Inspection on 26/06/06 for The Friendly Inn

This inspection was carried out on 26th June 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 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 Unannounced Inspection 26th June 2006 09:45 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.V294658.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.V294658.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 Mrs Joanne Shaw Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places The Friendly Inn DS0000004561.V294658.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th March 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. 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 fees at the home range from £335.00 to £405.00 per week. The Friendly Inn DS0000004561.V294658.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out by two inspectors over one day in June 2006. During the inspection a tour of the premises was carried out, three resident and four staff files were sampled as well as other care and health and safety records. The inspectors spoke with the manager, two staff members and eight of the twenty-seven residents. Prior to the inspection the manager had forwarded a completed a pre inspection questionnaire to the CSCI which included some details of the staffing and the residents at the home, the policies and procedures available and the maintenance records held. What the service does well: What has improved since the last inspection? There had been further improvements to the care plans in the home which were generally well detailed and informed staff of how to meet the needs of the residents. Tissue viability and nutritional screenings were being undertaken to identify any needs in these areas and corresponding care plans put in place. The care plans were being reviewed monthly and updated as needs changed. The manager had held a meeting for the residents and their relatives/representatives to pass on information about the home and ask for their views on the service. During the course of the meeting an updated The Friendly Inn DS0000004561.V294658.R01.S.doc Version 5.1 Page 6 service user guide was issued to ensure everyone knew what was available in the home and what to expect. Staff recruitment had vastly improved and no staff were being employed without the appropriate checks being undertaken. This ensured the residents were safe guarded. The manager of the home had been registered with the CSCI since the last inspection ensuring there was someone accountable on a day to day basis. 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.V294658.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.V294658.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. There was adequate information available for prospective residents to enable them to make an informed choice about where they lived. The home were aware of the needs of residents prior to admission ensuring the manager could make a decision as to whether the home could meet the identified needs. All residents or their representatives needed to be issued with a contract so that they were aware of the terms and conditions of their stay. EVIDENCE: Three resident files were sampled. There was evidence that all residents had been issued with an updated service users guide and this was available for prospective residents. One of the files sampled was for a resident recently admitted to the home. This evidenced that a comprehensive assessment had been undertaken by a social worker and that staff from the home had also undertaken an assessment prior to admission of the individual. Two of the files sampled included contacts that detailed the terms and conditions of residence at the home. The manager was not sure if the other The Friendly Inn DS0000004561.V294658.R01.S.doc Version 5.1 Page 9 resident had been issued with a contract as the person was admitted prior to her being in post. The Friendly Inn DS0000004561.V294658.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The system for care planning had been further improved but further development was still required to ensure all the residents’ needs were detailed and how these were to be met by staff. Risk assessments needed to be further developed to ensure all the residents’ identified risks were minimised and that staff complied with safe working regulations. The documentation in the home did not evidence that the residents’ health care needs were being met. The medication system was generally well managed and safe. EVIDENCE: Three resident files were sampled and these all included a number of care plans, which had been further developed since the last inspection. The care plans covered areas such as personal hygiene, oral care, health, foot care, hearing, orientation and continence. These were generally well detailed and included what the residents could do for themselves and instructions for staff as to how they were to meet any identified needs. Two of the care plans sampled for personal care needed to be further detailed as they stated ‘assistance needed’ but did not detail the type of assistance. It was also noted The Friendly Inn DS0000004561.V294658.R01.S.doc Version 5.1 Page 11 that none of the files included care plans for social care needs. The care plans were being reviewed on a monthly basis and updated where necessary. There was no evidence that either the resident or their representatives had been involved in drawing them up. All the files sampled included manual handling and falls risk assessments And where any risks had been identified there was a corresponding care plan. The manual handling risk assessments needed to include the actions to be taken