Random inspection report
Care homes for older people
Name: Address: The Friendly Inn Gloucester Way Chelmsley Wood Birmingham West Midlands B37 5PE one star adequate service 19/02/2009 The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Lesley Beadsworth Date: 0 9 0 7 2 0 0 9 Information about the care home
Name of care home: Address: The Friendly Inn Gloucester Way Chelmsley Wood Birmingham West Midlands B37 5PE 01217795128 Telephone number: Fax number: Email address: Provider web address: TheFriendlyInnCH@aol.com Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Mr Michael John Goss care home 30 Number of places (if applicable): Under 65 Over 65 30 old age, not falling within any other category Conditions of registration: 0 The maximum number of service users who can be accommodated is: 30 The registered person may provide the following category of service only: Care Home Only (Code PC); To service users of the following gender: Either; Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) 30 Date of last inspection Brief description of the care home The Friendly Inn Care Home is a converted public house. There have been several major extensions to the home over a number of years. The owner is currenly in the process of upgrading the property with a new entrance along with other improvements and a new kitchen ato be fitted. The home is registered to accept up to 30 residents in the category of old age requiring personal care.
Care Homes for Older People Page 2 of 12 1 9 0 2 2 0 0 9 Brief description of the care home Accommodation is provided over two floors. The home has 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 a well-maintained garden area at the front and 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 weekly fees for living in the home were not discussed at this inspection. Additional items such as the services of a hairdresser, newspapers and toiletries are paid for separately. Care Homes for Older People Page 3 of 12 What we found:
This Random and unannounced inspection was carried out by one inspector in response to concerns about the health and safety at the home following a safeguarding referral and subsequent meetings. The visit was over two days, 6th July 2009 and 9th July 2009, to enable time to be spent with the manager who had been called away during the first day. The owner of the home and the deputy manager assisted with the inspection throughout the first day and the manager and the deputy during the second day. The inspection included a visit to The Friendly Inn, the inspection of records and documents related to residents and staff, a random selection of mobility aid equipment, some policies and procedures and discussion with the manager and staff regarding safeguarding and health and safety. The front of the home has car parking spaces and a rockery and other shrubs, and the addition of a newly built porch, make the entrance attractive and welcoming. A tour of the home with the deputy manager showed that there were many improvements either completed recently or in the process of being completed. These included several bedrooms and their ensuite facilities, and a walk in shower being refurbished to a high standard and with top quality fittings. The managers office had also been extended and refurbished and offered excellent office facilities. The communal and private areas of the home offered residents comfortable and attractive accommodation and outdoor space that was well maintained and provided appropriate seating for the people living at the home to enjoy sitting outdoors. A new kitchen was planned for the immediate future and the manager was making plans for catering during the building work. Residents sitting in the lounge were well groomed and appropriately dressed. They appeared content and alert. Several relatives or friends visited and a friendly and welcoming banter was witnessed between them and the owner and staff of the home. There had been some concerns raised previously that thermostats were inaccessible to residents. However the home owner was able to explain that the thermostats were guarded to prevent inappropriate changes being made to the level of heat in the home. Underfloor and inner wall central heating provides a good level of heating throughout the home, but the owner said that it can take two or three hours to get back to this heat if it is inadvertently turned down. Staff have easy access to the thermostats for residents if they need to increase or decrease the heat. Staff Files were looked at to assess the recruitment practices of the home and whether these safeguard the residents from the appointment of unsuitable employees. We found that several files of staff employed several years ago were without the appropriate Criminal Records Bureau (CRB) disclosures or Protection of Vulnerable Adult (POVA) register checks at the time of their appointment, although they had been received afterwards and mostly within a short time of the person beginning their employment. Staff files looked at belonging to more recently appointed staff had these checks in place at the beginning of their employment but two had only one reference, rather than the two written references required; one person had two references from from colleagues and none from an employer; another person had only one reference and this from a very short term employer; one person had no references although these and the paperwork of
Care Homes for Older People Page 4 of 12 another employee were said to be at the owners office. The references that were available showed no evidence that they had been validated and there was no evidence that any gaps in employment history had been checked. This is good practice to further safeguard residents from the employment of unsuitable people. We were made aware that the cook working that day was a voluntary worker. Rotas showed that they had been working several days a week in the kitchen and also, we were told, spends time in the lounge chatting to the residents. There was no paperwork related to her voluntary work in the home including POVA checks and CRB disclosures, references or evidence of interview. The deputy manager was told that the person must not work in the home until these checks were in place. On our second visit the manager told us that the person was now not working at the home until a POVA check/CRB disclosure was receive. This was being applied for. The files looked at showed us that staff misconduct/gross misconduct had not always been managed in a way that safeguarded the people living at the home. The owner and the manager said that action taken was to give the staff the benefit of the doubt and in order to protect their future careers in care. The recorded outcome in the persons staff file further confirmed this. One care file was looked at. The care plan was appropriate and appeared to be up to date. Daily records reflected the care plans but could have been in more detail. Whilst they recorded the meals, and amount, taken by that person they did record what action was taken when meals had been refused. Nor did they record any fluids taken. An incident that occurred between a member of staff and a resident earlier in the year should have been seen as verbal abuse but this was not managed by the home as a safeguarding referral. Discussion with the manager showed that she was now aware that this should have been referred. She was also able to show that she had awareness of safeguarding and when referrals should