Inspection on 15/11/06 for The Friendly Inn

This inspection was carried out on 15th November 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 26/06/06

The Friendly Inn 14/03/06

The Friendly Inn 16/08/05

The Friendly Inn 08/03/05

The Friendly Inn 24/09/04

The Friendly Inn 17/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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 Brenda O’Neill Key Unannounced Inspection 15th November 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.V319871.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V319871.R01.S.doc Version 5.2 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 vacant Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places The Friendly Inn DS0000004561.V319871.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th June 2006 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. The home has a number of aids and adaptations to assist any frail residents including, emergency call system, shaft lift, hand and grab rails, a mobile hoist and assisted toilet and bathing facilities. There is an ample well maintained garden area at the rear of the building. Parking facilities are available at the front of the building and on-road parking is readily available outside of the home. The fees at the home range from £335.00 to £405.00 per week. The Friendly Inn DS0000004561.V319871.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second key inspection for the service for 2006/2007 and was carried out by two inspectors over one day in November 2006. During the course of the inspection a tour of the premises was carried out, four resident and three staff files were sampled as well as other care, health and safety and training records. The inspector’s spoke with the acting manager, two staff members and six of the nineteen residents. A letter of serious concern was sent to the proprietor of the home during August 2006. CSCI had received copies of assessments undertaken by an occupational therapist which raised issues over the lack of manual handling equipment for the safe moving and handling of the residents. These issues had also been raised at the key inspection in June 2006. At the time of this inspection the situation had improved. A new hoist had been purchased, the bath hoist had been repaired and staff were receiving training on the use of the hoist. Some concerns had been raised anonymously with the CSCI since the previous key inspection. The concerns were in relation to night staffing levels, the numbers of residents still up at 11pm one night and personal care. The concerns were no breaches of regulations and standards. No complaints had been lodged at the home since the last inspection. What the service does well: There were good systems in place for assessing the needs of prospective residents to the home. This ensured staff were able to decide if they could meet any identified needs. Prospective residents could visit the home to assess the facilities available to them should they decide to live there. Care plans that were in place were quite well detailed and included some details of what residents were able to do for themselves. The majority gave clear instructions for staff to follow to enable them to meet the residents’ needs. The risk assessments that were in place for the residents had corresponding care plans of how staff were to manage/minimise the risks. The residents spoken with were satisfied with the meals being served at the home and described the food as ‘good’. The menus seen were varied and nutritious and offered choices at each meal and rotated over four weeks. Residents were asked prior to meal times what their choices were. The Friendly Inn DS0000004561.V319871.R01.S.doc Version 5.2 Page 6 Visiting at the home was flexible and visitors were made welcome by the staff. There had been very little staff turnover at the home since the last inspection which was very good for the continuity of care of the residents. Good staffing levels were being maintained. The home had more than 50 of staff qualified to NVQ level 2. Residents spoken with were very positive in their comments about the staff stating they were ‘nice’, ‘friendly’ and ‘they will do what we want’. Throughout the course of the inspection friendly relationships were evident between the staff and the residents. The procedures for recruiting staff were robust and safeguarded the residents. The home provided residents with a well furnished and comfortable environment in which to live. All but one of the bedrooms had en-suite facilities. Residents were able to personalise their bedrooms to their choosing. What has improved since the last inspection? What they could do better: The Friendly Inn DS0000004561.V319871.R01.S.doc Version 5.2 Page 7 Care plans needed to show that the residents had been consulted about how they wanted their care delivered and be reviewed monthly. Care plans needed to include any social care needs of the residents and details of how these were going to be met. The manual handling risk assessments needed to be reviewed and detail the handling methods to be used by staff when transferring residents when using the hoist. Daily recordings needed to be made every day on all residents. The daily recordings and health care visit recordings needed to be cross referenced to each other so that staff were kept fully informed of the well being of the residents. The medicine management within the home needed to improve to safeguard the residents. There was no evidence seen that any activities were facilitated by staff in the home. As there were still no social care plans in place for the residents and evidence