Care Home: Frethey House

What the care home does well Frethey House provides a well-maintained, comfortable and clean environment for the people living there. All bedrooms are for single occupancy and are fitted with en-suite facilities. The standard of cleanliness is good and there are procedures in place to reduce the risk of the spread of infection. The home ensures that people are provided with the information they need to enable them to make an informed decision about living there. Procedures are in place to ensure that people thinking about using the service are appropriately assessed. The home has a varied activity programme available for people living at the home and people were positive about the range of activities on offer. The home`s care planning procedures have improved. Each person has a plan of care that identifies their assessed needs and preferences. People told us that they received care in the way they preferred and that they had been involved in the care planning process. People have access to appropriate health care professionals and the home`s procedures for ensuring peoples` health care needs are met have improved. The home follows safe procedures for the management and administration of peoples` medication. People are treated with respect and their right to privacy is upheld. People told us that the staff were kind and that `they will do anything to help you`. Through our observations during the day we noted staffs` interactions with people using the service to be kind and professional. Interactions appeared unhurried and staff were noted to knock on peoples` bedroom doors before entering. People told us that their needs were met and that staff responded promptly to call bells. Procedures are in place to seek the views of people using the service and other stakeholders. Regular meetings are held for staff and for people living at the home. People told us that they felt confident that any issues raised would be addressed. At the time of this inspection, the home was following appropriate procedures to ensure the health and safety of persons at the home. What has improved since the last inspection? Nine statutory requirements were raised at the last inspection and it was positive to note that the home had taken action to address all of these. The home`s care planning procedures have improved. Care plans were found to be up to date and contained a range of appropriate assessments which had been used to develop a plan of care. Care plans contained information about the individuals` preferences that help to promote a more person centred approach to care. People told us that they had been involved in their care planning and review process. All staff spoken with during the inspection were positive regarding the changes in the care planning process. Care plans for people with pressure sores and weight loss were found to be much improved. Wound care plans contained detailed information, including photographs which help to monitor the progress of the treatment prescribed. Clear nutritional assessments and care plans were in place to address concerns regarding weight loss. The home`s procedures for staff recruitment have improved and now offer better protection for people using the service. We examined a number of staff recruitment files and found all to contain all required information. We were able to see that staff had not commenced employment until receipt of two satisfactory references and an enhanced criminal record check (CRB) and checks against the protection of vulnerable adults register (POVA). The acting manager demonstrated a good understanding of required procedures. Action has been taken to ensure that the home is effectively managed. An acting manager was employed in October 2008 and the Commission are currently processing an application for registered manager. The acting manager is supported by a `head of care`. Management support is also provided by the home`s responsible individual who conducts monthly visits/reports. Staff spoken with during the inspection were positive about the acting manager and of improvements made. We noted that staff moral had improved since the last inspection. Systems are now in place to ensure that staff are appropriately supervised. What the care home could do better: No statutory requirements were raised as a result of this inspection. We made three good practise recommendations. These related to the following; The home has a complaints procedure but this needs to be updated to include timescales for action. At the time of this inspection we were informed that the home is assisting two people to manage small amounts of money. We found appropriate records to be in place and monies were seen to be securely stored. We have recommended that the home introduces a system so that transactions are audited on a monthly basis.Following the last inspection the home have taken action to ensure that newly appointed staff follow a more in-depth induction programme. As this is completed by staff on the computer, we have recommended that the home introduces a formal recording/monitoring system to demonstrate that staff are confident and competent in all areas covered. CARE HOMES FOR OLDER PEOPLE Frethey House Frethey Lane Bishops Hull Taunton Somerset TA4 1AB Lead Inspector Kathy McCluskey Unannounced Inspection 11th March 2009 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Frethey House DS0000064474.V374563.