Care Home: Frindsbury Hall

What the care home does well The level of care planning is high and health care needs are very well met. The staff group work well together as a team and all stated they felt well supported by senior management. Senior management stated they felt well supported by the new owners. The home has good links with specialist health services. The intermediate care service has recorded a high level of success in the rehabilitation of individuals enabling them to return to their own homes. The home has a warm, friendly atmosphere and residents` visitors are made welcome. All of the residents were very complementary of the staff within the home. All residents said the food was of a very high quality and that there was always plenty of choices at each mealtime. The home manages health and safety very well and provides a safe environment in which to live. What has improved since the last inspection? Some work on the internal environment has improved the quality of life for the residents. New furniture has been purchased for the lounges including a new plasma television. Residents` care plans are now more comprehensive and detailed. One new sluice room has been fitted and this helps improve the infection control on that wing. New radiator covers also improve the internal environment. Some new bedroom furniture has also been purchased. Security has been improved with the installation of external lighting and security keypads on the entrances to the individual wings. Some new window restrainers have been fitted. What the care home could do better: The main concern for the residents was the lack of garden space, what was the garden is now a building site. It will be a requirement that the external grounds are suitable, and safe for use by, the service users. The home does have five hoists but there appears to be more demand for one of a particular type. It is recommended the home purchase another hoist, which meets the specific needs of the residents. CARE HOMES FOR OLDER PEOPLE Frindsbury Hall Frindsbury Hill Strood Rochester Kent ME2 4JS Lead Inspector Sue McGrath Unannounced Inspection 18th April 2008 09:00 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 Frindsbury Hall DS0000071078.V361348.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. Frindsbury Hall DS0000071078.V361348.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Frindsbury Hall Address Frindsbury Hill Strood Rochester Kent ME2 4JS 01634 715337 01634 715337 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) Southern Cross BC OpCo Ltd Mrs Deborah Mabey Care Home 74 Category(ies) of Old age, not falling within any other category registration, with number (74) of places Frindsbury Hall DS0000071078.V361348.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 with Nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following category: Old Age, not falling within any other category, Code OP - maximum number of places 74 The maximum number of service users who can be accommodated is: 74 2. Date of last inspection Brief Description of the Service: Frindsbury Hall Nursing Home is situated in a residential area of Frindsbury with bus and train services nearby and within easy reach of the town centres of Rochester and Strood. The home provides services to 75 older people with nursing care needs. The home has wing specifically for the provision of Intermediate Care. There is a mixture of single and shared rooms and residents accommodation is arranged over two floors. Two passenger lifts provide access to the first floor. The large detached premises are easily accessible from the main road with ample parking for visitors. The home employs registered nurses and care staff working a roster, which provides 24-hour cover. Ancillary staff for catering, laundry, maintenance and domestic duties are also employed. Current fees range from £520.20 to £ 636.00 per week according to assessed personal need. Frindsbury Hall DS0000071078.V361348.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 3 star. This means the people who use this service experience excellent quality outcomes. This was a Key Unannounced inspection that took place in accordance with the Inspecting for Better Lives (IBL) process. Key inspections are aimed at making sure that the individual services are meeting the standards and that the outcomes are promoting the best interests of the people living in the home. The IBL process for a Key inspection involves a pre-inspection assessment of service information obtained from a variety of sources including an annual selfassessment and surveys. It is now a legal requirement for services to complete and return an Annual Quality Assurance Assessment (AQAA). This assessment is aimed at looking at how services are performing and achieving outcomes for people. Judgements have been made with regards to each outcome area in this report, based on records viewed, observations and verbal responses given by those people who were spoken with. These judgements have been made using the Key Lines of Regulatory Assessment (KLORA), which are guidelines that enable The Commission for Social Care Inspection (CSCI) to be able to make an informed decision about each outcome area. Further information can be found on the CSCI website with regards to the IBL process including information on KLORA’s and AQAA’s. The actual site visit to the service was carried out over one day by one inspector, who was in the home from approximately 09.00 until 16.00. The main focus of the visit was to review the progress of the new providers and the well-being of the service users. Time was spent touring the building, talking to people living in the home, talking to staff and reviewing a selection of assessments, service user plans, medication records, menus, staff files and other relevant documents. Prior to the site visit the AQAA had been returned and surveys had been sent out to service users and professionals to gain further feedback as to their opinion of the service. A number of surveys have been returned (12). At all times the manager and staff were helpful and demonstrated a pro-active approach to ensuring that service users were being supported to the best of their abilities and resources. Frindsbury Hall DS0000071078.V361348.