Care Home: Frenchay House

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What the care home does well Those living in the home who were spoken to said that the staff are kind and caring. Staff were observed to treat people with respect, to respond to them appropriately and to have a good rapport with them. Relatives said that they were happy with the care that they were kept informed, their concerns are listened to and acted upon and any questions they might have answered readily. Friends and relatives can visit at any reasonable time and those spoken to said they are always made welcome. Everyone asked said that the food was good and the meals seen during the inspection looked and smelled appetising. Information contained within individual staff files were all of a consistent standard. The files for three staff were reviewed; including a recently recruited staff member. All of the required documentation was in place in respect of robust recruitment and selection practices. It was found that all of the checks and records required under Schedule 2 of the Regulations had been complied with; including two references being taken up, a Criminal Record Bureau check and clearance from the register of people deemed unsuitable to work with vulnerable adults had been checked before the staff started working at the home. Frenchay House provides people with a pleasant and comfortable environment in which to live. The home is well equipped to provide the care required. Many improvements have been made to the environment since our last visit including redecoration, a new bathroom and re location of the hairdressing room. What has improved since the last inspection? This was the services first inspection. What the care home could do better: Clear contractual arrangements are in place for most people living at the home, however, the home must ensure that people living in the home prior to the new ownership must also have contracts in place. Care plans are in place and improvements within the recording of these was noted by us, however, care plans must fully reflect the complex emotional needs, and support that is provided for the individual identified during our visit who lives at the home. We saw that generally there were good arrangements in place for the disposal of medication that is no longer required and that stock held medication is alsoFrenchay HouseDS0000073145.V376491.R01.S.doc Version 5.2 well managed and clearly recorded, however, we found that for four residents medication given had not been signed for, this included eye drops we also found one controlled item of medication which had only been signed for by one member of staff, instead of two. Recording in this area must be improved upon to ensure the safety of residents and to evidence clear auditing processes We reviewed peoples `end of life wishes`, we saw that for two of the four people we checked only two people had their views and wishes recorded, whilst this is a difficult subject to broach, however, it is an important area, it is recommended that the home obtain this sensitive information to ensure that peoples wishes and preferences are recorded and known. Key inspection report CARE HOMES FOR OLDER PEOPLE Frenchay House Beckspool Road Frenchay Common Frenchay South Glos BS16 1NE Lead Inspector Odette Coveney Key Unannounced Inspection 16th July 2009 09:00 DS0000073145.V376491.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought 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. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Frenchay House DS0000073145.V376491.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) 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. www.cqc.org.uk Internet address Frenchay House DS0000073145.V376491.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Frenchay House Address Beckspool Road Frenchay Common Frenchay South Glos BS16 1NE 0117 9567611 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) www.AbleCare-homes.co.uk Willcox Bros Ltd t/a Ablecare Homes Mrs Jacqueline Woodman Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Frenchay House DS0000073145.V376491.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category (Code OP) The maximum number of service users who can be accommodated is 30 First Inspection of this service Date of last inspection Brief Description of the Service: Frenchay House is located in the rural area of Frenchay, close to Frenchay Common, in South Gloucestershire. Frenchay House is a period property with attractive gardens to the front of the house. The accommodation within the home is unique in that the people who live at Frenchay House have ‘suites’, these usually comprise of a lounge, bedroom, bathroom and small kitchen area. Communal areas such as the lounge and dining area are well furnished; these areas are comfortable and provide a pleasant area in which to socialise. Bathroom facilities, individual’s suites and communal facilities have improved with refurbishments that have taken place at the home since the new ownership. Fees charged at the home range from £530 - £680 per week, this is dependent on individuals assessed needs and level of care support required. Frenchay House DS0000073145.V376491.