by staff in the event of a fall if the resident was not injured. It was also noted that for one resident who had specific handling needs these were not clearly detailed on the manual handling assessment. It was also detailed on the assessment that the individual was now not weight bearing at all however the manager stated the person could weight bear to a certain degree. It was not clear to the inspectors how this person was being transferred or if the methods being used complied with the Manual Handling Regulations. If the individual was not weight bearing then there needed to be a working hoist in situ for the staff to use. The hoist on site at the time of the inspection was not in working order and had been like this for a considerable amount of time. These issues were fully discussed with the manager at the time of the inspection. Clearly one of the residents displayed some challenging behaviours on an ongoing basis. There was a care plan in place for managing the behaviour however this was not adequately detailed. The behaviours varied and staff needed clear guidance as to how they were to manage verbal and physical aggression and how they were protect themselves and the other residents. The resident in question was attending a specialised centre on a weekly basis to have the behaviour assessed and had regular visits from a community psychiatric nurse. All the files sampled included tissue viability and nutritional screenings which had been put in place since the last inspection. The screenings had corresponding care plans that detailed how any identified needs were to be met. There were details of how to maintain good skin condition, specific likes and dislikes in relation to diet and space for any special dietary needs to be detailed. Residents were being weighed on a monthly basis however where there had been any significant weight loss there was no evidence that this had been followed up by staff. It was also noted that staff were unable to weigh one of the residents and it was strongly recommended that the manager discussed with the district nurses other methods of determining if the resident was losing weight. Staff were recording when the residents saw the chiropodist, dentist and optician. Staff were recording some very general comments on the backs of the care plans about the residents but there were no daily recordings about the general wellbeing of the residents. There was a communal handover book which did highlight any concerns staff may have about the general health of The Friendly Inn DS0000004561.V294658.R01.S.doc Version 5.1 Page 12 the residents and a doctors list that was faxed to the doctor on a weekly basis with details of who they were to see and why but these did not always detail the outcome of the visit. Both of these methods of recording were unsatisfactory as it was not possible to track when any issues had been identified and how they presented, what had been done about them and how they were being monitored. Also communal recordings do not comply with the Data Protection Act and do little to respect the confidentiality or privacy of the residents. The manager needed to ensure that there was as a minimum one daily recording about the general well being of the residents and that any professional visits to the residents were recorded individually and included the outcome of the visit. Medication continued to be administered via a monitored dosage system and the system was generally well managed. Some discrepancies were noted in the amounts of tablets available in the home, those received into the home and those that been administered and it was not always possible to identify how this had happened. The manager had been auditing the system and was aware of the issues. One of the residents was self administering some of her medication and there was no evidence that a risk assessment had been undertaken for this. There were controlled drugs being administered and records for these were satisfactory. The home did not have a controlled drug cabinet but the inspectors were informed that this was on order. Staff were not recording the temperatures of the medication fridge which was a requirement at the last inspection. The medication policy had been amended since the last inspection and reflected the current practice in the home. The care plans sampled detailed how the residents’ privacy and dignity were to be maintained. Staff were observed assisting residents to the toilet and bathroom and this was done sensitively. As previously stated the use of communal books for recording details about residents did not respect their privacy. Residents could have keys to their bedrooms if they wished and there were quiet areas in the home where residents could meet with their visitors if they wished. The Friendly Inn DS0000004561.V294658.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. There did not appear to be any rigid rules or routines in the home. There were some activities available in the home but it could not be determined if these met the needs of the residents. All residents spoken with were satisfied with the catering arrangements at the home. EVIDENCE: There did not appear to be any rigid rules or routines in the home. Throughout the course of the inspection residents were seen to wander freely around the home, spend time in their bedrooms, watch television, have their hair done, play bingo or sit chatting with other residents or their visitors. There was some evidence on the residents’ individual activity sheets of them taking part in Easter celebrations, a trip to the Black Country Museum, girl guides visiting the home and a show being put on by the church. There was also