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Some work on the internal environment has improved the quality of life for the residents. New furniture has been purchased for the lounges including a new plasma television. Residents’ care plans are now more comprehensive and detailed. One new sluice room has been fitted and this helps improve the infection control on that wing. New radiator covers also improve the internal environment. Some new bedroom furniture has also been purchased. Security has been improved with the installation of external lighting and security keypads on the entrances to the individual wings. Some new window restrainers have been fitted. Frindsbury Hall DS0000071078.V361348.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Frindsbury Hall DS0000071078.V361348.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 Frindsbury Hall DS0000071078.V361348.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes statement of purpose and service user guide are comprehensive and provide prospective residents with the information they need to make an informed choice about moving into the home. Residents are provided with a statement of terms and condition of residency. Residents’ benefit from a comprehensive assessment of their needs prior to moving into the home to ensure their assessed needs can be met. Residents’ in the intermediate care unit are helped to maximise their independence and return home. EVIDENCE: Evidence was seen that the home has a current and updated statement of purpose, which reflects life at Frindsbury Hall and meets with Schedule one of the Care Standards Act 2001. Frindsbury Hall DS0000071078.V361348.R01.S.doc Version 5.2 Page 10 Copies were seen of the contracts used for both private and social service funded residents and these were robust and informative. The manager confirmed all residents or their representatives were provided with a formal contract/terms of condition. Evidence was seen in resident’s files that a comprehensive assessment of need was completed by senior staff prior to admission to the home. The assessment could take place in the prospective residents home or current setting. If social services were involved a care management assessment was also obtained. The manager stated that she was confident a place would not be offered if it were considered the person’s needs could not be met within the home. Some residents confirmed they visited the home prior to admission some said their relatives visited on their behalf as they were in hospital at the time. The homes admission procedure encourages visits and a trial period is always offered. The manager confirmed this could be flexible according to need. Residents on the intermediate care unit were initially assessed by members of the rehabilitation team (Physiotherapist/Occupational Therapist), they identified the individuals potential for inclusion in the 6-week rehabilitation programme. The assessment was then checked by the homes manager/ deputy prior to admission to ensure the individual corresponds to the home’s registration category and their needs can be fully met. The original assessment and the home’s additional assessment then form the basis for the individual’s plans of care. The aim of this service is to maximise independence and enable individuals to return to their own home. Evidence was seen that this unit has a high success rate. Several of the current residents said how much they had gained from staying there. One resident stated she had regained her confidence following a fall at home and was now looking forward to returning home. Frindsbury Hall DS0000071078.V361348.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents have clear and in-depth care plans that identify their individual needs and give clear guidance to staff. Care plans are robust and ensure both physical, emotional and healthcare needs are well met. Residents are protected by the home’s policies and procedures for dealing with medicines. Residents are treated with respect and can be assured the home will handle the issue of illness and ageing sensitively. EVIDENCE: The new organisation had introduced new care plans and the staff had worked hard to ensure all residents care plans had been changed to the new format. The manager admitted this had been an extensive piece of work but that she was now satisfied that it had been worthwhile. Staff also confirmed they now liked the new plans and had received training on them initially. Frindsbury Hall DS0000071078.V361348.R01.S.doc Version 5.2 Page 12 Several of the plans were viewed and were found to be very comprehensive and detailed. Risk assessments were detailed and where a high risk was identified clear instruction were given to staff on how to