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience Good quality outcomes. This was an unannounced visit as part of the key inspection process. The service was taken over by AbleCare Homes in January 2009 and this was the first key inspection of this service. Due to their being new providers of the service there have been changes within the management structure at the home. There is a new registered manager and two deputy managers, the directors of the company play an active role in monitoring the services provided at Frenchay House and ensuring effective delivery. The provider has kept the Commission informed throughout the process. The registered manager was on duty on both days of the visit and was informative and demonstrated a sound understanding of her role. The Commission for Social Care Inspection, now known as The Care Quality Commission have received no complaints about the service. The focus of this inspection visit was on the general care of a sample group of people who use the service and the environment, including a general tour of the premises and a review of staffing records such as recruitment, selection and training. Some surveys were received by us prior to our visiting the home, these were received from people who live and work at the home and relatives of people living at Frenchay House, feedback was positive and comments have been included within the main section of this report. The home has been sending information in respect of regulation 37 notices of events affecting the well being of the people who use the service. These have evidenced tat the home has responded to and managed incidents well. Ensuring the safety and protection of people living at the home. The manager and director completed an Annual Quality Assurance Assessment in June 2009, this was well written and sufficiently detailed, this visit by us confirmed information provided within the report. The inspection was conducted over two days and took 9.45 hours. Frenchay House DS0000073145.V376491.R01.S.doc Version 5.2 Page 6 What the service does well: Those living in the home who were spoken to said that the staff are kind and caring. Staff were observed to treat people with respect, to respond to them appropriately and to have a good rapport with them. Relatives said that they were happy with the care that they were kept informed, their concerns are listened to and acted upon and any questions they might have answered readily. Friends and relatives can visit at any reasonable time and those spoken to said they are always made welcome. Everyone asked said that the food was good and the meals seen during the inspection looked and smelled appetising. Information contained within individual staff files were all of a consistent standard. The files for three staff were reviewed; including a recently recruited staff member. All of the required documentation was in place in respect of robust recruitment and selection practices. It was found that all of the checks and records required under Schedule 2 of the Regulations had been complied with; including two references being taken up, a Criminal Record Bureau check and clearance from the register of people deemed unsuitable to work with vulnerable adults had been checked before the staff started working at the home. Frenchay House provides people with a pleasant and comfortable environment in which to live. The home is well equipped to provide the care required. Many improvements have been made to the environment since our last visit including redecoration, a new bathroom and re location of the hairdressing room. What has improved since the last inspection? What they could do better: Clear contractual arrangements are in place for most people living at the home, however, the home must ensure that people living in the home prior to the new ownership must also have contracts in place. Care plans are in place and improvements within the recording of these was noted by us, however, care plans must fully reflect the complex emotional needs, and support that is provided for the individual identified during our visit who lives at the home. We saw that generally there were good arrangements in place for the disposal of medication that is no longer required and that stock held medication is also Frenchay House DS0000073145.V376491.R01.S.doc Version 5.2 Page 7 well managed and clearly recorded, however, we found that for four residents medication given had not been signed for, this included eye drops we also found one controlled item of medication which had only been signed for by one member of staff, instead of two. Recording in this area must be improved upon to ensure the safety of residents and to evidence clear auditing processes We reviewed peoples ‘end of life wishes’, we saw that for two of the four people we checked only two people had their views and wishes recorded, whilst this is a difficult subject to broach, however, it is an important area, it is recommended that the home obtain this sensitive information to ensure that peoples wishes and preferences are recorded and known. 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 on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Frenchay House DS0000073145.V376491.R01.S.doc Version 5.2 Page 8 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 Frenchay House DS0000073145.V376491.R01.S.doc Version 5.2 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 6. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home’s admission process ensures that people are fully informed and their needs fully understood before they are admitted. Clear contractual arrangements are in place for most people living at the home, however, the home must ensure that people living in the home prior to the new ownership also have contracts in place. EVIDENCE: The home has a comprehensive statement of purpose in place. This and the services users’ guide have been produced by the new providers of the service; all who live at the home have been given an updated copy of the service user’s guide for their information. The information within this document was comprehensive and contained clear information for residents and their relatives about the services and facilities provided at the home and furthermore Frenchay House DS0000073145.V376491.R01.S.doc Version 5.2 Page 10 contained information about the staff and the management arrangements at the home, there was also information about the admissions process into the home and how to raise issues of concern and how these would be responded to. There is a clear process to ensure that the service is able to meet the assessed care needs of prospective people moving to the home. There is an admission procedure, which is included in the statement of purpose and full assessments of needs were undertaken. We spoke to people who had recently moved into the home, they told us they were ‘well settled’ and ‘a good move for me, I am happy and safe here’. People are able to visit the home and spend time their prior to deciding if they wish to move into the home. When people move into the home they are able to have a trial period of up to four weeks (this can be extended in some circumstances) in order to decide whether to make Frenchay House their home. The home completed an Annual Quality Assurance Assessment (AQAA) of their service in June 2009, within this the home informed us of their plans for improvement over the forthcoming 12 months, which are:‘The implementation of the Mental Capacity Act means that our pre-admission assessment is now more detailed. We realise that this is still a new area for staff to understand and further training and adjustment of our documents may be necessary as we learn to work within the Act. (Although we do believe that we already work within and support the overall ethos of the Act.)’. At this visit we spoke with the manager about the pre admission processess and reviewed this for one of the people who had recently been admitted into the home. Clear contractual arrangements are in place for most people living at the home, however, the home must ensure that people living in the home prior to the new ownership must have contracts in place. Of four people whose contracts we checked only two were in place, these were for people who had been admitted into the home since the new ownership. Contracts should be in place for in order to ensure equity and clear information about the terms and conditions of the placement. Contracts for people living at the home have been seen by us previously and the manager was unable to locate these for the two individuals concerned. Intermediate care is not provided at this home. Frenchay House DS0000073145.V376491.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individual’s personal and health care needs are well recorded, one persons care plan requires further detail, however other care plans were well detailed and are kept under review. With these care plans we could see the areas of individuals care support needs being met. Medication procedures are in place and staff have received training in this area, however, improvements must be made to the recording of medication administered on a daily basis to ensure that errors are not made. EVIDENCE: Six people told us they always receive the care and support they need and two told us they usually do. Comments included: “Excellent care” and “No complaints here. Care and support is superb”. All who we spoke with told us they always receive the care and medical support they need. Frenchay House DS0000073145.V376491.R01.S.doc Version 5.2 Page 12 We looked at a number of care records. The care files reviewed by us during this site visit showed evidence of pre-admission assessments to enable staff to develop personalised care plans for residents and record how the needs were to be met. The home has adopted a new system for recording care information; staff told us they are still getting used to it, but had found them to be better than previously. We found that on the whole care plans were detailed and informative and a reflection of the person’s needs. We did note that one person had some complex mental health issues and the home had contacted health professionals and had sought specialist advice in order to ensure that this persons needs, (on an emotional level), were being fully understood and that consistent appropriate support has been given. Staff we spoke with had a good understanding of the complexities of this person’s care; however this individual’s care plan did not fully reflect this. For this individual the home must ensure that the care plan is detailed and demonstrates the level of support given, ensuring that all needs are assessed and are not left unmet. We noted that of the plans we looked at, with the exception of one individual, care plans are reviewed and updated as necessary and take into account sudden changes in needs, such as a chest infection. Staff should therefore usually have the written information they need available to them. Staff confirmed that there is also a verbal hand over of information between them. We found the standard of personal care delivered was extremely high and people were