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Frethey House DS0000064474.V374563.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Frethey House Address Frethey Lane Bishops Hull Taunton Somerset TA4 1AB 01823 253071 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) info@affirmativecare.co.uk www.caringhomes.org Affirmative Care Ltd Manager post vacant Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places Frethey House DS0000064474.V374563.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate up to 41 persons from the age of 60 years who require nursing care (OP). May accommodate up to three persons from the age of 50 years who require nursing care. 9th September 2008 Date of last inspection Brief Description of the Service: Frethey House is situated on the edge of the village of Bishops Hull on the outskirts of Taunton. The home is registered with the Commission for social Care Inspection (CSCI) for 41 people not less than 60 years of age, who require general nursing care. The home is not registered to provide care to people whose primary care needs are for their dementia or mental health needs. Affirmative Care Ltd has owned the home since July 2005, in January 2008 the Commission were informed that the major share of the company had been sold. The Registered Individual is Susan Murphy. The home has been without a registered manager since 1st July 2008 when the post holder resigned from the post. An acting manager is in post and the Commission are processing an application for registered manager. We were informed that the home’s current fees are between £630 & £800 per week. Extra costs include; hairdressing, personal items/toiletries, chiropody and escorts for appointments. Full details about the home’s fees/costs should be obtained from the home. Frethey House DS0000064474.V374563.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 star. This means the people who use this service experience Good quality outcomes. The focus of this inspection visit was to inspect relevant key standards under the Commission’s ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service for each outcome group under four general headings. These are; - excellent, good, adequate and poor. Following the home’s last key inspection conducted in September 2008, the home was required to submit an improvement plan which told us how they would address the statutory requirements raised and how they would improve the quality of the service delivered. This was received by the Commission and, following this inspection, we were able to see that the home had taken appropriate action to address the requirements raised. This unannounced key inspection was conducted over one day (7hrs) by CSCI regulation inspector Kathy McCluskey. The acting manager was available throughout this inspection and the home’s responsible individual Susan Murphy was available during the afternoon of the inspection. We were given unrestricted access to all parts of the home and records requested for this inspection were made available to us. We sent surveys to a number of people who use the service, staff working at the home and healthcare professionals to seek their views on the quality of the service provided. We received completed comment cards from 8 people using the service, 7 members of staff and 3 health care professionals. Comments have been included in this report as appropriate. We would like to thank all concerned for their time and cooperation with the inspection process. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. Frethey House DS0000064474.V374563.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Frethey House DS0000064474.V374563.R01.S.doc Version 5.2 Page 7 Nine statutory requirements were raised at the last inspection and it was positive to note that the home had taken action to address all of these. The home’s care planning procedures have improved. Care plans were found to be up to date and contained a range of appropriate assessments which had been used to develop a plan of care. Care plans contained information about the individuals’ preferences that help to promote a more person centred approach to care. People told us that they had been involved in their care planning and review process. All staff spoken with during the inspection were positive regarding the changes in the care planning process. Care plans for people with pressure sores and weight loss were found to be much improved. Wound care plans contained detailed information, including photographs which help to monitor the progress of the treatment prescribed. Clear nutritional assessments and care plans were in place to address concerns regarding weight loss. The home’s procedures for staff recruitment have improved and now offer better protection for people using the service. We examined a number of staff recruitment files and found all to contain all required information. We were able to see that staff had not commenced employment until receipt of two satisfactory references and an enhanced criminal record check (CRB) and checks against the protection of vulnerable adults register (POVA). The acting manager demonstrated a good understanding of required procedures. Action has been taken to ensure that the home is effectively managed. An acting manager was employed in October 2008 and the Commission are currently processing an application for registered manager. The acting manager is supported by a ‘head of care’. Management support is also