Inspection on 03/08/05 for Frodsham Christian General Care Home

This inspection was carried out on 3rd August 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

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

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

Frodsham Christian General Care... 27/09/06

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

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 Announced 3 August 2005 9.00 AM rd 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 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 F51 F01 S18744 Frodsham CNH V230010 120705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Frodsham Christian General Care Home Address Chapelfields The Main Street Frodsham Cheshire WA7 6BB 01928 734743 01928 734745 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) Trinity Care PLC Care Home 70 Category(ies) of OP Old Age, not falling within any other category registration, with number (40) of places TI Terminally Ill (3) DE(E) Dementia Over 65 (30) DE Dementia (1) FRODSHAM CHRISTIAN GENERAL CARE HOME F51 F01 S18744 Frodsham CNH V230010 120705 Stage 4.doc Version 1.30 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). 2 The registered provider must, at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Date of last inspection 21 March 2005 Brief Description of the Service: Frodsham Christian Care home is a purpose built care home with separate units for the provision of 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. A planned programme of care is formulated for each service user, reflecting individuality, privacy, dignity and choice. These are reviewed monthly or as required. Trained nursing staff are on duty twenty-four hours a day. FRODSHAM CHRISTIAN GENERAL CARE HOME F51 F01 S18744 Frodsham CNH V230010 120705 Stage 4.doc Version 1.30 Page 5 SUMMARY This announced inspection took place over 6 hours; during which time a tour of the premises took place, and staff records and care records were inspected. The inspectors, Denis Coffey and Helena Dennett spoke with eleven of the residents, eight members of staff and two sets of visitors. All but one of the requirements made at the last inspection had been complied with. The outstanding requirement is in relation to the risk assessments for the use of bed rails.. What the service does well: What has improved since the last inspection? What they could do better: Care records could be improved by ensuring that plans of care are devised that addresses all of the identified needs/problems of the residents. The risk assessments for the use of bed rails could be improved by documenting in these a more detailed awareness of the risk of entrapment and the measures needed to reduce such a risk. FRODSHAM CHRISTIAN GENERAL CARE HOME F51 F01 S18744 Frodsham CNH V230010 120705 Stage 4.doc Version 1.30 Page 6 Ascertain whether staff have understood the training provided with regard to the protection of vulnerable adults in relation to abuse and poor practices. 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 F51 F01 S18744 Frodsham CNH V230010 120705 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection FRODSHAM CHRISTIAN GENERAL CARE HOME F51 F01 S18744 Frodsham CNH V230010 120705 Stage 4.doc Version 1.30 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 standard(s) 3, 4 & 6 Assessments of needs are carried out before most residents move into the home to check that their needs can be met at the home. The home does not provide intermediate care; therefore Standard 6 does not apply. EVIDENCE: The home has an assessment document that is used to identify the needs, problems and abilities of prospective residents in areas relating to their activities of daily living. A review of the care files of five residents recently admitted to the home showed that the assessment document for one resident had not been filled in, and the information for another resident was incomplete in that it did not address the mental and physical well being of the resident; the date of the assessment and who had carried it out was not identified. The home employs trained nursing staff and a team of care staff for the delivery of care to the residents. Where a need is identified for more specialised care, other healthcare professionals are consulted. See Requirement 1 FRODSHAM CHRISTIAN GENERAL CARE HOME F51 F01 S18744 Frodsham CNH V230010 120705 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 & 10 Although there were care plans for the residents, there were gaps in them that could lead to residents not receiving all the care they needed. Medicines are generally well managed so that residents receive their correct medication, but there were instances where the records of the residents medicines were not filled in. EVIDENCE: Residents have an individual plan of care that shows how their needs will be met. These are reviewed each month and amended to show any changes to their health. This information provides staff with guidance on what care they need to give each resident. However, there were some problems with the care records that need attention. For example, one resident was prescribed a strong pain relief medicine but their care records did not identify why this medicine had been prescribed. The records of another resident identified that they had lost weight and that this problem would be monitored. The nutritional assessment for this resident had not been reviewed in light of this problem. One resident had recently returned from hospital where they had been an in-patient due to their blood pressure being below the normal range. FRODSHAM CHRISTIAN GENERAL CARE HOME F51 F01 S18744 Frodsham CNH V230010 120705 Stage 4.doc Version 1.30 Page 10 There was no plan of care in place for the resident in relation to this problem after their return from hospital, nor was there evidence of their blood pressure being monitored on a regular basis. It was also noted that this resident had been prescribed medicine, a side effect of which can be a lowering of blood pressure. All of the resident are registered with a general practitioner and have access to the NHS services. The medicines were inspected on both units of the home. The Medicine Administration Record (MAR) sheets of the residents on the dementia unit were filled in correctly, and evidence was seen of the residents’ general