helped to be individual in the way they present – staff go the ‘extra mile’. There are good arrangements for access to health services including dental, optician and chiropody. We saw that the home maintain primary care records and this showed us that people access a wide range of health and emotional care support service. The community district nursing service also provides a service to the home to support those individuals who require regular support with wound dressings. Records were kept of the appointments that people had with their GPs and other healthcare professionals. Records had been completed after each appointment, which provided a good report of the outcome and any action that needed to be taken as a result. Since our last visit the home have reviewed how medication is recorded, administered and stored at the home. Since our last visit a new medication cabinet has been installed and relocated and a new pharmacist supplies medication to the home. We also saw in training records and confirmation from staff that they are in the process of completing a distance learning pack in respect of medication administration and competencies. We reviewed a number of residents medication. We saw that there were good arrangements in place for the disposal of medication that is no longer required and that stock held medication is also well managed and clearly recorded, however, we found Frenchay House DS0000073145.V376491.R01.S.doc Version 5.2 Page 13 that for four residents medication given had not been signed for, this included eye drops and also that one controlled medication which had only been signed for by one member of staff, recording in this area must be improved upon to ensure the safety of residents and to evidence clear auditing processes. People are treated with dignity and respect at Frenchay House. We were told this and observed it repeatedly throughout the two visits. Where people required assistance with their care this was offered discreetly. Each person is able to lock their door to their suite for privacy should they wish. We reviewed peoples ‘end of life wishes’, we saw that for two of the four people we checked only two people had their views and wishes recorded, whilst this is a difficult subject to broach is it an important area, it is recommended that the home obtain this sensitive information to ensure that peoples wishes and preferences are recorded and known. Staff observed caring for people seemed to have a genuine rapport with them. Those living in the home spoken to during the inspection said that the staff are kind and helpful. Visitors said that they were happy with the care provided and that they were kept informed of any changes in their relative’s condition. They also said that they felt able to ask questions and that these were readily answered. Frenchay House DS0000073145.V376491.R01.S.doc Version 5.2 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home offers a suitable range of activities and entertainments to stimulate and occupy people. Links with visitors and the community are good, giving opportunities to support and enrich people’s social life. Meals provide nutritious variety and choice for individuals. EVIDENCE: Discussion with staff and those who live at Frenchay house evidenced that the home supports residents to maintain contact with friends and family and the local community. One resident spoken with stated, “My daughter visits when she can and my family comes to see me regularly and are always made welcome by the staff”. People spoken with confirmed that they have a choice of when to get up and retire. One person who lives at the home stated, “The staff are so good at making you feel at home”. Frenchay House DS0000073145.V376491.R01.S.doc Version 5.2 Page 15 During lunch people were seen enjoying their meal in the dining room, other people were supported to have their meal in their rooms, as per their choice. People living in the home and visitors praised the standard of the meals. Lunch was seen on both days of the inspection and the meals looked and smelled appetising. The menus for the home were updated in January 2009 and we saw in minutes of residents meetings that they are consulted about meal choices and adjustments to the menus are made as requested. We saw that the home had recorded within individuals records peoples likes, dislikes and special dietary requirements, we spoke to the chef, she was fully conversant with the needs and wishes of the people who live at the home and was able to demonstrate a sound understanding of her job role and responsibilities in line with food hygiene, infection control and health and safety legislation. People living at the home told us they enjoyed the entertainment provided at the home and in particular enjoyed it when they played tabletop skittles and went for trips in the local community. People confirmed they are able to participate, or not, in activities as per their choice. The home have held a number of social events including Easter and St Georges day celebrations. A notice board displaying recent photographs of social events showed people enjoying themselves and having a good time. We saw that the home were planning for a garden party the forthcoming weekend, preparations were well in hand and responses to the invitations were positive with a good response received, residents told us that they were looking forward to the party and told us that their relatives were always made welcome by staff at the home. Communion is given at the home by visiting local clergy and there are varied places of worship and church clubs within walking distance of the home During our visit people were seen enjoying a daily newspaper, local news and magazines had been delivered. People were seen listening to music of their choice, watching television and enjoying conversations with each other. We saw within minutes of residents meetings and records of visits completed by the registered provider that they are consulted about life at the home and people living at the home confirmed to us that ideas and suggestions made by them had been listened to and acted upon. Frenchay House DS0000073145.V376491.