Inspection on 14/03/06 for The Friendly Inn

This inspection was carried out on 14th March 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Friendly Inn 29/10/09

The Friendly Inn 06/07/09

The Friendly Inn 19/02/09

The Friendly Inn 17/12/08

The Friendly Inn 21/02/08

The Friendly Inn 31/05/07

The Friendly Inn 15/11/06

The Friendly Inn 26/06/06

The Friendly Inn 16/08/05

The Friendly Inn 08/03/05

The Friendly Inn 24/09/04

The Friendly Inn 17/02/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Friendly Inn Gloucester Way Chelmsley Wood Birmingham West Midlands B37 5PE Lead Inspector Sean Devine Unannounced Inspection 14th March 2006 09:30 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 The Friendly Inn DS0000004561.V285802.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. The Friendly Inn DS0000004561.V285802.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Friendly Inn Address Gloucester Way Chelmsley Wood Birmingham West Midlands B37 5PE 0121 779 5128 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) TheFriendlyInnCH@aol.com Mr Michael John Goss Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places The Friendly Inn DS0000004561.V285802.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th August 2005 Brief Description of the Service: The Friendly Inn Care Home is a large converted former public house. Extended by the current owner in 2003, the home is now registered to accept up to 30 residents in the category of old age requiring personal care. Accommodation is provided over two floors. The home comprises of 30 single bedrooms, of which 29 have en-suite facilities. The Friendly Inn is located in Chelmsley Wood and is readily accessible to amenities such as shops, places of worship and public transport. There is an ample well maintained garden area at the rear of the building. A shaft lift provides access to the upper floor. Parking facilities are available at the front of the building and on-road parking is readily available outside of the home. The Friendly Inn DS0000004561.V285802.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted on an unannounced visit by one regulation inspector. The inspector was able to meet with some residents and view many of their rooms. Records pertaining to care and health and safety were seen. It is recommended that the last inspection report dated the 16th August 2005 be considered when reading this report. What the service does well: What has improved since the last inspection? There have been improvements in the management of residents’ medicines, including the training of staff and acting upon concerns raised in medicine checks. Menus have been developed that inform residents of all the possible choices for breakfast, lunch, tea and supper. Staff rotas have been further developed to inform which senior care worker is in charge and also to indicate the hours worked by each member of staff. Records indicate that all staff are now regularly attending fire drills and also that fire equipment is tested. The Friendly Inn DS0000004561.V285802.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Friendly Inn DS0000004561.V285802.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 The Friendly Inn DS0000004561.V285802.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): 3, 6 The home are aware of the needs of residents prior to admission, which ensures the manager can make a decision on whether the home can meet these needs and approve the admission. EVIDENCE: Three residents files were sampled. They all included information gathered pre-admission that informed the home as to the needs and risks of residents. They included needs assessments and care plans completed by the local social services department and from recent admissions into hospitals. The home does not provide an intermediate care facility. The Friendly Inn DS0000004561.V285802.R01.S.doc Version 5.1 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 the following standard(s): 7, 8, 9, 10 Residents’ needs are not always adequately assessed and planned for, risks are not altogether identified and plans are not always made to reduce the level of risk. Medicines are well managed on behalf of residents and the residents are supported to have their privacy and dignity maintained. EVIDENCE: It was evident from sampling residents’ files that their care plans and risk assessments were being developed using new formats. Those care plans that had been completed on the new format (approximately five out of thirty) were based upon assessments of need, there was clear aims, objectives and clear instructions for staff. Specific risk assessments had been completed including falls, manual handling, pressure areas, oral care and nutrition. Those on old formats did not have clear aims and instructions; they were not developed from a detailed assessment and were not being reviewed. Care plans for a resident with Diabetes were not available; risk assessments were not always undertaken, including the risk of falls for one resident who was recently found lying on the floor. The home manages medicines on behalf of residents, which are supplied in a blister pack system from a local chemist. Copies of GP prescriptions are made The Friendly Inn DS0000004561.V285802.R01.S.doc Version 5.1 Page 10 to enable staff to check the medicines when received from the chemist. Medication administration records are available for all residents, these records are accurately completed for when medicine is received and administered. Other records are available for disposal of medicines and for the administration and stock levels of controlled drugs; it is a concern that controlled drugs are not stored in a controlled drug cupboard. A medicine policy, which reflects current practice was not available. The district nurses are provided with a small fridge to store insulin, there is also a fridge for ointments, creams and other medicine that need to be stored in a fridge, however this appeared not to be working. No records of the temperature of the fridges are made and no thermometer was available in either fridge. Care plans completed on the new format described how the privacy and dignity of residents is maintained including when delivering personal care. Staff were observed assisting residents about the home, to the toilet and bathroom, this was done sensitively and light heartedly where appropriate. The Friendly Inn DS0000004561.V285802.R01.S.doc Version 5.1 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 the following standard(s): 12, 14 Residents are not always able to make choices and decisions about the care they receive and influence how it is provided by the staff at the home. EVIDENCE: Some residents are provided with a