of any activities was limited it could not be determined if the residents’ social needs were being met. Staff needed to ensure that daily records included some detail of how residents were spending their days to evidence their social needs were being met. There needed to be some discussion with the residents to establish the types of in house activities they would like and action taken to ensure the outcome of the discussions were actioned. To ensure staff were able to identify and report adult protection issues appropriately they needed to undertake training in this area. Induction training needed to be improved to ensure the staff had all the necessary skills and knowledge to care for the residents. To ensure the safety of the residents and staff the infection control procedures, food hygiene practices and the monitoring of health and safety records needed to be vastly improved. Quality monitoring within the home needed to be a formalised system for obtaining the residents’ views the results of which needed to be collated and made public on an annual basis. A manager needed to be appointed for the home so that residents were assured someone was accountable on a day to day basis for the running of the home. The Friendly Inn DS0000004561.V319871.R01.S.doc Version 5.2 Page 8 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 summary of this inspection report can be made available in other formats on request. The Friendly Inn DS0000004561.V319871.R01.S.doc Version 5.2 Page 9 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.V319871.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The pre admission assessment procedures ensured the needs of the residents were known by the staff prior to admission. Prospective residents could visit the home prior to admission to assess the facilities available. EVIDENCE: There had not been any new permanent residents admitted to the home since the last inspection. The files for two residents staying at the home for a short stay were sampled. Both files included a pre admission assessment that had been completed by the acting manager. The assessments covered all the required areas and included a lot of detail of the residents’ needs. There was also evidence that residents could visit the home prior to admission if they wished. On the day of the inspection a prospective resident was visiting and stayed to have lunch with the other residents. The Friendly Inn DS0000004561.V319871.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Further developments were needed to the care plans, risk assessments and recordings in the home to ensure all the needs of the residents were met, their risks minimised and their health care needs were met. Whilst some good practice for the handling of medication was seen, the service must make sure that this is further developed in order to maintain the safety and welfare of the service users. EVIDENCE: Four files were sampled, two for permanent residents and two for short stay residents. Three of the files sampled included a number of care plans. The care plans covered areas such as personal hygiene, oral care, health, foot care, continence and orientation. These were generally well detailed and included some details of what the residents were able to do for themselves and instructions for staff as to how they were to meet any identified needs. As at the last inspection none of the files included care plans for the residents social The Friendly Inn DS0000004561.V319871.R01.S.doc Version 5.2 Page 12 care needs. There was no evidence that the plans were being reviewed on a monthly basis or that the residents had been involved in drawing them up. The fourth file did not have any care plans in place. This resident was at the home for a short stay and had only been in the home for a little over a week. However there was enough detail on the pre admission assessment for an interim care plan to have been drawn up so staff were informed of how their needs were to be met. This person would have been able to contribute fully to drawing up the care plan. There were numerous risk assessments in place on three of the files sampled. The file for one resident receiving a short stay did not have any risk assessments. The risk assessments that were in place included manual handling, tissue viability, nutritional screenings, falls and challenging behaviours. Where any risks had been identified there were corresponding care plans of how staff were to manage/minimise the risks. Several issues were raised at the last inspection in relation to manual handling risk assessments as the free standing hoist and one of the bath hoists in the home were not working. Due to this staff were handling residents in ways that contravened the Manual Handling Regulations. The home had a new hoist and the bath hoist was working. On the day of the inspection the staff were having training on how to use the hoist. The manual handling risk assessments will now need to be reviewed and the appropriate instructions included for staff where the use of a hoist is needed. The risk assessments also needed to include the actions to be taken by staff in the event of a fall if the resident was not injured. The tissue viability and nutritional screenings that were in place were generally well detailed and had corresponding care plans where necessary. There were details of how to maintain good skin condition, specific likes and dislikes in relation to diet and any special dietary needs could be detailed. One of the care plans for nutrition identified that the resident must be weighed monthly, the records indicated this person had not been weighed since