Inspection on 27/09/06 for Frodsham Christian General Care Home

This inspection was carried out on 27th September 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 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

Frodsham Christian General Care... 16/04/08

Frodsham Christian General Care... 11/07/07

Frodsham Christian General Care... 09/02/06

Frodsham Christian General Care... 03/08/05

Frodsham Christian General Care... 21/03/05

Frodsham Christian General Care... 27/07/04

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

CARE HOMES FOR OLDER PEOPLE Frodsham Christian General Care Home Chapelfields The Main Street Frodsham Cheshire WA6 7BB Lead Inspector Denis Coffey Key Unannounced Inspection 09:00 27 September 2006 th 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 Frodsham Christian General Care Home DS0000018744.V294215.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. Frodsham Christian General Care Home DS0000018744.V294215.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Frodsham Christian General Care Home Address Chapelfields The Main Street Frodsham Cheshire WA6 7BB 01928 734743 01928 734745 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) Trinity Care Limited Mrs Linda Siddell Care Home 70 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (30), Old age, not falling within any other of places category (40), Terminally ill (3) Frodsham Christian General Care Home DS0000018744.V294215.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1 This home is registered for a maximum of 70 service users to include: * Up to 40 service users in the category of OP (old age not falling within any other category) * Up to 3 service users in the category of TI (terminally Ill) * Up to 30 service users in the category of DE(E) (dementia- over 65 years of age) *1 service user in the category of DE (dementia) The registered provider must, at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidance which may be issued through the Commission for Social Care Inspection 9th February 2006 2 3 Date of last inspection Brief Description of the Service: Frodsham Christian Care Home is a purpose built care home with separate units providing nursing care for 40 elderly frail people, and 30 people who have dementia. The home has two storeys and all bedrooms are single rooms with ensuite facilities. There is a choice of lounges with a communal dining room on the ground floor of the unit for elderly people, and lounges and separate dining facilities on both floors of the dementia unit. In addition there are accessible ground floor gardens, and a large patio area, both of which are enclosed. The home is situated within a very short walk of the town centre. Public transport services, i.e. trains and buses are accessible close to the home. A planned programme of care is drawn up for each service user, which are reviewed monthly, or as required. Trained nursing staff are on duty twentyfour hours a day. The weekly fee payable at the home ranges from £390.35 to £627.17. The registered manager provided this information on 20th May 2006. Frodsham Christian General Care Home DS0000018744.V294215.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place on 26 and 27 September 2006. The total time taken for the visit to the home was 11 ½ hours. The inspector spoke with the home manager, the operations manager, and staff on all units, residents and their visitors. Records for three residents were examined to check the care they were receiving. Completed CSCI comment cards were received from healthcare professionals who are involved in the care of some of the residents at the home. The comments made in these were positive with regard to the health and social care needs. Records, documents, policies and procedures of the home were checked and a tour of the home was undertaken. What the service does well: What has improved since the last inspection? Frodsham Christian General Care Home DS0000018744.V294215.R01.S.doc Version 5.1 Page 6 Refurbishment in the lounges and the dining room of the dementia unit has improved the environment for the residents. Improvements have been made to hygiene practices so the risk to the residents of cross infection has been reduced. 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. Frodsham Christian General Care Home DS0000018744.V294215.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 Frodsham Christian General Care Home DS0000018744.V294215.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): 1&3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health needs of the residents are fully assessed before they move into the home to ensure their needs can be met. EVIDENCE: The home has a statement of purpose that is available to residents and their families. This document identifies the services provided at the home along with information about the staff employed there. As there have been recent changes in the management structure of the home, the statement of purpose is in the process of being amended to reflect this. Frodsham Christian General Care Home DS0000018744.V294215.R01.S.doc Version 5.1 Page 9 The care records of three residents who had moved into the home since the last inspection contained a pre-admission assessment that had been carried out by a trained nurse employed at the home. Also included were assessments relating to their social and care needs that had been completed by a social worker. Problems/needs identified at assessment were included in the residents care records with plans of care developed to address these. Frodsham Christian Nursing Home does not provide intermediate care so Standard 6 does not apply. Frodsham Christian General Care Home DS0000018744.V294215.R01.S.doc Version 5.1 Page 10 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 adequate. This judgement has been made using available evidence including a visit to this service. Care records and medicines are generally well managed but improvements are needed to ensure that residents in all units of the home receive appropriate care to meet their needs and to show that they receive their medicines as prescribed. EVIDENCE: The care records of three residents were examined at this inspection. Assessments of their health and safety needs were well documented. There were appropriate plans of care to show how the identified needs of residents were to be met. However, there was evidence in one file to show that a resident’s health care needs had changed but the care plan for this had not been updated. All of the residents are registered with a doctor and have access to the NHS facilities. The care records of the residents included information about the involvement of other healthcare professionals, such as chiropodists and opticians, in the care of the residents. Frodsham Christian General Care Home DS0000018744.V294215.R01.S.doc Version 5.1 Page 11 The arrangements for the safe administration and record keeping of medicines were inspected on both units of the home. The medicines were well managed on the dementia unit with appropriate safe storage and clear, accurate records being kept. However, there were problems with the storage and recording of medicines found on both floors of the unit for older people. Some medicines found were out of date and not all the records were being maintained accurately which could put residents at risk of not receiving effective medicines as prescribed. Residents spoken with said that they are treated with respect and that the staff made sure that they maintained their dignity. Staff were seen to knock on doors before entering bedrooms and to speak to the residents appropriately. Frodsham Christian General Care Home DS0000018744.V294215.R01.S.doc Version 5.1 Page 12 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. Daily life is varied for the residents and there is a choice of daily activities and meals, providing them with choice about their