provided by the home’s responsible individual who conducts monthly visits/reports. Staff spoken with during the inspection were positive about the acting manager and of improvements made. We noted that staff moral had improved since the last inspection. Systems are now in place to ensure that staff are appropriately supervised. What they could do better: No statutory requirements were raised as a result of this inspection. We made three good practise recommendations. These related to the following; The home has a complaints procedure but this needs to be updated to include timescales for action. At the time of this inspection we were informed that the home is assisting two people to manage small amounts of money. We found appropriate records to be in place and monies were seen to be securely stored. We have recommended that the home introduces a system so that transactions are audited on a monthly basis. Frethey House DS0000064474.V374563.R01.S.doc Version 5.2 Page 8 Following the last inspection the home have taken action to ensure that newly appointed staff follow a more in-depth induction programme. As this is completed by staff on the computer, we have recommended that the home introduces a formal recording/monitoring system to demonstrate that staff are confident and competent in all areas covered. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Frethey House DS0000064474.V374563.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Frethey House DS0000064474.V374563.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 4. Standard 6 is not applicable as the home is not registered to provide intermediate care. Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. The home has produced a Statement of Purpose and Service User Guide that provides people with information about the home and services offered. Documents have been updated to reflect management changes. Appropriate procedures are in place to ensure that the assessed needs of individuals are fully assessed by the home before a placement is offered. Procedures are in place to ensure that peoples’ assessed needs can be met. EVIDENCE: The home’s Statement of Purpose and Service User Guide provide people at the home and those thinking about moving there, with information about the Frethey House DS0000064474.V374563.R01.S.doc Version 5.2 Page 11 home and services offered. These documents have been updated since the last inspection to reflect the changes in the management structure. During this inspection we noted that these documents were available in all bedrooms viewed and in the reception area of the home. All 8 people using the service, who completed comment cards for the Commission, confirmed that they had received sufficient information about the home to enable them to make an informed decision about moving there. One person who had recently moved to the home told us that at their request, their family had been given the opportunity to visit the home before they decided to move there. We examined five care plans at this inspection, two of which related to people who had recently moved to the home. We were able to see evidence that the home had carried out a pre-admission assessment to ensure that the assessed needs and aspirations of the individuals could be met by the home, before a placement was offered. Assessments from other health care professionals were also in place. The acting manager provided us with evidence of actions taken where there were concerns about meeting the changing needs of two people living at the home. We were able to see that the involvement of appropriate specialised health care professionals had been sought. There was also evidence that there had been effective communication with the individuals’ family members. Staff told us that they did not experience any problems meeting the needs of people currently at the home. They also told us that they had received the training needed to care for the people living at the home. Three health care professionals completed comment cards for the Commission and all responded ‘Always’ to the question; ‘Are individuals health care needs met by the service?’ The home has been suitably designed and adapted to meet the needs of people with mobility difficulties. The home has a good supply of moving and handling equipment and assisted bathing facilities. Staff told us that they had received the training needed to enable them to meet the needs of the people using the service. Frethey House DS0000064474.V374563.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. The home’s care planning procedures have improved and these now ensure that peoples’ needs are clearly identified and that care is delivered in a person centred way. People have access to appropriate health care professionals and the home’s care planning systems ensure that health care needs are met. The home follows safe procedures for the management and administration of peoples’ medication. People are treated with respect and their right to privacy is upheld. EVIDENCE: We examined five care plans during this inspection and found that procedures were much improved from the last inspection. Frethey House DS0000064474.V374563.R01.S.doc Version 5.2 Page 13 Clear risk assessments were in place and care plans had been raised where a need had been identified. Information for staff as to how assessed needs should be met were clear and included the preferences of the individual thus promoting a more person