practitioners signing the home’s ‘homely remedies’ policy whereby trained nurses can give identified non prescribable medicines for a limited time to the residents without the need for the doctor to prescribe them. Medicines with a limited life efficacy upon opening were dated when their use had commenced. When inspecting the MAR sheets of the residents’ on the elderly frail unit it was observed that some of these contained gaps, and a code had not been used to identify why the resident had not had their medicine administered. Staff were observed assisting residents in various activities throughout the course of this inspection in a friendly and supportive manner. Residents spoken with were complimentary about the care they received, and a visitor spoken with said that the staff were kind and approachable. See Requirement 2 See Requirement 3 FRODSHAM CHRISTIAN GENERAL CARE HOME F51 F01 S18744 Frodsham CNH V230010 120705 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 15 Social activities and meals are well managed, providing variety and interest for people living at the home. Residents said the standard of the food available at the home is good so they enjoyed the meals provided. EVIDENCE: An activities co-ordinator is employed at the home and is responsible for the planning and delivery of social and recreational activities for the residents. Residents spoken with said that the activities provided were varied and that they were happy with these. The weekly activities programme was on display and included, aromatherapy, a sing-a-long with an external entertainer, a musical afternoon and a film show. The home’s newsletter for August advertised a trip on the Bridgewater canal on 23rd August, and a visit to Norton Priory on a date to be confirmed in September. A record was seen of a group of residents visiting Chester Zoo in June, and of a small party of residents going for lunch at a public house close to Dunham Massey. The home has an open visiting policy and visitors spoken with at the time of inspection said that they are made to feel welcome when visiting. One resident and his visitor told the inspector that resident/relative meetings are held on a regular basis, and another resident said that the staff discussed her care needs with her and that she was enabled to exercise choice. FRODSHAM CHRISTIAN GENERAL CARE HOME F51 F01 S18744 Frodsham CNH V230010 120705 Stage 4.doc Version 1.30 Page 12 Menus were on display, and they showed that residents have a choice of main courses at lunch and evening mealtimes. The menus were varied an appeared nutritious in content. Residents’ spoken with were complimentary about the standard of meals provided, and one visitor commented that the chef knew the preferences and dislikes of their relative. The home was in receipt of a Gold Food Safety award issued by the local authority. FRODSHAM CHRISTIAN GENERAL CARE HOME F51 F01 S18744 Frodsham CNH V230010 120705 Stage 4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 Complaints are managed well and anyone making a complaint is assured that their concerns are taken seriously and acted upon. There are procedures and guidance available for staff to ensure that residents are protected from abuse, harm and poor practice. EVIDENCE: There was one recorded complaint being made since the last inspection in the home’s complaint log book. This complaint related to the attitude of one member of staff. A record was seen of this person receiving counselling about this and of the complainant being informed and satisfied with the action taken. The home has its own adult protection policy and a copy of the Department of Health’s document ‘No Secrets’. This document contains guidance that identifies the different forms abuse can take and how to report this. One member of staff spoken with displayed a sound awareness of their responsibilities in the protection of vulnerable adults, but a second member of staff could not recall the advice given in these documents. There has been an incident recently at the home where a resident complained about the manner in which they were spoken to. This matter has been investigated, and appropriate action has been taken with regard to this. See Recommendation 1 FRODSHAM CHRISTIAN GENERAL CARE HOME F51 F01 S18744 Frodsham CNH V230010 120705 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21,22, 24 & 26 The home provides a comfortable and safe environment for the residents to live in. Bedrooms were carpeted and comfortably furnished, many with items residents had brought into the home with them. EVIDENCE: The standards of the home’s furnishings and décor have been well maintained apart from the carpets in both lounges of the dementia unit that were noticeably stained. However, the home manager said that new carpets had been ordered for both these rooms. Bedrooms were comfortably furnished and there was evidence of residents and/or their families personalising these. The home has a large garden situated at the rear of the premises that has been well tended with flowerbeds, lawns and garden furniture. The maintenance person employed at the home grows vegetables and strawberries in one part of the garden and these are used in the preparation of meals for the residents. There are sufficient baths and toilets provided for the number of residents accommodated at the home. FRODSHAM CHRISTIAN GENERAL CARE HOME F51 F01 S18744 Frodsham CNH V230010 120705 Stage 4.doc Version 1.30 Page 15 However, the bath on the first floor of the dementia unit is a domestic style bath and is raised off the floor, and the staff said that they are unable to use this bath due to the height they would have to hoist residents into it. They went on to say that the shower is more commonly used, but if a resident requests a bath they are taken to the bathroom on the ground floor. Portable air conditioning units are provided in the lounge, dining and corridor areas on the dementia unit to reduce the heat in good weather in these areas. The home manager said that a new permanent air conditioning system for the dementia unit had recently been ordered, and that it was expected to be installed before the end of September. All areas of the home were visited at this inspection and found to be clean, tidy and free from unpleasant smells. The laundry is equipped with three washing machines all of which have