reduce the identified risk. Nutritional assessments were ongoing and emphasis was placed on providing a high quality nutritionally sound diet. Regular monthly assessments were completed and if any conditions changed the original care plan were also changed to reflect the new need. Key workers also completed a weekly over view of each resident. There was clear evidence that health care needs were well met and well recorded. The homes administration of medication was viewed and found to comply with the guidelines of the Royal Pharmaceutical Society of Great Britain. Medication was correctly stored and there was a robust system in place for reordering supplies. The home uses a local Pharmacy and blister pack system for dispensing. Nurses who administer drugs are trained in this field. No errors were found in the medication administration records viewed and the controlled drugs were well managed, again with no errors found in the records viewed. Throughout the day staff were seen to respect residents in the manner they addressed them and in the general way they cared for them. All of the residents spoken with were very happy with the care they received and all spoke very highly of the staff at the home. Comments made included: ‘The girls are smashing and I feel well cared for’. ‘The staff look after me very well. The girls are very helpful and work hard to make me happy’. ‘I like it here and want to come again. I feel well looked after and have made some new friends.’ ‘I could not wish for better care and attention. I feel really secure and have found a nice place to end my days’. Families also confirmed the staff were very caring: ‘Cannot fault the home. My wife is so happy and that makes all the difference to me’. ‘The staff are super’. The home has worked hard on developing the approach to end of life care. Training had been undertaken from the Hospice Nurse. A specific end of life Frindsbury Hall DS0000071078.V361348.R01.S.doc Version 5.2 Page 13 care plan has been developed and some work around resuscitation is being developed in conjunction with the local PCT (Primary Care Trust). The manager confirmed this had really raised the awareness of the importance of taking into account personal wishes at this difficult time. Frindsbury Hall DS0000071078.V361348.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to make choices and lead a life that meets their individual preferences. Residents are supported to maintain contact with family and friends, which ensures they continue to receive stimulation and emotional support. Residents’ social and recreational interest and needs are well provided for with a wide range of activities organised. EVIDENCE: Residents were complimentary of the activities offered and enjoyed a range of different experiences which most said met with their expectations. The home had a dedicated activities co-coordinator who organised a range of entertainments as well as activities. Some residents and their families said they would like to go out more. This was discussed with the manager who confirmed she had been given permission to hire transport for some summer outings. One resident said she missed being able to go into the garden as several years ago work had started on the conservatory but had been stopped. Frindsbury Hall DS0000071078.V361348.R01.S.doc Version 5.2 Page 15 This area used to be the garden and is still unusable. Discussion with the Area Manager confirmed they have plans to remove the footings and to restore the garden for this summer. Church service were arranged in the home and the manager was confident they could meet all cultural and religious needs of the residents Several visitors to home were spoken with and all confirmed they could visit at any time and were always made very welcome. Tea or coffee was offered or there was the facility for visitors to make their own as they wished. Residents also stated that there was no restrictions on visiting times and that they could see who they wished. Residents confirmed that they were given choices over bedtimes and were able to make their own decision over daily living options, such as what to wear and where to sit. They confirmed they could stay in their rooms all day if they wished. One lady was enjoying ‘lovely long lay in’ which she said she really appreciated. All residents spoken with complimented the kitchen on the quality of the food and choices offered at each mealtime. There was an exceptionally high regard for the food at the home from the residents The home works hard to ensure all meals are nutritionally balanced and are currently introducing the ‘Nutmeg Food Screening programme’ which is designed to ensure all meals are nutritionally balanced and of good quality. Evidence was seen that fresh vegetables were used and fresh fruit was freely available. Menus indicated that there was always a choice of two hot meals or four to five other alternatives at lunchtime. At teatime two hot meals or sandwiches were normally offered. Cakes all looked homemade and fresh. Specialist diets could be catered for. Frindsbury Hall DS0000071078.V361348.