July. At this time there was a significant weight loss. It was evident from the professional visits records that the G.P. had visited in relation to this and had referred the individual to hospital. Daily records evidenced they had attended the appointment but the outcome of the visit was not recorded anywhere. The acting manager needed to ensure that daily records guided the reader to any entries on the professional visits sheet and that any outcomes of hospital visits were recorded. In most instances staff were recording when residents saw doctors, chiropodists, dentists and district nurses. Records were not always cross referenced to each other, for example, it had been noted by staff that a resident was not well and had a cold. The professional visits sheets evidenced the doctor had visited and prescribed antibiotics but this was not mentioned on The Friendly Inn DS0000004561.V319871.R01.S.doc Version 5.2 Page 13 the daily records. All recordings made about residents needed to be cross referenced to each other so that staff were kept fully informed. Daily recordings for each resident had been put in place since the last inspection which gave a general overview of the well being of the residents. The use of the communal recording book had stopped. There were some occasions when the daily records had not been completed for all residents. As previously stated these needed to include references to other recordings so that the readers were kept fully informed. It was strongly recommended that the files for the residents were divided up into smaller files. A lot of the recording issues were due to staff having to go through a lot of paper work to find what they needed. If daily records and professional visit sheets were together on one file, care plans and risk assessments on another and old information archived staff would be able to access and track information much more easily. The pharmacist inspector visited the home on 08/11/06. Audits of medicines and records were undertaken to demonstrate whether the medicines were administered as prescribed and two care assistants were interviewed to assess their knowledge of the medicines they routinely administer. All the medication was kept in a dedicated medication room and trolley. The medication trolley was too small to safely store all the medicines so some medicines were kept on top of the trolley and could not be locked away during a medicine round if an emergency occurred. The home had purchased a Controlled Drug cabinet but this had not been fixed to the wall in the medication room so Controlled Drugs were still incorrectly stored in the medication trolley. A system had been installed to check the medicines received into the home and all the quantities of medicines received had been recorded. Audits were undertaken for nine residents to see if they had been administered the correct medication and the records supported practice. All medicines dispensed in a monitored dosage system supplied by the pharmacist were administered as the doctor prescribed. Medicines dispensed in traditional bottles and boxes were not always administered correctly. Some medicines had been recorded as administered but had not been, others were unaccounted for. Concern was raised, as the medicine warfarin was not administered correctly to three residents. This was because of three main reasons 1 Incorrectly writing the dose on the medicine chart. 2 Signing the medicine chart but not actually giving the medicine and 3 Giving the incorrect dose (for example one tablet instead of two). The Friendly Inn DS0000004561.V319871.R01.S.doc Version 5.2 Page 14 This was to be addressed by the acting manager following the pharmacist inspection. The administration of Controlled Drugs were recorded in the CD register only and not on the medicine chart, but the balances in the register matched those counted. Previously some CDs had been missing which had been identified by a routine visit by the community pharmacist. Residents were encouraged to self-administer their own medicines but no risk assessments were available for inspection and no compliance checks completed to assess whether they can safely do so. Two care assistants were interviewed at the end of the inspection. One had a good knowledge of the medicines she administered and had undertaken an accredited training course. This was commended. The other was relatively new to the home but was allowed to administer medicines despite minimal training and no knowledge of the medicines she gave out. No issues were raised at this inspection in relation to privacy and dignity. Residents could spend time in the privacy of their rooms if they wished. Staff spoke to the residents respectfully and assisted them with personal care appropriately. Residents could have keys for their rooms if they wished and there were quiet areas in the home where they could meet with their visitors. The Friendly Inn DS0000004561.V319871.