daily living plan, and a blank template was seen to describe these needs within the developing new care plans, of those completed in the old format many are not reviewed and they are not completed in consultation with residents. Written care plans on the new format do contain evidence that residents are consulted about the care being planned, their likes, dislikes, abilities and disabilities are considered when plans are made. Two residents informed the inspector that staff support them with choices they make such as spending time in their room or when they wish to get up or go to bed. The Friendly Inn DS0000004561.V285802.R01.S.doc Version 5.1 Page 12 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 Complaints made by residents or their representatives are recorded and some are effectively managed, however some complaints are not responded to in a timely fashion and residents’ health and well-being could be affected. EVIDENCE: A complaints record is maintained by the home. In the past twelve months two formal complaints have been received at the home, one of the complaints the inspector had been made aware of. This complaint was recorded, however it was not resolved to the complainants satisfaction, the social worker and the commission were informed about no heating in one residents room for in excess of two months, on checking this concern the radiator had been repaired. The second complaint had also been recorded, actions taken to improve the service regarding personal care of one resident had been taken and indicated that the complainant was satisfied with the response. Training records available at the home indicate that staff are not receiving training about how they are to protect residents from possible abuse. The manager has been responsive and raised a concern to social services and to POVA in regard to one incident of poor staff practice. The Friendly Inn DS0000004561.V285802.R01.S.doc Version 5.1 Page 13 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, 20, 25 Residents are provided with a well-furnished and a well maintained home, both in their bedrooms and in communal areas, their rooms are individualised and provide residents with adequate facilities to meet their needs. EVIDENCE: The premises are generally well maintained, safe and comfortable to meet the individual and collective needs of residents. The garden area has a substantial decking area with fence poles that have no fencing, the fencing needs to be replaced to ensure the safety of residents when using this area. There are four lounges (day rooms) including a small library area and a large dining area. Residents were seen using these areas and are able, some with staff support to talk to each other and take part in activities. Many of the residents’ rooms were seen, all but one room is en-suite and many have been personalised. The lighting is good, bedside lights are available and the windows help with natural lighting. All rooms are centrally heated either under floor or by radiator, all but one was pleasantly warm and this was the residents’ choice to turn the thermostat down. The Friendly Inn DS0000004561.V285802.R01.S.doc Version 5.1 Page 14 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, 29 The residents are supported to have their needs met by good numbers of staff. Staff are not fully vetted before commencing employment, which does present a risk to residents at the home. EVIDENCE: The staff rotas indicate that residents are supported by good numbers of staff throughout the day and night. There is normally four care staff on duty 8am to 10pm and two care staff on night duty. There is two staff working in the kitchen, being the cook and the assistant and a cleaner who works five days a week. The care staff also undertake laundry duties. The manager is not included on the care rota, however the deputy manager shares her time between care and management duties. Two residents commented that there was always enough staff available to help them when this was needed and staff always responded quickly when they pressed the call system The recruitment records were seen for the most recent member of staff who works in the kitchen, on examining the records it was evident that no Criminal Records Bureau disclosure or POVA check was available, no application form had been completed and only one reference had been received. An immediate requirement and subsequent letter of concern was issued to address this poor practice. The Friendly Inn DS0000004561.V285802.R01.S.doc Version 5.1 Page 15 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, 36, 38 The residents are supported by a manager, whose fitness is currently being assessed by the commission. There are processes in place to consult residents about the quality of service but no audits and reports are produced. Some staff are supervised yet others are not and some health and safety issues have not been adequately addressed presenting a possible risk to safety. EVIDENCE: The commission has received an application made by the registered individual to register the current manager. The application is currently being assessed to determine fitness. The residents were positive about the manager and indicated that she often comes to talk with them. The deputy manager advised she was unaware of any quality system in place to reflect and audit a set of quality standards. However residents are now involved in care planning, the home manager and staff have regular meetings The Friendly Inn DS0000004561.V285802.R01.S.doc Version 5.1 Page 16 with residents and relatives and staff also have a monthly meeting. Records regarding these meeting were not seen by the inspector. Some residents request the home to help manage money on their behalf and keep it in safekeeping. Four records maintained by the home were sampled, all balances and money available were accurate. The manager frequently conducts audits and checks to ensure they are accurate. One record identified an outstanding amount due to the owner, yet it was not clear on the records that this had been reconciled. Of the four sampled three had receipts for all purchases made for them by the home, mainly being for hairdressing. On one file a receipt for hairdressing could not be found. Staff supervision has commenced with records being maintained and there is a plan for this to be extended to all staff, it was evident that there are some staff who are not receiving supervision. Fire records in respect of service and tests for the system, equipment, emergency lights and the alarm are regularly completed. There were records available confirming that staff are attending frequent fire drills. The call system used by residents in their rooms and in communal areas has recently been serviced. There was no evidence available in maintenance files that the electrical installation had been subject to periodic inspection. One residents room door accessed from the corridor close to the office was found to be wedged open, as required at the last inspection consultation with the local fire service was needed in respect of many residents room doors not having self closing devices. On examination of fire records there was no evidence that the fire service had been consulted and there were many doors without self-closing devices. The Friendly Inn DS0000004561.V285802.