evidence on the home’s notice board of visiting entertainers and of a planned trip to Weston. The manager also informed the inspector that ‘Pat pals’ visit the home on a regular basis. The manager informed the inspectors that one resident continued to go out independently and others went out with relatives. One of the residents told the inspectors he had visited the hospital to see his wife. As there were no social care plans for the residents it was difficult to determine if The Friendly Inn DS0000004561.V294658.R01.S.doc Version 5.1 Page 14 their social needs were being met. Also as there were no specific daily recordings there were no details of what the residents did on a daily basis for stimulation. It was noted that one resident had a specific religious need identified on her care plan and this had been met. Visitors were seen to come and go throughout the course of the inspection and appeared to be made welcome. 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. It was noted that at lunch time drinks were poured out ready for the residents giving them no choice of what they had and at tea time cups of tea were poured out and brought into the dining room for the residents. Residents needed to be allowed more autonomy and choice at meal times, for example, enabled to pour their own drinks where possible and what had they had to drink. Residents were encouraged to personalise their rooms to their choosing and evidence of this was seen during the tour of the home. The inspector received copies of the menus for the home prior to the inspection and these were varied and nutritious with choices available. Menus were on the dining room tables for the residents. Residents spoken with were satisfied with the food at the home and records of food served to the residents were being kept. The manager discussed with the inspector that she had tried to introduce a break fast menu but the residents did not want this as the majority wanted the same every day, for example, some had cooked breakfast, others toast and cereals, others kippers and they wanted it to remain this way. The Friendly Inn DS0000004561.V294658.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. There was a complaints procedure at the home and a copy had been issued to the residents or their representatives. To ensure staff were able to identify and report adult protection issues appropriately they needed to undertake training in this area. EVIDENCE: There was evidence on residents’ files and in the minutes of the residents meeting that residents or their representatives had been issued with the complaints procedure for the home. A complaints log was being kept by the home. No complaints had been lodged with the home since the last inspection and none had been lodged with CSCI. There was also evidence in the complaints log that the manager will complain on the behalf of residents about such things as their care in hospital. The manager was aware of her responsibilities in relation to adult protection and had in the past raised a concern with Social Care and Health and POVA. There were policies and procedures on site in relation to adult protection. A slight amendment was needed to these 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 inspection. The Friendly Inn DS0000004561.V294658.R01.S.doc Version 5.1 Page 16 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, 21, 22, 24, 25, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the 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 entirely 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. The most recent inspection by the fire officer had been very favourable with only one requirement being made which had been met. Two general repairs were noted: There was an emergency light hanging from the ceiling on one of the ground floor corridors and there was evidence in the fire book that this had been outstanding for a considerable amount of time and The Friendly Inn DS0000004561.V294658.R01.S.doc Version 5.1 Page 17 an area of the garden had fence posts in place with no fencing, this was outstanding from the last inspection. The home had 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 about giving it a very homely feel. 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 however one of the hoists was not working and this needed to be 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 only used by one resident. It was noted that several of the extractor fans in communal facilities were not working and in need of cleaning. The home had a variety of aids and adaptations available including shaft lift, emergency call system, hand and grab rails and so on. There was a mobile hoist on site but this was not in working order and had not been for a considerable amount of time. This needed to be repaired or removed from the premises. There were several residents using wheelchairs and it was noted that the majority of these did not have footrests fitted. This was dangerous practice and needed to stop unless specifically detailed in an individual’s care plan. 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 water temperatures checked were appropriate. The home was generally clean and odour free and there were systems in place for the disposal of clinical waste. Several bathrooms and toilets had hard soap in them as well as liquid soap and this needed to be removed due to the risk of cross infection. Several items of personal toiletries had been left in the bathrooms after use and needed to be returned to the appropriate residents’ rooms. It was also noted that several COSHH substances were accessible to the residents on trolleys that were being stored in a bedroom and in bathrooms and toilets. COSHH substances needed to be locked away when not in use. The kitchen and laundry were appropriately located and equipped. The Friendly Inn DS0000004561.V294658.