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People at the home are protected by the accessibility of the staff and providers and the home’s policies and procedures. EVIDENCE: There is a complaints procedure displayed in the entrance hall and within the guide about services and is well written within the homes statement of purpose. The home also has a clear policy in respect of how to raise issues of concern and this had been discussed with people who live at the home, when the new providers took over the home all were sent a copy of the homes complaint/compliment/suggestion leaflet. The complaints policy and procedure shows a clear timeline and action to be taken in event of a complaint and the format can be amended in order to be produced in a larger format for those with sight difficulties. It also directs the complainant to the CSCI (now the Care Quality Commission) and South Gloucestershire Social Services. A copy is made available to residents and relatives should they request it. The Commission has not received any complaints about the home. It was clear from observation that people who use the service and their family/visitors felt comfortable discussing issues with the staff and managers. The record of concerns and complaints showed that there had been no entries. Frenchay House DS0000073145.V376491.R01.S.doc Version 5.2 Page 17 When this was discussed we were told that any issues raised were dealt with promptly and did not lead to a complaint. Each of the six people we spoke with said they know who to speak to if they are not happy and how to make a complaint, one adding: “Never had occasion to do so”. The home’s policy and procedures for safeguarding adults from abuse is readily available to staff. Staff told us they have received training in the safeguarding of vulnerable adults and were able to describe the types of abuse and what steps they should take if they had concerns. Records of recently employed staff members were viewed and contained personal information and record of identity. Other information seen included, record of previous employment, two references and satisfactory Criminal Record Bureau disclosures. Frenchay House DS0000073145.V376491.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from a home that is extremely clean, fresh, well maintained, full of character and contained all necessary equipment to meet people’s needs. EVIDENCE: Frenchay House is one of six homes owned and managed by AbleCare Homes. Frenchay House was taken over by the current owners in January 2009. Frenchay House is a period property set within the rural setting of Frenchay, within close walking distance to Frenchay Common. The home itself is set within attractive gardens, these are well maintained and we noted that new garden furniture and parasols have been purchased in order that residents can enjoy the garden. The home has its own mini bus and the home provides outings and trips to the local community and places of interest. Frenchay House DS0000073145.V376491.R01.S.doc Version 5.2 Page 19 The home has an impressive main entrance hall and staircase. The Main lounge is close to the main dining room and is furnished comfortably; we saw a number of people sat enjoying the company of others in this area. Since our last visit the hairdressing room has been moved downstairs and is a more attractive area for residents to use. We visited some shared areas of the home, the kitchen, bathrooms and some bedroom suites. For both visits the home was fresh and cleanliness was of a very high standard. This included areas unseen by visitors: bathrooms, toilet areas and kitchen. Bedrooms/suites were very personalised and homely and each person is able to have a key to their suite so that it could be locked when leaving if they wished. Those living in the home had been encouraged to bring with them personal items such as furniture, ornaments and photographs and these were evident during a tour of the home and visits to bedrooms. Each room also has lockable facilities for valuables. The home is well equipped with specialist items such as pressure relieving mattresses and cushions, hoists and height adjustable beds. Bathrooms also have facilities to make assistance with bathing or showering as easy as possible. It should also be noted that since our last visit a new bathroom suite with a bath/chair hoist has been installed, in order to support those with limited and mobility difficulties. Efforts have been made to ensure that the environment is as safe as possible. Fire precautions are in place and all fire regulations are complied with, water temperatures are controlled, there are hand washing facilities in every bedroom and elsewhere in the home and a shaft lift to provide safe access to the first floor. Infection control policies and procedures are in place. Frenchay House DS0000073145.V376491.