a sluicing facility and three tumble dryers. The laundry staff label all of the clothing belonging to the residents, and when laundered, clothing is placed in named baskets for return to the residents bedroom where it is put away. See Requirement 4 FRODSHAM CHRISTIAN GENERAL CARE HOME F51 F01 S18744 Frodsham CNH V230010 120705 Stage 4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30 There are enough staff rostered to be on duty to meet the needs of the residents at all times. Recruitment procedures did not wholly nclude thorough checks of all new staff which are needed to ensure that the residents are protected from any possible harm. EVIDENCE: The staffing rotas showed that adequate staffing levels were being provided. The personnel files of four staff recently employed at the home were inspected, and were found to contain completed application forms, health declarations, interview assessments and satisfactory references. Three of the files inspected contained satisfactory Criminal Records Bureau (CRB) disclosures. The fourth file was that of a foreign national nurse who had a satisfactory police clearance check from their country of origin but not a CRB disclosure. Staff spoken with said that they had received training within the past six months on such topics as safe moving and handling of residents, food hygiene, dementia and adult protection. See Requirement 5 FRODSHAM CHRISTIAN GENERAL CARE HOME F51 F01 S18744 Frodsham CNH V230010 120705 Stage 4.doc Version 1.30 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33,35 & 38 The home is well managed and residents views are taken into account so they have an influence in how the home is run. Generally, the practices in the home ensure that that residents are safe and their welfare is promoted. EVIDENCE: The home manager took up post in June 2005, prior to which she was employed at the home in the post of deputy home manager. She is a trained general nurse with many years of experience of working in a hospice, and has applied to the Commission to become the registered manager at the home. A satisfaction survey is sent to approximately 10-15 families/residents on a monthly basis, the results of which are compiled at the home’s head office. When collated, the results of the surveys are sent to the home where they are displayed. FRODSHAM CHRISTIAN GENERAL CARE HOME F51 F01 S18744 Frodsham CNH V230010 120705 Stage 4.doc Version 1.30 Page 18 Any personal money held by the home for residents’ is deposited in a none interest making bank account. Individual records are maintained for each resident and a regional administrator employed by the company audits their records. The administrator at the home keeps a record of all money deposited or withdrawn for residents, and a random sample of some residents’ money was made and found to be correct. Appropriate risk assessments were in place in the residents’ care files, e.g. falls, aggression, and safe moving and handling. However, the risk assessment for the use of bedrails for one resident did not identify whether the resident was at risk from climbing over the rails, or that staff should ensure that there is not a gap in which a resident could become entrapped when such equipment is used on a resident’s bed. The home manager audits accidents sustained by residents’ on a monthly basis. The accident records for the period May to July were inspected, and a total of 78 accidents had been recorded for this period, the majority of which were attributed to falls/trips. A fire risk assessment of the home was documented as being carried out in March 2005, and records were seen of the fire alarm and emergency lighting systems being tested on a weekly basis. Nine fire drills were recorded as being held since March this year along with the signatures of staff attending these. Records were also seen of 28 staff having received fire safety training since the last inspection. Evidence was seen of the home being in receipt of a current gas safety certificate, and of the portable electrical appliances being safety tested. See Requirement 6 FRODSHAM CHRISTIAN GENERAL CARE HOME F51 F01 S18744 Frodsham CNH V230010 120705 Stage 4.doc Version 1.30 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 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 3 3 2 3 x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 x 3 x 3 x x 2 FRODSHAM CHRISTIAN GENERAL CARE HOME F51 F01 S18744 Frodsham CNH V230010 120705 Stage 4.doc Version 1.30 Page 20 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 3 Regulation 14 Requirement An assessment must be carried out and documented for all prospective residents prior to them moving into the home to ensure that the home can meet the persons needs in respct of their health and welfare. Care plans must be in place that address all of the identified needs/problems of the residents accommodated at the home. Records must be maintained of all medicines administered to the residents of the home. A suitable bath must be provided on the first floor of the dementia unit for residents who cannot get into and out of a domestic style bath without assistance. A satisfactory enhanced Criminal Records Bueau disclosure must be obtained for all people employed at the home. A risk assessment must be in place for all residents that have bed rails fitted to their beds, and that these assessments address all of the risks involved when using this equipment. This requirement remains outstanding. F51 F01 S18744 Frodsham CNH V230010 120705 Stage 4.doc Timescale for action 31/08.05 2. 7 15 31/08/05 3. 4. 9 21 13 23 31/08/05 15/09/05 5. 29 19 31/08/05 6. 38 23 31/08/05 FRODSHAM CHRISTIAN GENERAL CARE HOME Version 1.30 Page 21 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 18 Good Practice Recommendations The manager should ensure that all staff are aware of, and have read and understood the homes policies and procedures on the protection of vulnerable adults. FRODSHAM CHRISTIAN GENERAL CARE HOME F51 F01 S18744 Frodsham CNH V230010 120705 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Unit D, Off Rudheath Way Gadbrook Park Northwich Cheshire 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 F51 F01 S18744 Frodsham CNH V230010 120705 Stage 4.doc Version 1.30 Page 23 - 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. 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