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There were no rigid rules or routines in the home and some activities were available but it could not be determined if these met the needs of the residents. All the arrangements for meals and catering met residents’ needs and preferences. EVIDENCE: There were no rigid rules or routines in the home. Residents were seen to wander freely around the home, sit reading, spending time in their bedrooms, watching television and chatting in small groups. Residents did have individual activity sheets on their files but these had not been completed for some time. The acting manager stated that residents had regular activities facilitated by people coming into the home for exercise and sing a longs. A party had been organised for Halloween and birthdays were celebrated. Residents had been taken out to the Black Country museum and Weston. A trip to the see the Christmas lights was also planned. There was very little evidence seen that any in house activities were facilitated by staff on an ongoing basis. As there were still no social care plans in place for the residents and evidence of any activities was limited it could not be determined if the residents’ social needs were being The Friendly Inn DS0000004561.V319871.R01.S.doc Version 5.2 Page 16 met. Staff needed to ensure that daily records included some detail of how residents were spending their days to evidence their social needs were being met. There needed to be some discussion with the residents to establish the types of in house activities they would like and action taken to ensure the outcome of the discussions are actioned. There were no restrictions on visitors to the home during reasonable waking hours. Several visitors were seen to come and go throughout the course of the inspection and were made welcome by staff. Residents appeared to exercise some choice and control over their lives in that they chose how they spent their time, what time to get up and go to bed, what they ate and so on. Residents were encouraged to personalise their rooms to their choosing and evidence of this was seen during the tour of the home. All the residents spoken with described the food at the home as ‘good’ and that there was plenty of it. The menus seen were varied and nutritious and offered choices at each meal and rotated over four weeks. Residents were asked prior to meal times what their choices were. Records of food being served to the residents were on individual files but these were not always being completed. The Friendly Inn DS0000004561.V319871.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was an appropriate complaints procedure at the home. To ensure staff were able to identify and report adult protection issues appropriately they needed to undertake training in this area. EVIDENCE: A complaints log was being kept by the home. No complaints had been lodged with the home since the last inspection. There was evidence in the complaints log that the home will complain on the behalf of residents about such things as their care in hospital. Some concerns had been raised anonymously with the CSCI since the previous key inspection. The concerns were in relation to night staffing levels, the numbers of residents still up at 11pm one night and personal care. The concerns were discussed with the manager at the time they were raised and there was no evidence that the home had breached the regulations and standards. The acting manager demonstrated her knowledge of the procedures to be followed in the event or suspicion of abuse. There were policies and procedures on site in relation to adult protection. A slight amendment was needed to these The Friendly Inn DS0000004561.V319871.R01.S.doc Version 5.2 Page 18 to ensure that staff were aware that all allegations or suspicions of abuse had to be reported regardless of the individual’s desire not to proceed. Staff had not received training in adult protection issues and this was an outstanding requirement from the previous two inspections. The Friendly Inn DS0000004561.V319871.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provided residents with a well furnished and comfortable environment in which to live. Some issues needed to be addressed to ensure the home was safe for the residents. EVIDENCE: There had been no changes to the layout of the home since the last inspection which was suitable for its stated purpose. The home was comfortable with a good standard of furnishings and fittings throughout. Some general repairs were needed to the two small kitchen areas in the home in relation to missing door cupboards and one work surface that was worn and needed replacing. It was also noted that all the bedroom doors in the newest part of the building were open. These are fire doors and must be kept closed. The Friendly Inn DS0000004561.V319871.R01.S.doc Version 5.2 Page 20 Staff needed to ensure that these doors were shut or self closures must be fitted. The communal space at the home was unchanged and comprised of four lounges including a small library area and a small quiet lounge/visitors lounge. Communal areas were nicely furnished and very comfortable with many pictures and ornaments giving it a very homely feel. It was noted that the carpets in the ground floor communal areas and several of the armchairs were dirty and this needed to be addressed. There was ample outdoor space for the residents with areas of shrubs and flowers, lawn, decking and paving. Seating was available in the grounds for residents to use. There were adequate numbers of toilets and bathrooms throughout the home and all but one of the bedrooms had en-suite toilets and some en-suite showers. There were two assisted bathrooms on the ground floor with bath hoists. The issue raised at the last inspection in relation to one bath hoist not working had been addressed. There was also a floor level shower on the ground floor that allowed for assistance from staff. The bathroom on the first floor of the home was not an assisted facility and the inspectors were informed this was not used. It was noted that some of the extractor fans in communal facilities and en-suites were not working and in need of cleaning. The aids and adaptations in the home met the needs of the residents and included, emergency call system, shaft lift, hand and grab rails and a new mobile