centred approach to care. Care plans were up to date and were now being reviewed at least monthly. People told us that they were now being involved in their plan of care. Care plans were also available in peoples’ bedrooms. Care staff told us that they were now encouraged to be involved in the care planning process. People living at the home told us that they felt their needs were met by staff in the way they preferred. Five of the eight people who completed comment cards for the Commission stated their needs were ‘Always’ met by staff. Three responded ‘Usually’. People told us that; ‘the staff are always ‘kind and cheerful’, ‘They will do anything for you, they are marvellous’. People also told us that call bells were answered promptly by staff. Three of the care plans examined related to people with pressure sores and nutritional needs. We noted that concerns raised at the last inspection had been addressed. Wound care plans were in place that clearly identified how the wounds should be managed, treatment prescribed and frequency of treatment. Photographs were in place so that the progress of the wound could be monitored. Clear nutritional care plans were in place for those with an assessed need and an appropriate nutritional assessment tool had been used. By ‘tracking’ peoples’ care and by talking to staff and people living at the home, we were able to see that people were receiving care as agreed in their individual plan of care. There was evidence that people were being weighed at least monthly. Care plans contained evidence that people had access to a range of appropriate health care professionals. Records are maintained in individuals plan of care. Three health care professionals completed comment cards for the Commission and in response to the question; ‘Does the home seek advice and act upon it to manage and improve peoples’ health care?’, all responded ‘Always’. ‘Information is always acted upon and communicated well’, ‘the home always follow up on recommendations raised’. We examined the home’s procedures for the management and administration of peoples’ medication. Medication administration records (MAR) were found to be fully completed. All medicines were securely stored and there were no excess stocks apparent. As recommended at the last inspection, the home have introduced systems to ensure that stock items do not exceed their expiry date. Frethey House DS0000064474.V374563.R01.S.doc Version 5.2 Page 14 We found that appropriate procedures were being followed for the management of controlled drugs. Medicines are only administered by the registered nurses on duty. Throughout the day we were able to observe staff interactions with people using the service. Communications between staff and people using the service were noted to be kind and respectful and people were assisted in an unhurried manner. Everybody spoken with during this inspection commented on the kindness of the staff. People also told us that their personal care needs were met in a sensitive manner. People appeared well attired and relaxed in their surroundings. We observed staff knocking on peoples’ bedroom doors before entering. People are able to lock their bedroom doors. In comment cards received by the Commission from health care professionals, all confirmed that they felt the home respected the privacy and dignity of the people living there. Frethey House DS0000064474.V374563.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. The home has a varied activity programme available for people living at the home and people are able to choose how to spend their day. The home offers a wholesome and varied four-week menu though many people felt that the meals could be improved. The home ensures that visitors are welcome in line with the preferences of the people living there. EVIDENCE: We were informed that the home employs two activity co-ordinators who cover a 5 day period, 1000hrs – 1600hrs. A programme of activities was displayed in various areas of the home and was also available in the Service User Guide within people’s bedrooms. Eight people using the service completed comment cards for the Commission and in response to the question; ‘Are there activities arranged by the home that you can take part in?’ 2 responded ‘Always’, 2 ‘Usually’ & 4 ‘Sometimes’. Frethey House DS0000064474.V374563.R01.S.doc Version 5.2 Page 16 ‘There are plenty of activities and communion and a short service are regularly arranged’ We spoke with a number of people during the inspection and all were positive about the range of activities available. People told us that they were able to make choices about what activities they would like to join in with. One person told us that the activities staff ‘always let them know what is going on’. We were informed that the mornings are dedicated to spending one to one time with people. Care plans contained details about peoples’ social history and social assessments were also available. Records are maintained for each individual relating their participation in activities. People told us that their relatives were made to feel welcome when they visited and that refreshments were always made available. The home displays a range of information for people living there and for visitors. This includes information on how to contact external advocates. Information is also available in the service user guide in peoples’ bedrooms. We were able to see that people were able to personalise their