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home ensures that all staff have been employed following robust recruitment and selection processes. Staff are trained to support older people, and core skills have been undertaken by staff. EVIDENCE: The home maintains a core of staff that have worked there for many years providing consistency and experience. During the visit the manager and staff were able to demonstrate a clear understanding and knowledge of the individuals who use the service, and of their role in the home. Asked if staff are available when needed five people told us they always are and two said they usually are. One told us: “The staff are always available, courteous and responsive to the needs of residents and their families. Kitchen staff are exceptionally kind also”. Another said: “Staff work very, very hard and generally answer (call bell) as soon as possible”. The manager was able to demonstrate that she and the staff team have developed good relationships with those who live at the home and have a Frenchay House DS0000073145.V376491.R01.S.doc Version 5.2 Page 21 sound understanding of their needs, wishes and aspirations. These are well recorded in individual’s records A sample of staff files were viewed and all of the required documentation was in place in respect of recruitment and selection practices and it was found that these were robust. Records of formalised one to one supervision support sessions were seen, these evidence that staff are given appropriate information and advice and are supported by the management team within their role. Whilst at the home we reviewed the homes training records of staff training which had been completed between January 2009 and June 2009. We saw that staff had undertaken training in areas such as first aid (2), manual handling (15), managing medication (7), mental capacity act (6), deprivation of liberty safeguards (4), record keeping (3), continence and bowel care (1), dementia and challenging behaviour (5), also a number of staff have completed an induction training package with the home in order that that they have an awareness and understanding of the homes expectations in line with company policy and procedures. Surveys completed by staff and returned to us prior to our visit spoke favourably of the new proprietors and the management arrangements at the home, staff reported: ‘Since taking over I feel everyone is more relaxed and its really going from home to home, residents smile more and we have many more social activities for the residents’, ‘I am very happy I enjoy the training and feel well supported by the management team’. Surveys completed by residents and relatives of people who live at the home included: ‘The staff are always polite and helpful and treat people as an individual’, ‘it is a lovely place to live, am very happy with my care’. Frenchay House DS0000073145.V376491.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37, 38. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is run in the best interests of the residents. The home is well managed ensuring that individual’s interests and rights are promoted and protected by a committed staff and management team. EVIDENCE: AbleCare Homes Ltd is a family run company that was set up in 1983 with its first home, Belvedere Lodge. Belvedere Lodge was purchased as a family home and it was converted by the family. It opened for business in 1984. This was followed by Rosewood House in 1990, an existing home with a purpose built courtyard wing. Patron House is the smallest of AbleCare Homes Frenchay House DS0000073145.V376491.R01.S.doc Version 5.2 Page 23 and has been part of the group since 1997. In 1998 Crossley House was added and has since been expanded to make full use of the facilities available. In 2007 the business expanded again to include Hengrove Lodge and in January 2009 Frenchay House joined the group. The emphasis of Ablecare Homes is on family involvement and this has continued as the business has evolved. The company is owned and Managed by Father and Daughter team, John Willcox and Sam Hawker. Sam Hawker is responsible for business development and keeps track of current legislation and its implementation in the homes. The Registered manager of Frenchay House is Mrs J Woodman. Mrs Woodman is experienced, appropriately qualified and committed to improving the quality of life for the people who live at the home. People living in the home spoke positively of the care provided. Practice observed was of good relationships between those who live at the home, staff and management. Within the homes statement of purpose they have recorded that Mrs Woodman has 28 years experience in working in the Care Sector. Experience in residential and domiciliary care of the elderly. Mrs Woodman has worked in and managed homes for Residents with Alzheimer’s disease and Dementia as well as working in both Residential and Community Care settings for people with mental health needs. Mrs Woodman has worked for AbleCare Homes since 1995 in the role of Deputy Manager and Registered Manager. Completed NVQ 2 in care and the NVQ 4 Registered Managers Award. Qualified as a Manual Handling Trainer and an NVQ Assessor. Mrs Woodman fully engaged with us during this visit and was able to locate most of the necessary information and documents easily. This shows that the home has good systems in place and