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 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 3 X X X X 3 X STAFFING Standard No Score 27 3 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 2 X 2 The Friendly Inn DS0000004561.V285802.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 15(1) 15(2) Requirement The written care plans must include specific instruction for staff as to how the needs of residents following the assessment are to be met. Previous timescale of 30 June 2005 not met, this requirement is carried forward. Evidence is required to demonstrate that care plans are drawn up with the involvement of the residents and/or their representative. Previous timescale of 31 July 2005 not met, this requirement is carried forward. Timescale for action 07/04/06 2 OP7 15(1) 15(2c,d) 07/04/06 The Friendly Inn DS0000004561.V285802.R01.S.doc Version 5.1 Page 19 3 OP7 15(2b,c) The outcome of the review of care plans must be updated and cross-referenced into main care plan documentation to reflect changing needs and current objectives for health and personal care. This process must involve consultation with the resident and/or representative. Previous timescale of 30 June 2005 not met, this requirement is carried forward. All care plans must be reviewed on a monthly basis. 07/04/06 4 OP7 15(1) Previous timescale of 30 November 2005 not met, this requirement is carried forward. Residents with a specific health 31/03/06 need such as diabetes must have a written plan of care. Previous timescale of 30 June 2005 not completed, this requirement is carried forward. The registered provider must ensure residents receive a comprehensive assessment of their care needs on admission to the home. This must include risk assessments for tissue viability and nutrition. Previous timescale of 30 June 2005 not met, this requirement is carried forward. All assessments must be regularly reviewed. Previous timescale of 31 October 2005 not met, this requirement is carried forward. 5 OP8 15(1) 31/03/06 The Friendly Inn DS0000004561.V285802.R01.S.doc Version 5.1 Page 20 6 OP8 12(1) Care plans developed to meet oral hygiene needs must contain sufficient and appropriate information to support staff in meeting the needs of individual residents. Previous timescale of 31 May 2005 not met, this requirement is carried forward. The medicine policy must reflect the practice in managing controlled drugs and also how staff are trained to effectively handle medicines. A medicine policy that reflects all current practices must be available in the home. A controlled drug cupboard must be provided and used where necessary. Previous timescale of 31 October 2005 not met, these requirements are carried forward. The maximum, minimum and current medicines refrigerator temperatures must be recorded on a daily basis and lie between 2°C and 8°C at all times to ensure medication requiring refrigeration complies with their product licences. Previous timescale of 30 June 2005 not met, this requirement is carried forward. The daily living plans must be reviewed and updated regularly and involve the residents. Previous timescale of 30 June 2005 not met, this requirement is carried forward. 31/07/06 7 OP9 13(2) 07/04/06 8 OP9 13(2) 31/03/06 9 OP9 13(2) 31/03/06 10 OP12 16(2m,n) 15(2b) 07/04/06 The Friendly Inn DS0000004561.V285802.R01.S.doc Version 5.1 Page 21 11 OP18 13(6) All staff must receive training and have knowledge of measures to be taken to adequately protect residents from the risks of abuse. Previous timescale of 31 January 2005 not met, this requirement is carried forward. The fencing in the garden must be adequately repaired. All staff must have a current criminal records bureau disclosure completed. The staff recruitment practice must be improved and include all information and documents listed within schedule 2 of the Care Home Regulations 2001. Previous timescale of 31 October 2005 not met, this requirement is carried forward. The member of staff who commenced duty on the 13 March 2006 without CRB, POVA and references must only work under supervision of a senior member of staff until the checks are completed. 30/04/06 12 13 OP19 OP29 23(2)(o) 19(1) Sch2 p1-7 30/04/06 30/04/06 14 OP29 19(1a-c) Sch2 13/03/06 The Friendly Inn DS0000004561.V285802.R01.S.doc Version 5.1 Page 22 15 OP33 24 The registered provider must establish a system of reviewing the quality of care, this must include consultation with residents and their representatives. This should reflect the Homes aims and objectives and include formalised systems for ascertaining the residents’ views, the results of which should be collated and made public on an annual basis. Previous timescale of 17 February 2004 not met, this requirement is carried forward. Residents must be provided with a receipt to reflect all purchases made on their behalf by the home, this must be kept on file. The registered provider must ensure that all care staff receive supervision at least six times a year, this must be recorded and be available for inspection. Previous timescale of 17 February 2004 not met, this requirement is carried forward. All fire doors must be kept closed and not wedged open. Following consultation with the fire service and where advised self closing devices must be fitted to fire doors. Previous timescale of 30 August 2005 not met, this requirement is carried forward. 31/05/06 16 OP35 13(6) 17(2) Sch4 18(2) 31/03/06 17 OP36 30/04/06 18 OP38 23(4) 13(4) 14/03/06 The Friendly Inn DS0000004561.V285802.R01.S.doc Version 5.1 Page 23 19 OP38 13(4) Evidence that the fixed electrical installations is inspected and tested at regular intervals must be available at the home and a copy forwarded to the commission. Previous timescale of 31 October 2005 not met, this requirement is carried forward. 30/04/06 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 The Friendly Inn DS0000004561.V285802.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 The Friendly Inn DS0000004561.V285802.R01.S.doc Version 5.1 Page 25 - 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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