bedrooms. Some people had brought pieces of their own furniture. The home employs catering staff who cover a seven day period. All meals are freshly prepared at the home. Since the last inspection, staff hours have increased to ensure that they are available during the tea time period. People told us that choices were always available and that staff ask them on a daily basis what their preferences for the day are. Copies of a four-week menu were available on tables in the dining room and the days menu was clearly displayed. We spoke with a number of people during this inspection and the general consensus was that they were not entirely satisfied with the meals at the home. They told us that this was the only area that could be improved. They made the following comments; ‘The meat is often tough but they have changed supplier now’, ‘too many casseroles’, ‘the food is not always hot enough’, ‘sometimes it is not well presented and that puts me off’, ‘sometimes it just doesn’t taste of anything’. Eight people living at the home completed comment cards for the Commission and in response to the question; Do you like the meals at the home?’ 4 said ‘usually’, 2 ‘sometimes’ and 2 ‘always’. They also made the following comments; ‘Sometimes the meals are not up to standard’ ‘when I first came to the home the meals were very good but they have deteriorated’, ‘there seems to be good variety and choice’. Some people told us that they had raised their concerns about the food at a residents meeting and, as a result, the quality of the meat had improved since changing supplier’. Frethey House DS0000064474.V374563.R01.S.doc Version 5.2 Page 17 As a number of people stated their dissatisfaction with the meals, we discussed our findings with the acting manager and responsible individual at the time of the inspection. It was agreed that a resident meeting would be called so that this could be addressed. During this inspection we were able to see lunch being served. The meal was roast beef, Yorkshire pudding, vegetables and potatoes. This appeared appetising and plentiful. People were positive about the lunch served. Soft diets had been attractively presented. Frethey House DS0000064474.V374563.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. The home has satisfactory complaints procedures in place, though the complaints procedure should be updated to include timescales for action. Procedures are in place to ensure that people are protected from the risk of harm or abuse. EVIDENCE: The home has a complaints procedure which is also included in the Service User Guide which is located in individuals’ bedrooms. The complaints procedure needs to be updated to include timescales for action. The complaints procedure displayed in the reception area needs to include the contact details of the Commission. Eight people living at the home completed comment cards for the Commission and all confirmed that they knew how to make a complaint. The home has a copy of Somerset’s policy on Safeguarding Adults and we were able to see evidence that staff had received training in the protection of vulnerable adults. The home has a range of satisfactory policies in place for staff to reduce the risk of harm or abuse to people. These include acceptance of gifts policy, restraint and whistle blowing. Frethey House DS0000064474.V374563.R01.S.doc Version 5.2 Page 19 Staff spoken with at this inspection were clear about action to take should they suspect abuse. Frethey House DS0000064474.V374563.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25 & 26 Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. People live in a comfortable and well-maintained environment and they are able to personalise their bedrooms. The home has appropriate specialist equipment in place. The standard of cleanliness is good and the home has procedures in place to reduce the risk of the spread of infection. EVIDENCE: During a tour of the premises, we found all areas to be comfortably furnished and well maintained. Frethey House DS0000064474.V374563.R01.S.doc Version 5.2 Page 21 The home has two passenger lifts and a wheelchair lift giving access to accommodation on the first floor. All areas of the home are fitted with a nurse call system and people are provided with a ‘pendant’ so that they can easily alert staff when needed. Grab rails are appropriately sited throughout the home and the home have an adequate supply of moving and handling equipment and all bedrooms have the provision of adjustable beds. All bedrooms are for single occupancy and all are fitted with en-suite toilet facilities as a minimum. Bedrooms are fitted with locks, which can be overridden by staff in the event of an emergency. Bedrooms are also fitted with lockable storage. People told us that they were ‘very happy’ with their bedrooms. It was apparent that people are able to personalise their bedrooms. The home has appropriate procedures in place to reduce the risk of the spread of infection. Notices and cleansing gels are displayed for visitors and staff hand washing facilities are appropriately sited throughout the home. Staff have access to good supplies of protective clothing. The home employs domestic staff who cover a seven day period. At the time of this inspection the standard of cleanliness in all areas viewed were very good. The home was fresh smelling with no malodours. All eight people who completed comment cards for the Commission were very positive about the standard of cleanliness at the home. Frethey House DS0000064474.V374563.