be made, having undertaken the relevant training. There had been no further safeguarding training since the previous inspection but this was planned for later in the year for all staff, after which they should be able to safeguard the people living at the home by being able to identify, and understand what is abuse and what to do if they suspect or witness any form of it. Fire awareness training had been undertaken by the majority of the staff in the previous month and further training related to safe working practices had been planned. The home did not have a policy or a procedure that informed the management of the steps to take if a CRB disclosure showed a criminal record. At the first visit there was no information to show that the appointment of an applicant with a criminal record is a considered and informed decision. However on the second visit and after discussion with the manager this had been addressed. During a tour of the home on the first day it was noted that a walking frame had ferrules (rubber stops at the feet of the frame) that were worn and were quite thin, although not worn through completely. The owner and the deputy manager advised us that these had been replaced two weeks previously. On the second day the manager showed us a chart for monitoring of mobility equipment that she has now implemented in order that equipment is maintained to minimise risk of falls or injury due to this equipment and told us that ferrules would show the date they were changed in future. The files of new staff included Skills for Care induction paperwork but this had not yet
Care Homes for Older People Page 5 of 12 begun to be completed. The manager told us that she will use this with all new staff and also with recently appointed staff that have not completed a National Vocational Qualification since their appointment. This should give them the knowledge and skills they need to carry out their job effectively. The manager is familiar with standards of care but needs to gain more knowledge and skills regarding the National Minimum Standards and Health and Safety regulations. She is currently undertaking the Registered Managers Award (RMA) and plans to bring forward Health and Safety training, booked for September, for herself and the deputy manager in order to further this. Staff spoken with said that they felt supported by her. Confidential files of staff and residents had recently been relocated to alternative secure facilities as the manager and owner were concerned that the previous location had been accessed by unauthorised persons. The files were secure at our visit, protecting the confidentiality of residents and staff. There was evidence that the manager had sought professional advice regarding a resident having frequent falls. Records and discussion showed that a resident had been referred to the GP and subsequently referred to the Falls Clinic. Following the safeguarding referral the manager had implemented the procedure of the night staff using the call bell in each bedroom they entered in order to monitor their observations of residents. Each call is recorded on the alarm system print out. However this could be disruptive and disturbing to residents. The home does not have any equipment for alerting staff that someone at risk of falling has got out of bed. There are a number of different devices that do not impinge on the dignity of the person and are not forms of restraint. What the care home does well:
The home provides attractive, well maintained accommodation, which is decorated, furnished and fitted out to a high standard. Improvements to the environment are on going with plans for a new kitchen in the immediate future. Residents in the lounge looked well groomed, were appropriately dressed and appeared content. Visitors were made welcome and there was comfortable interaction between them and people working at the home. The owner, the manager and the deputy manager showed that they were anxious to meet the National Minimum Standards and to further their knowledge and skills in order to move the home forward in safeguarding the people living at the home and meeting their needs. Several of the concerns identified at the first visit had been addressed by the second visit. The home had devised a monitoring chart to ensure that equipment was maintained in a satisfactory and safe condition and and there were plans for Health and safety training to be brought forward in order that management would have the knowledge required to make the home safer place to live and work. The home had gained the advice of the Falls Clinic in relation to a resident who had sustained frequent falls so that the cause of the falls could be identified and minimised. When suspecting that confidential information had been accessed by unauthorised people
Care Homes for Older People Page 6 of 12 alternative and more secure facilities were provided and used. The majority of staff have undertaken Fire Awareness training. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 7 of 12 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 8 of 12 Requirements and recommendations from this inspection:
Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours.
No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action 1 18 13 Any suspicion or allegation of 31/07/2009 abuse must be managed appropriately and in accordance with the local authoritys safeguarding procedure. This will safeguard people living at the home. 2 18 13 Poor staff practice must be managed in a way that safeguards residents. This protects residents from the risk of abuse and poor care. 24/07/2009 3 29 29 The required recruitment documentation must be available in the home for all employees and volunteers. This will ensure that they are available for inspection in order to protect people living at the home. 24/07/2009 4 29 19 The recruitment practices at the home must be sufficiently robust and 31/07/2009 Care Homes for Older People Page 9 of 12 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action thorough. This will protect residents by minimising the risk of the employment of unsuitable people. 5 30 18 The plans for induction 25/09/2009 training for new and recently appointed staff must proceed promptly. This will give them the skills and knowledge to provide people living at the home with the proper care and support. 6 38 13 The plans for all staff to 31/08/2009 undertake training related to safe working practices and safeguarding of vulnerable adults must proceed promptly. This will assist the home to be a safe place to live and work. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No Refer to Standard Good Practice Recommendations 1 22 The home should investigate the equipment available to alert staff when someone at risk of falling has got out of bed in order to reduce the risk of unobserved falls. The home should implement a policy that informs of the process if a prospective employee or volunteer has a criminal record. 2 29 Care Homes for Older People Page 10 of 12 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No Refer to Standard Good Practice Recommendations 3 31 The manager should ensure that she completes the Registered Managers Award as promptly as is practicable and develops her knowledge of the Standards and Regulations that relate to her role. Care Homes for Older People Page 11 of 12 Reader Information
Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 12 of 12 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