hoist. It was strongly recommended that consideration is given to fitting handrails in the corridors to further assist those residents with mobility difficulties. Bedrooms varied in size, were all single occupancy and all but one had en-suite facilities. All those seen were well furnished and nicely decorated. Residents had personalised the bedrooms to their choosing and keys were available for them to use. The heating, lighting and ventilation in the home appeared to meet the needs of the residents. Windows had restrictors fitted where necessary and the hot water outlets were thermostatically controlled. The home had recently had an infection control audit by the health protection nurse. Numerous issues were raised in the report following the audit in relation to infection control and food hygiene. Some of the issues had been addressed but several remained outstanding. Of particular concern was the main kitchen which only achieved an overall score of 50 . Several of these issues remained outstanding, including, fridge and freezer temperatures were not being recorded, some foods in the fridge were not labelled when opened, the only cleaning schedule in the kitchen was for the ovens and some areas needed to be thoroughly cleaned. There was no food probe on site to enable staff to check the core temperatures of cooked foods. Some of the issues in the The Friendly Inn DS0000004561.V319871.R01.S.doc Version 5.2 Page 21 environment and the laundry that had been addressed included: towels were no longer stored in the bathrooms, clean linen was being stored appropriately liquid soap and disposable towels were available in all toilets and bathrooms. Hard soap and a cotton towel were still evident in the staff toilet, there were no disposable gloves available in the laundry and no foot operated bins had been purchased for the bathrooms, toilets and sluices. It was also noted that the home does not have a washing machine with a sluice cycle. It is strongly recommended that when the machine is to be replaced one with a sluice cycle is purchased. It is recognised that some of the issues raised by the audit require considerable financial expenditure, for example, installing a washer disinfector for commode pans and urinals. However many required little or no expenditure and these must be addressed. Some immediate requirements were left at the home in relation to the issues. The Friendly Inn DS0000004561.V319871.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Adequate staffing levels were being maintained to meet the needs of the residents. Induction training needed to be improved to ensure the staff had all the necessary skills and knowledge to care for the residents. Recruitment procedures were robust and protected the residents. EVIDENCE: There had been very little staff turnover at the home since the last inspection which was very good for the continuity of care of the residents. Appropriate staffing levels were being maintained without the use of the acting manager’s hours which is an improvement since the last inspection. Rotas evidenced there were three care staff on duty throughout the waking day and two waking night staff. The home also employed catering and domestic staff. Residents spoken with were very positive in their comments about the staff stating they were ‘nice’, ‘friendly’ and ‘they will do what we want’. Throughout the course of the inspection friendly relationships were evident between the staff and the residents. Three staff files were sampled and with the exception of one reference all the required checks had been undertaken prior to the staff commencing work at The Friendly Inn DS0000004561.V319871.R01.S.doc Version 5.2 Page 23 the home. CRBs were evident on all files. The acting manager was advised she must pursue the second reference where the staff member had only one on file. There was no evidence that the staff who had been appointed at the home had received the appropriate induction training. They had signed to say they received some policies and procedures and some had a checklist stating they had had some very basic induction. All staff must have appropriate induction training and all care staff must have induction training as specified by skills for care that is completed within the first 12 weeks of their employment. The training matrix for the home did not include the new staff appointed at the home. The matrix did evidence that staff other staff had had the majority of their mandatory training including, food hygiene, manual handling and first aid. The home had more than 50 of staff qualified to NVQ level 2. The Friendly Inn DS0000004561.V319871.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. A manager needed to be appointed for the home so that residents were assured someone was accountable for the running of the home on a day to day basis. Improvements were needed in the management of health and safety in the home to ensure the safety of the residents and staff. EVIDENCE: The registered manager had left the home since the last inspection. The deputy manager was acting manager at the time of the visit and five senior care assistants supported her. The acting manager had a very good knowledge of the residents needs and had worked at the home for three years. She was finding it difficult to keep up with all that was involved with the running of a The Friendly Inn DS0000004561.V319871.R01.S.doc Version 5.2 Page 25 residential home and as this was the first time she had been a manager was not fully aware of the expectations of her role. She informed the inspectors that the proprietor of the home now had two applicants for the managers’ post. The home needed to have a manager in post so that the management team was complete and to ensure all the management tasks could be completed. Several good systems had been put in place, for example, care planning and risk assessments but these were falling behind. The need for a quality monitoring system in the home had not progressed. No further residents meetings had taken place and the key worker system had not been fully developed. Some of the monitoring systems that were in place had lapsed, for example, care plan reviews. Staff meetings were being held. Quality monitoring within the home needed to be a formalised system for ascertaining the residents’ views the results of which needed to be collated and made public on an annual basis. The acting manager was handling some of the personal allowance for the residents and the records for this were sampled. The records were well maintained and included the amounts deposited for residents, records of any expenditure made on their behalf and receipts were available. Improvements had been made to the system in place. Two staff were signing for all transactions and the hairdresser was signing for the money she received from the home. The records were being regularly audited. The previous manager had started a staff supervision system however there had been no progress with this. The staff files sampled had no evidence that any supervision sessions had been undertaken. As at the last inspection there was no evidence that the registered provider was making any unannounced visits to the home to oversee the management/conduct of the home. It is a requirement that these visits takes place and that the responsible individual inspects the environment, samples administration and speaks to the residents and then prepares a report on the outcome of the visit. Some improvements were needed to the management of the health and safety of the staff and residents particularly in the areas of infection control and kitchen hygiene as stated previously. The in house checks on the fire alarms and emergency lighting had lapsed. An immediate requirement was left at the home in relation to this. There was an extensive fire risk assessment on site but this needed to be reviewed. The home still had no evidence on site that the portable electrical appliances had been checked or that the water system had been checked for the prevention of legionella. These are outstanding requirements from the previous inspection. The service report for the shaft lift had identified the need for a lot of remedial work and there was no evidence that this had been completed. There was evidence on site that the fire alarm, gas equipment, emergency call system and emergency lighting had been The Friendly Inn DS0000004561.V319871.R01.S.doc Version 5.2 Page 26 serviced. Evidence that the electrical wiring in the home had been checked was sent to the CSCI following the last inspection along with a copy of an up to date insurance certificate. It was pleasing to note that the issues raised at the last inspection in relation to manual handling were being addressed. The Friendly Inn DS0000004561.V319871.R01.S.doc Version 5.2 Page 27 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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 2 2 3 X 3 3 1 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 1 2 1 The Friendly Inn DS0000004561.V319871.R01.S.doc Version 5.2 Page 28 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 OP2 Regulation 5(1)(b) Requirement All residents must be issued with a contract/terms and conditions of residence. Previous time scale of 31/07/06 not assessed for compliance at this visit. Evidence is required to demonstrate that care plans are drawn up with the involvement of the residents and/or their representative and that they are reviewed monthly. Previous timescales of 31/07/05, 07/04/06 and 01/08/06 not met. Care plans must detail all the needs of the residents including social care needs and specify how all identified needs are to be met by staff. Previous time scale of 01/08/06 not met. 3. OP7 13(5) Manual handling risk assessments must be reviewed and clearly detail: DS0000004561.V319871.R01.S.doc Timescale for action 31/01/07 2. OP7 15(1) 15(2c,d) 01/01/07 14/12/06 The Friendly Inn Version 5.2 Page 29 The handling methods to be used by staff when transferring residents. The actions to be taken by staff in the event of a fall if the person is uninjured. Previous time scale of 14/07/06 not met. They must be in place for all residents. All appropriate risk assessments must be in place for short stay residents. Wherever possible residents must be weighed on a monthly basis. The outcomes of any hospital visits must be recorded. Daily recordings and professional visit sheets must be cross referenced to each other. Daily records must be completed every day for all residents in the home. The right medicine must be administered to the right service user at the right time and at the right dose and records must support practice. Staff drug audits before and after a drug round must be undertaken to assess staff competence in the administration and recording of medicines to service users. Appropriate action must be taken if discrepancies are found. The administration of Controlled Drugs must be recorded on the The Friendly Inn DS0000004561.V319871.R01.S.doc Version 5.2 Page 30 4. OP8 13(4)(c) (5) 12(1)(a) 14/12/06 5. OP8 14/12/06 6. OP9 13(2) 06/12/06 Medicine Administration Record (MAR) chart in addition to the controlled drug register. Any service user who wishes to self administer their own medicine must be risk assessed as able and compliance