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The manager was covering care shifts on a regular basis to ensure staffing numbers were appropriate for the needs of the residents. Staff were receiving training to equip them with the necessary skills for the job. Staff recruitment procedures had improved ensuring residents were not put at risk. EVIDENCE: There had been little staff turnover at the home since the last inspection which was good for the continuity of care of the residents. Residents spoken with were very positive in their comments about the staff. There were adequate numbers of staff on duty throughout the day and night and the home also employed cooks, kitchen assistant and domestic staff. It was noted that the manager was often expected to cover the duties of a care assistant when staff were on annual leave or off sick. The manager’s hours needed to be supernumery to the care rota except in emergency situations. There needed to be appropriate numbers of staff employed in the home to cover for annual leave. Four staff files were sampled two of these being for staff recently employed. It was evident from these that the recruitment procedures at the home had vastly improved since the last inspection. All the required checks had been undertaken on the staff appointed and all the relevant documentation was in The Friendly Inn DS0000004561.V294658.R01.S.doc Version 5.1 Page 19 place. It was strongly recommended that the application form for the home was further developed to ensure applicants could enter a full employment history and that the manager kept records of the interviews undertaken to include any discussions about gaps in employment. There was evidence that staff undertake induction training at the home during which several topics were covered. The manager needed to ensure that the induction training for staff was in line with the specifications laid down by Skills for Care and completed within the first twelve weeks of employment. Staff had also received training in other topics including, manual handling, food hygiene, first aid, fire safety and challenging behaviour. Of the thirteen care staff employed at the home nine had NVQ level 2 or the equivalent which is in excess of the required 50 . The Friendly Inn DS0000004561.V294658.R01.S.doc Version 5.1 Page 20 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, 37, 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The manager had made some improvements to the service but further improvements were required to ensure the safety of the residents. The home needed to have in place a system for monitoring the quality of the service based on seeking the views of the residents. EVIDENCE: The manager of the home had been in post for just over six months at the time of the inspection. She was appropriately qualified for the post and had been registered with the CSCI since the last inspection. She had made several improvements to such things as care plans and the recruitment of staff but further improvements were needed to risk assessments, general recording about the residents, COSHH storage, use of wheelchairs and so on to ensure the safety of the residents. The Friendly Inn DS0000004561.V294658.R01.S.doc Version 5.1 Page 21 There were some systems in place for monitoring the quality of the service offered to the residents including internal audits on medication. In addition a key worker system was being developed and there were staff meetings. The manager had had one meeting with the residents and their relatives/representatives to get their views on the service and resident questionnaires had been completed. Quality monitoring within the home needed to be a more formalised system for ascertaining the residents’ views the results of which needed to be collated and made public on an annual basis. The manager was handling some of the personal allowance for the residents and the records for this were sampled. The records were generally well maintained and included the amounts deposited for residents, records of any expenditure made on their behalf and receipts were available. The manager needed to ensure that where residents could not sign for their own transactions there were two staff signatures and that the hairdresser signed for money received. The manager had started staff supervision sessions however this was a little ad hoc with some staff having had some supervision and others having none. All care staff needed to have a minimum of six supervision sessions per year. 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 residents and staff. There was evidence that staff had received training in safe working practices but it could not be ascertained if they were following manual handling regulations and other areas of practice needed to be improved, for example, the use of wheelchairs and COSHH storage. The in house checks on the fire system were being undertaken, the fire equipment, gas appliances and emergency call system had been serviced. It could not evidence that all the portable electrical appliances in the home had been checked, the bath hoists had not been serviced, there was no evidence that the hard wiring in the home had been inspected as required, this was an outstanding requirement from the previous two inspections, there was no evidence that the water system had been checked for the prevention of legionella and the employers liability insurance certificate on display expired in March 2006. The Friendly Inn DS0000004561.V294658.