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by a robust complaints system and residents and relatives feel their views are listened to and acted upon. The home has robust adult protection policies and procedures to ensure that residents are protected from abuse. EVIDENCE: The home has a robust complaints procedure in place, which is accessible and had given timescales. The complaints policy was also seen on the home’s notice boards in the lobby area. Residents and families said they felt confident that the management of the home would deal with any complaints promptly and fairly. The home had received only one complaint, which was anonymous. This was dealt with immediately and did not affect care to any of the residents. The commission has not received any complaints and there are no outstanding SVA (Safeguarding Vulnerable Adults) alerts raised. Staff are fully trained in adult protection and when spoken with demonstrated a good understanding of this subject. Both the Manager and Administrator are qualified SVA trainers and all staff undergo refresher training sessions on this subject. Evidence was seen that staff training in the Mental Capacity Act was arranged for May 2008. Frindsbury Hall DS0000071078.V361348.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a clean, safe, well-maintained environment and have safe access to comfortable indoor communal areas. Residents do not benefit from adequate outside facilities. Residents are encouraged to maximise their independence by having access to the range of specialist equipment supplied by the home. EVIDENCE: There had been several improvements in the internal environment since the last inspection. These include one of the lounges being refurbished with new furniture and a new plasma television. Residents spoken with said they liked the new furniture and that it was comfortable. Frindsbury Hall DS0000071078.V361348.R01.S.doc Version 5.2 Page 18 New outside lighting had improved security and security pads had been fitted to all units. All of the radiators had new covers and the stair well at the rear of the building, which has been a problem area for some time, had been treated and re plastered. When dry it will be repainted. The home has one new sluice room, which is a big improvement on the old room. The manager is hoping to refurbish the remaining sluice rooms to the same high standard in the coming year. A range of moving and handling equipment was seen and the home has invested in several new specialist beds. One resident complained that there were insufficient hoists in the home and sometimes they had to wait a long time for one to be free for them to use. The home should consider the purchase of a further hoist to ensure all residents’ needs are fully met. The home currently has five hoists all with different uses. The new owners have allocated a sum of money to continue with the refurbishments and plans are to refurbish the bathrooms. These are in need of an overhaul, as they are showing signs of wear and tear. The manager confirmed they do not currently use all of bathrooms. New window restrainers on the upper floors also improve safety and security. The kitchen was seen to be clean and tidy and the relevant paperwork was well maintained. New windows with built in blinds had been fitted and a new hot holding food trolley had been purchased. Many of the bedrooms were viewed and were clean and tidy and well maintained. Domestic staff clearly worked hard to maintain the cleanliness of the home and no odours were detected throughout the home. Several residents confirmed ‘the home was always nice and clean’. The main problem identified was the outside garden space. Several residents and visitors had highlighted this issue. The area that used to be the main garden was the area chosen to build a conservatory on. Unfortunately the work was started in 2005 but was never completed. Only the footings remain. This has meant that for several years residents have not been fully able to enjoy sufficient outdoor space. This was discussed with both the manager and area director during the inspection. Both confirmed there were plans to remove the footings and restore the garden this year. Frindsbury Hall DS0000071078.V361348.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents benefit from staff that are well trained and competent to do their jobs and who enjoy good morale. Staffing arrangements provide for a suitable mixture of care staff, administrative staff, domestic, catering, and maintenance staff, ensuring residents assessed needs can be met. Residents are protected by robust recruitment procedures. EVIDENCE: The manager said that Frindsbury Hall continues to give training for their staff a high profile. The staff files viewed confirmed that mandatory training is up to date and that NVQ (National Vocational Qualification) is also given a high profile. The organisation has a training matrix that clearly identifies what training has been completed and when it is due for refreshing. Information given in the homes AQAA confirmed that currently twenty one out of the thirty three care staff have achieved NVQ level two or above. This is sixty nine per cent of staff, which exceeds the required level of fifty percent. The manager confirmed three more staff are currently undertaking their award. Staff also confirmed that training is given a high priority with weekly sessions available on various subjects. Frindsbury Hall DS0000071078.V361348.R01.S.doc Version 5.2 Page 20 Three staff files were viewed and found to meet with the requirements of Schedule two of the Care Standards Act 2001. The files viewed were well maintained and comprehensive. CRB (Criminal Record Bureau) and POVA (Protection of Vulnerable Adults) checks for all staff were in place. All qualified registered nurses had the correct documentation to support their role in the home. The home works hard to promote equality