checks undertaken on a regular basis to confirm they can safely do so. Previous timescale of 14/07/06 not met. The Controlled Drug cabinet must be fixed to a permanent wall and all CDs stored within. The purchase of a larger trolley to safely store all the medicines is required. All staff must undertake accredited training before they administer and handle medicines. Further training must be sought detailing the general indications and side effects of the medicines they administer. Staff must record how residents are spending their days to evidence their social needs are being met. Previous time scale of 31/07/06 not met. There must be some discussion with the residents to establish the types of in house activities they would like and action taken to ensure the outcomes of the discussions are actioned. Records of the food being served to the residents must be kept in sufficient detail to enable any DS0000004561.V319871.R01.S.doc 7. OP12 12(1)(a) 31/12/06 8. OP15 17(2) schedule 4(13) 31/12/06 The Friendly Inn Version 5.2 Page 31 9. OP18 13(6) person inspecting the records to determine whether the diet is satisfactory in relation to nutrition and otherwise and of any special diets being catered for. All staff must receive training and have knowledge of measures to be taken to adequately protect residents from the risks of abuse. Previous timescales of 31/01/05, 30/04/06 and 31/08/06 not met. 31/01/07 10. OP18 13(6) The adult protection policy for the home must be amended to ensure that staff report any issues to Social Care and Health. Previous time scale of 31/07/06 not met. 01/01/07 11. 12. OP19 OP19 23(2)(b) 23(4)(a) 13. 14. OP20 OP21 23(2)(d) 23(2)(c) The general repairs in the two small kitchen areas must be addressed. Staff must ensure they close the bedrooms doors in the newest part of the home or self closures must be fitted. The carpets and armchairs in the communal areas must be cleaned. All extractor fans in the home must be clean and in working order. Previous time scale of 31/07/06 not met. Fridge and freezer temperatures must be recorded on a daily basis to ensure they are working efficiently. There must be measures put in place to ensure that the kitchen and all equipment is cleaned to satisfactory standard. 31/12/06 31/12/06 14/12/06 31/01/07 16. OP26 13(3) 17/11/06 The Friendly Inn DS0000004561.V319871.R01.S.doc Version 5.2 Page 32 The cleaning schedules in the kitchen must include all equipment. The home received these as immediate requirements. The hard soap and cotton towel must be removed from the staff toilet. Disposable gloves must be available for staff to use in the laundry. A food probe must be purchased for the kitchen and staff must record the core temperatures of foods served to the residents. Foot operated bins must be purchased for use in toilets, bathrooms and sluices. Two written references must be obtained for all staff prior to their commencing their employment. All staff must have appropriate induction training. Care staff must have induction training in line with the specifications laid down by Skills for Care. The registered person must ensure that all staff undertake all the required regulatory training. The registered provider must 14/01/07 ensure an appropriately qualified and experienced manager is appointed for the home. 01/02/07 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 The Friendly Inn DS0000004561.V319871.R01.S.doc Version 5.2 Page 33 17. OP26 13(3) 14/12/06 18. 19. OP26 OP29 13(3) 19 schedule 2(5) 18(1)(a) 31/12/06 14/12/06 20. OP30 31/01/07 21. OP31 8(1) 22. OP33 24 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 timescales of 17/02/04 31/05/06 and01/09/06 not met. 23. OP36 18(2) 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 timescales of 17/02/04 30/04/06 and 31/08/06 not met. 24. OP37 26 The registered provider for the home must visit the home unannounced at least monthly and prepare a report about the conduct of the care. These reports must be made available for inspection. Previous time scale of 31/07/06 not met. There must be evidence on site that all the portable electrical appliances have been checked for safety. Previous time scale of 31/07/06 not met. There must be evidence on site that the water system has been checked for the prevention of legionella. Previous time scale of 30/08/06 not met. A system must be put in place to ensure the fire alarm is checked weekly and the emergency lighting is checked monthly. DS0000004561.V319871.R01.S.doc 01/01/07 31/01/07 25. OP38 23(2)(c) 31/12/06 26. OP38 13(3) 31/01/07 27. OP38 23(4)(c) (v) 17/11/06 The Friendly Inn Version 5.2 Page 34 28 29 OP38 OP38 23(4)(c) (v) 23(2)(c) The home received this as an immediate requirement. The fire risk assessment must be 31/01/07 reviewed. Evidence that the remedial works 31/01/07 identified on the lift service have been carried out must be forwarded to the CSCI. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP8 OP22 OP26 Good Practice Recommendations It is strongly recommended that the resident files are restructured to enable staff to record and track information more easily. It is strongly recommended that consideration is given to fitting handrails along the corridors to further assist those residents with mobility difficulties. It is strongly recommended that when the washing machine is replaced that one with a sluice cycle is purchased. The Friendly Inn DS0000004561.V319871.R01.S.doc Version 5.2 Page 35 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V319871.R01.S.doc Version 5.2 Page 36 - 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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