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 2 2 X 3 3 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 2 2 1 The Friendly Inn DS0000004561.V294658.R01.S.doc Version 5.1 Page 23 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. 2. Standard OP2 OP7 Regulation 5(1)(b) 15(1) 15(2c,d) Requirement All residents must be issued with a contract/terms and conditions of residence. Evidence is required to demonstrate that care plans are drawn up with the involvement of the residents and/or their representative. Previous timescales of 31/07/05 and 07/04/06 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. Manual handling assessments 14/07/06 must clearly detail: • 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. Any handling methods used by staff must comply with the Manual Handling Regulations. The Friendly Inn DS0000004561.V294658.R01.S.doc Version 5.1 Page 24 Timescale for action 31/07/06 01/08/06 3. OP7 13(5) 4. OP7 13(5) 5. OP7 13(4)(c) 6. OP8 12(1) 7. OP8 12(1)(a) (b) The registered provider must ensure that any necessary manual handling equipment is available for staff use. There must be comprehensive strategies in place for staff to follow so that they are able to manage any challenging behaviours. There must be systems in place at the home to ensure that any significant weight loss of the residents is followed up by staff. Daily records must be kept of the general well being of the residents. Records must include any identified health care needs and how these are followed up and monitored. The numbers of tablets in the home must correspond with the amounts that were received and what has been administered. Risk assessments must be undertaken for any residents that self administer medication. The maximum, minimum and current temperatures of the medicines fridge 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. The use of books for communal recording about the residents must cease. Staff must record how residents are spending their days to evidence their social needs are being met. Residents must be allowed more autonomy at meal times. DS0000004561.V294658.R01.S.doc 31/07/06 31/07/06 31/07/06 14/07/06 8. OP9 13(2) 14/07/06 9. 10. OP10 OP12 12(4)(a) & DPAct 12(1)(a) 14/07/06 31/07/06 11. OP14 12(2) 31/07/06 The Friendly Inn Version 5.1 Page 25 12. 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 timescales of 31/01/05 and 30/04/06 not met. The adult protection policy for the home must be amended to ensure that staff report any issues to Social Care and Health. The fencing in the garden must be adequately repaired. Previous time scale of 30/04/06 not met. The emergency light fitting that is hanging from the ceiling must be repaired. The bath hoist in the ground floor bathroom must be repaired. All extractor fans in the home must be clean and in working order. Wheelchairs must not be used without footrests unless specifically detailed in an individual’s care plan. The mobile hoist must be repaired or removed from the home. Hard soap must be removed from all communal bathrooms and toilets. Personal toiletries must be returned to residents’ bedrooms after use. All COSHH substances must be locked away when not in use. Adequate numbers of staff must be employed to ensure the manager does not have to cover care shifts on an ongoing basis. The registered provider must establish a system of reviewing DS0000004561.V294658.R01.S.doc 31/08/06 13. OP18 13(6) 31/07/06 14. OP19 23(2)(o) 31/07/06 15. 16. 17. 18. OP19 OP21 OP21 OP22 23(4)(c) (iv) 23(2)(c) 23(2)(c) 13(4)(c) 11/07/06 11/07/06 31/07/06 29/06/06 19. 20. OP22 OP26 23(2)(c) 13(3)(4) (c) 11/07/06 28/06/06 21. OP27 18(1)(a) 01/09/06 22. OP33 24 01/09/06 Page 26 The Friendly Inn Version 5.1 the quality of care, this must include consultation with residents and their representatives. (Partially met.) 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 timescales of 17/02/04 and 31/05/06 not met. There must be two staff signatures for any financial transactions undertaken on behalf of the residents. The hairdresser must sign for money received from the residents. 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 and 30/04/06 not met. 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. 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 timescales of 31/10/05 and 30/04/06 not met. 23. OP35 17(2) Sch4(9) (a) 31/07/06 24. OP36 18(2) 31/08/06 25. OP37 26 31/07/06 26. OP38 13(4) 11/07/06 The Friendly Inn DS0000004561.V294658.R01.S.doc Version 5.1 Page 27 27. OP38 25(2)(e) 28. 29. OP38 OP38 23(2)(c) 23(2)(c) 30. OP38 13(3) A copy of the current insurance certificate for the home must be forwarded to the CSCI. Evidence of this was forwarded to CSCI prior to this report being published. Evidence must be forwarded to the CSCI that the bath hoists have been serviced. There must be evidence on site that all the portable electrical appliances have been checked for safety. There must be evidence on site that the water system has been checked for the prevention of legionella. 11/07/06 11/07/06 31/07/06 30/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP29 OP29 Good Practice Recommendations It is strongly recommended that the staff application form for the home is further developed to enable applicants to enter a full employment history. It is strongly recommended that records are maintained of staff interviews to include any discussions about gaps in employment. The Friendly Inn DS0000004561.V294658.R01.S.doc Version 5.1 Page 28 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.V294658.R01.S.doc Version 5.1 Page 29 - 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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