is well run. In respect of senior management within the organisation within the homes completed AQAA they informed us that: one of the company directors has completed NVQ level 5 in management. She also continues to keep up to date with professional training and attends relevant seminars and conferences. She has developed a strong network of professional contacts within the care industry including solicitors, accountants, bankers, agents and training providers. This helps the company be able to gain access to relevant advice and support from suitable people. She is a member of the committee for Care and Support West as part of an overall ethos and commitment to the improvement of Social Care within the region. The director is a Dignity Champion and she recently set up a speaker at a Care & Support West general meeting to inform the membership about Dignity in Care. We also spoke with care staff and a senior member of staff we talked to spoke about treating people with dignity and respect and about valuing people as adults. Staff members we spoke with had a sound understanding of the diverse needs and wishes of people living at Frenchay House and spoke of people as Frenchay House DS0000073145.V376491.R01.S.doc Version 5.2 Page 24 ‘individuals’. The manager and staff members gave a number of examples to us to show how people are given reassurance, guidance and comfort and how this impacted on people’s quality of life at the home. The home has good systems for monitoring the quality of the care provided to the individuals living at Frenchay House these included regular reviews of care plans, review meetings where the individual was involved, supervisions and staff meetings. There are also no complaints recorded for this service. Prior to the site visit the Commission received from the registered provider a completed annual quality assurance assessment. The AQAA is in two parts: Part one is a self-assessment, part two is a dataset. It is a legal requirement for all services to return an AQAA to the Commission. The document received from the registered was sufficiently detailed. Within the AQAA, completed by the providers prior to the inspection they had reported that: ‘Frenchay House is a well run home providing excellent care to our residents. There is a stable staff team who are committed to the care of each individual. Our service offers a cost effective, anti-discriminatory environment in which to live. Care is provided by trained staff who promote service users comfort, safety and dignity. We work on a person centered approach where the resident is actively encouraged to make choices and their family and advocates are involved. Residents comment how caring staff are and how nothing is too much trouble. Staff work very hard to ensure that residents are happy’ Staff files also contained evidence of supervision and positive comments were noted in the feedback to staff. Frequency of supervision was generally good and staff had received the required sessions. Areas of discussion included guidelines and policies of the home, individual’s expectations and an evaluation of their performance and how this can be developed. Staff spoken with said that they are positive that the management team are committed to ensuring the needs of service users are met, that ideas and suggestion are listened to with regular individual supervision being held for continuity of care and effective communication. There was evidence that the home ensures so far as is reasonably practicable. The health and safety of resident’s staff and visitors. The home has robust policies and procedures in relation to aspect of health and safety. The home have manual handling assessments in place and these outline information about the support needed by those who live at the home and gave an indication of their level of risk and support required in this area. The fire logbook was viewed and was well maintained. The home was completing the appropriate checks on the fire equipments and recording of training and testing of equipments were satisfactory. Staff have attended fire Frenchay House DS0000073145.V376491.R01.S.doc Version 5.2 Page 25 drills to ensure that they have clear knowledge of action to be taken in the event of fire emergency. Frenchay House DS0000073145.V376491.R01.S.doc Version 5.2 Page 26 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 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 Frenchay House DS0000073145.V376491.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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 OP9 2 OP7 15 Standard Regulation 13 (2) Requirement Timescale for action 16/07/09 3 OP2 5 (1)b Medication Administered and given must be clearly recorded in records. Care plans must fully reflect the 16/08/09 complex emotional needs, and supported provided for the individual’s identified at the home. Each individual living at the 16/08/09 home must be provided with a contract which outlines the terms and conditions of the placement. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP11 Good Practice Recommendations The home should ensure that end of life wishes and preferences are known and recorded. Frenchay House DS0000073145.V376491.R01.S.doc Version 5.2 Page 28 Care Quality Commission Care Quality Commission South West Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.southwest@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. 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