 19 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.V275904.R01.S.doc Version 5.1 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!