lifestyle in the home. EVIDENCE: A weekly programme of activities was on display that identified the social and leisure activities for residents that take place both in the home and outside of it. Visitors are welcome at any reasonable time and on the day of inspection some visitors were taking their relative for a trip out. Visitors spoken with said that they are made to feel welcome and that the staff keep them informed of any changes in their relative’s condition. One visitor said that the staff enable them to be involved in the care of their relative. Residents spoken with said that they are able to make choices about their everyday lives, within the constraints of their condition. Alternatives are offered at meal times, and residents said that they were happy with the food provided. The main meal of the day is served at lunchtime, with a lighter meal served in the evening. Menus were on display and they appeared varied and nutritious in content. Frodsham Christian General Care Home DS0000018744.V294215.R01.S.doc Version 5.1 Page 13 One resident said that the quality of the meals was not as good at weekends when agency cooks were being used. In response to this, the manager said that the company has a bank of cooks and that this would now be used until a suitable cook could be recruited to fill the current vacancy. Frodsham Christian General Care Home DS0000018744.V294215.R01.S.doc Version 5.1 Page 14 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. Complaints are managed well so that residents and relatives can be confident that their concerns will be listened to and there is appropriate staff training, backed up by policies, to ensure that residents are protected from harm. EVIDENCE: One recorded complaint had been received at the home since the last inspection. This has been investigated and the complainant had indicated that they were satisfied with the outcomes from this. Records were seen to show that staff receive training on the protection of vulnerable adults when they undertake induction training shortly after starting work at the home. The home has a whistle blowing policy, and staff sign to confirm that they have read and understood this. Frodsham Christian General Care Home DS0000018744.V294215.R01.S.doc Version 5.1 Page 15 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, 24 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained, providing residents with safe, comfortable surroundings in which to live. EVIDENCE: The standards of décor and furnishings have been well maintained, and new carpets have been fitted in both lounges of the dementia unit since the last inspection. An operations manager of the company who was at the home on the second day of the visit said that costings have been made for the redecoration of the home, replacement of curtains, carpets and furniture in communal areas, and upgrading the lighting. Residents’ rooms were seen to be comfortably furnished and many of their bedrooms had been personalised with ornaments, pictures and small items of furniture that they had brought into the home with them. Frodsham Christian General Care Home DS0000018744.V294215.R01.S.doc Version 5.1 Page 16 All areas of the home were visited at this inspection and were found to be clean, tidy and free from unpleasant smells. Frodsham Christian General Care Home DS0000018744.V294215.R01.S.doc Version 5.1 Page 17 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. Recruitment procedures are robust and, although minor improvement is needed to bring some training up to date, there are enough qualified and trained staff on duty to ensure that residents receive the care they need. EVIDENCE: The home employs a team of trained nurses and carers for the provision of care for the residents. Staffing rotas showed that there are sufficient numbers of staff on duty to meet the care needs of the residents. More than 50 of care staff employed at the home have a qualification in care. The staff personnel files checked showed that the recruitment of staff is well managed and that residents are protected, i.e. all contained two satisfactory references, completed application forms and satisfactory Criminal Record Bureau disclosures. Information about training undertaken by staff is recorded on their individual files and the home manager is planning to keep an overall record so it is easier to track which staff have received which training. The records showed that some of the staff have not received safe moving and handling training within the past twelve months. The manager said that Frodsham Christian General Care Home DS0000018744.V294215.R01.S.doc Version 5.1 Page 18 arrangements had been made for this to be provided before the end of October 2006. Frodsham Christian General Care Home DS0000018744.V294215.R01.S.doc Version 5.1 Page 19 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 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run in the interests of the residents and there are opportunities for residents and their relatives to have a say in how the home is run to ensure the services provided are appropriate to their needs and wishes. EVIDENCE: A new manager had been in post for three weeks before this inspection visit took place. She is a trained nurse and is experienced, having previously managed a care home and been registered with the Commission. She has achieved the registered manager’s award and will be applying to the Commission to become the registered manager of this home. Frodsham Christian General Care Home DS0000018744.V294215.R01.S.doc Version 5.1 Page 20 A visitor spoken with said that the staff and management of the home are very responsive to any problems raised, and that they had been asked to complete a satisfaction survey. The manager said that a relatives’ meeting was being arranged and that a residents’ meeting was due to be held on 28th September 2006. The home has a policy on equality and diversity to ensure that religious, cultural and other issues are addressed. There is also an equal opportunities policy A small number of residents have their finances managed by social services. The families of the other residents leave small amounts of money at the home to pay for items such as newspapers, sweets and hairdressing. An individual record is maintained of all transactions that identify the amounts withdrawn along with the signatures of the people making the withdrawals. Detailed accidents records are kept, and the home manager audits these monthly. Fire safety systems are tested regularly, and equipment used in the home is serviced on a regular basis. Frodsham Christian General Care Home DS0000018744.V294215.R01.S.doc Version 5.1 Page 21 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 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 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 3 Frodsham Christian General Care Home DS0000018744.V294215.R01.S.doc Version 5.1 Page 22 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 OP9 Timescale for action 13(2) The registered person must 31/10/06 ensure that accurate records are maintained of all medicines administered to the residents. 13(2) The registered person must 31/10/06 ensure that residents are not given any medicines that are out of date. 13(4)(c) & The registered person must 30/11/06 (5) ensure that staff employed at the home receive training in safe moving and handling practices, at least once a year. Regulation Requirement 2. OP9 3. OP30 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 OP7 Good Practice Recommendations When the needs of a resident change, their plans of care should be amended to reflect the changes and the care they require. Frodsham Christian General Care Home DS0000018744.V294215.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 Frodsham Christian General Care Home DS0000018744.V294215.R01.S.doc Version 5.1 Page 24 - 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!