and diversity amongst its workforce, which reflects the multicultural aspect of the local area. The home had a good staff structure with advice and direction always available from trained nurses and senior staff. Staff spoken with were aware of their individual roles in the home and knew what was expected of them. All said they felt confident and well supported by the management team. Rotas seen on the day indicated there were sufficient staff on duty to meet the needs of the residents. Residents were mainly complimentary about the staff with some residents really praising their sensitivity and hard work. Comments included; ‘The staff are so kind’. ‘The staff are all very nice people with my best interests at heart’ ‘I am comfortable and get well looked after. The staff are very good’. ‘I could not wish for better care and attention. I feel really secure and have found a nice place to end my days’ Several visitors also confirmed they were happy with the staff group. ‘ Have good rapport with the staff and management team which helps’. ‘The staff are super and work really hard’ Frindsbury Hall DS0000071078.V361348.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The resident’s benefit from having a manager who is supported well by senior staff in providing clear leadership throughout the home and by staff who demonstrate an awareness of their roles and responsibilities. Resident’s benefit from having staff that receive regular supervision. The health, safety and welfare of residents and staff is promoted and respected. EVIDENCE: The manager had worked at the home for twenty-one years and had been the manager for twelve of those years. The manager had many years experience Frindsbury Hall DS0000071078.V361348.R01.S.doc Version 5.2 Page 22 in providing services for older people and holds professional nursing qualifications. During the inspection she displayed a sound understanding of the residents and of their needs. Throughout the inspection the manager and senior staff clearly had the residents welfare at heart and demonstrated openness and commendable honesty. Residents, relatives and staff all confirmed the management team was supportive and efficient. Evidence was seen that regular satisfaction surveys were carried out and that quality assurance within the service was given a high priority. Evidence was also seen that regular residents meetings were held, along with regular staff meetings. Residents spoken with said they were confident their views were listened to and acted upon by the management team. Families also felt confident about the management of the home and were encouraged to be involved with the planning of the care of their relatives where possible. Most residents were unable to manage their finances independently and the manager provided information that the home encourages residents’ families/ representatives to give support and assistance with this. Records are kept by the home for the management of some residents’ personal allowances. Residents’ relatives did not raise any concerns about the home’s management of monies or valuables held on residents’ behalf. Since the last inspection the home has notified the commission of deaths and incidents that adversely affect a residents well being in a timely fashion. Evidence seen in staff files and discussion with staff confirmed they received regular and structured supervision and they benefited from this time spent in a one to one situation The new owners had introduced all new policies and procedures, which complied with current legislation and good practice guidelines. Staff were currently working through the new policies and procedures The manager said that the new organisation is paying close attention to health and safety standards and fire protection. Staff have been retrained in fire safety and regular audits confirmed the home maintains a high level of safety checks within the home. The manager also confirmed that all records of maintenance were up to date. Comprehensive details were provided in the home’s AQAA, which was provided to the commission prior to the inspection. The home now has a Health and Safety committee in the home, which comprises of the heads of all departments. Minutes of these monthly meetings are sent to company headquarters. Frindsbury Hall DS0000071078.V361348.R01.S.doc Version 5.2 Page 23 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 3 3 3 3 4 HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 4 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 3 4 Frindsbury Hall DS0000071078.V361348.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP19 Regulation 23(2)(o) Requirement The registered person shall not use the premises for the purpose of a care home unless (o) External grounds which are suitable for, and safe for use by, service users are provided and appropriately maintained. Detailed action plan to be provided by 30/06/08 Timescale for action 30/06/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP21 OP26 OP22 Good Practice Recommendations It is recommended that all of the bathrooms be refurbished. It is recommended that the remaining sluices be refurbished to ensure good infection control measures. It is recommended that further hoists be provided to meet the needs of all the residents. Frindsbury Hall DS0000071078.V361348.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Frindsbury Hall DS0000071078.V361348.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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