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 & 30 Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. The home have taken action to ensure that staffing levels are appropriate to the needs of the people using the service. Staff recruitment procedures have improved and these now offer better protection for the people living at the home. The induction programme for newly appointed staff has improved though would benefit from further improvements. EVIDENCE: We were informed that 33 people were currently receiving nursing care at the home and that staffing levels were as follows; Morning – 2 registered nurses and 6 care staff Afternoon – 1 registered nurse and 5 care staff. Nights – 1 registered nurse and 3 care staff. The acting manager works during the week and is in addition to the care hours. The acting manager has the support of a head of care nurse who works in addition to the care hours for 6 hours a week. Frethey House DS0000064474.V374563.R01.S.doc Version 5.2 Page 23 The acting manager informed us that she had recently completed a recognised dependency tool to ensure that staffing levels at the home remained appropriate to the needs of the people receiving a service. We were informed that staffing levels would be increased where required. Staff spoken with during the inspection did not express any concerns about the current staffing levels. They told us that they were able to meet peoples’ needs. Eight people using the service completed comment cards for the Commission and in response to the question; ‘Are the staff available when you need them?’, 4 said ‘Always’ and 4 ‘Usually’. People spoken with during the inspection informed us that they felt their needs were currently being met by the home. They also told us that staff responded promptly to call bells. At the last inspection staff told us that morale was ‘low’ and that there was a lot of agency use. At this inspection staff appeared more positive and said that ‘things have improved’. They also told us that they ‘worked as a team’ and that staff morale was ‘good’. People living at the home commented on the kindness of staff and described them as ‘cheerful’. We examined the home’s procedures relating to staff recruitment. At the last inspection we raised serious concerns about the home’s procedures. At this inspection we were able to see that all requirements raised had been addressed. We examined recruitment files relating to four staff who had been recently employed. These contained all required information including evidence of an enhanced criminal records check (CRB) and checks against the Protection of Vulnerable adults register (POVA). The acting manager demonstrated a good understanding of recruitment procedures. At the last inspection we recommended that the home reviews the staff induction programme to ensure that it meets with the Skills for Care Common Induction Standards as only a basic two-day induction programme was available. At this inspection we were shown an ‘E learning’ induction programme which is completed by staff on the computer. Whilst this appears to be more in depth and appears to follow common induction standards, there were no formal recording systems in place to enable the home to ensure that staff were confident and competent to carry out tasks ‘on the floor’. We were informed that newly appointed staff are allocated a mentor who monitors and supports the staff member during their induction period. It has been recommended that records are maintained to demonstrate this and to confirm that the staff member is confident and competent in all areas covered. This was discussed with the acting manager and the responsible individual at the time of the inspection and they agreed to take action to address this. Frethey House DS0000064474.V374563.R01.S.doc Version 5.2 Page 24 Staff told us that training opportunities had improved. All spoken with told us that they had received the training needed to care for the people living at the home. Seven staff members completed comment cards for the Commission and all confirmed that they had received appropriate training. They also made the following comments; ‘There is always training on offer for all staff’ ‘In house training has always been good and informative’ ‘Being offered good training relevant to role and able to state training needs through good clinical supervision’. A staff training matrix supplied to us confirmed that staff had received up to date mandatory training. Frethey House DS0000064474.V374563.R01.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 35, 36 & 38 Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. Management arrangements have improved. The home has an annual quality assurance programme in place that seeks the views of people using the service, their representatives and other stakeholders. Procedures are in place to ensure that people’s financial interests are safeguarded. The home have taken steps to ensure that staff are appropriately supervised. The home’s arrangements for ensuring the health and safety of persons at the home have improved. Frethey House DS0000064474.V374563.R01.S.doc Version 5.2 Page 26 EVIDENCE: The home does not currently have a registered manager. The previous post holder left employment at the end of June 2008. An acting manager has been in post since October 2008 and an application for registered manager is currently being processed by the Commission. People using the service and staff were positive about the acting manager and of the support they received. Staff told us; ‘The manager always available to deal with any queries and is very approachable, ‘The manager is excellent and very person focused’, ‘Things have definitely improved since the new manager started’. People using the service also made comments about the acting manager; ‘She seems very good and always listen to what we have to say’, ‘The manager comes around to make sure that we are alright’, ‘I would have no hesitation in raising any concerns with the manager and I feel confident that she would address any issues’, ‘I feel that things have now improved’. The home has quality assurance procedures in place that seek the views of people using the service and other stakeholders. Questionnaires are sent out on an annual basis. Results of the home’s last surveys dated May 2008 were noted to be positive. As required at the last inspection, we were able to see evidence that the home’s responsible individual conducts monthly visits to the home in accordance with the Care Homes Regulations. Reports were available and these were noted to be in-depth. The acting manager stated that she felt well supported by the company’s management team. We were able to see evidence that regular meetings are held for all staff and for people using the service. Detailed minutes of meetings were made available to us. We were informed that the home is currently assisting two people to manage small amounts of money. Appropriate records of transactions were in place and receipts for transactions had been obtained. Monies held balanced with records seen. Money is securely stored. We have recommended that an appropriate individual, who is not involved in the day to day management of peoples’ money, carries out monthly audits on transactions. We were able to see that the home’s arrangements for ensuring staff are appropriately supervised had improved. Records of staff supervisions were available staff files examined and staff told us that they felt well supported. Seven staff completed comment cards for the Commission and all confirmed that they received regular supervisions; ‘Have regular supervision and manager supportive’. Frethey House DS0000064474.V374563.R01.S.doc Version 5.2 Page 27 Staff told us that they ‘worked well as a team’ and that ‘communications are very good’. During this inspection we noted staff morale had improved since the last inspection and this was also confirmed by staff spoken with. We examined some of the home’s procedures for ensuring the health and safety of persons at the home. We also toured the premises. The findings are as follows; FIRE SAFETY – Records indicated that systems and equipment had been serviced by an external contractor on 07/01/09. Records indicated that the home tests fire alarm systems on a weekly basis and as recommended at the last inspection, the zone tested had also been recorded. Records demonstrated that monthly checks are carried out on the home’s emergency lighting systems. Staff training records indicated that all staff had received up to date training in fire safety. This was also confirmed by staff spoken with during the inspection. The home has a fire risk assessment in place though this was not examined at this inspection. ELECTRICAL SAFETY – Records showed that annual testing on portable appliances was last carried out on 28/02/09. GAS SAFETY – The home has an up to date annual landlords gas safety certificate dated 28/10/08. EQUIPMENT SERVICING – six monthly servicing certificates were available for mobile and fixed hoists and lifts which indicated that servicing was last carried out in December 2008. HOT WATER OUTLETS/SURFACES – To reduce the risk of scalding, hot water outlets have been fitted with thermostatic controls. We were able to see evidence that, as required at the last inspection, monthly checks were being made on outlets to ensure that temperatures do not exceed HSE safe upper limits. Radiators are fitted with guards to reduce the risk of injury to people. The home’s records indicated that monthly health and safety checks are made on all areas of the home, including bedrooms. These were last conducted on 16/02/09. Frethey House DS0000064474.V374563.R01.S.doc Version 5.2 Page 28 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 x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x 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 x 3 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x 3 3 x 3 3 x 3 Frethey House DS0000064474.V374563.R01.S.doc Version 5.2 Page 29 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. Standard Regulation Requirement Timescale for action 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 OP16 OP30 Good Practice Recommendations The home should ensure that the complaints procedure is updated to include timescales for action The home should induce a formal recording system to support the staff induction programme. This should demonstrate that the staff member is competent and confident in each area. The home should introduce an auditing system for the management of peoples’ money. 3. OP35 Frethey House DS0000064474.V374563.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Frethey House DS0000064474.V374563.R01.S.doc Version 5.2 Page 31 - 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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