Care Home: Frintondene

What the care home does well What has improved since the last inspection? What the care home could do better: A recommendation was made regarding the detail recorded in care plans. This was with regard to a medication administration; for the only reference to medication requirements was a referral to the Medication Administration Record (MAR) sheet. The registered manager agreed to review this practice and add to the care plans at the planned monthly review. Basic training needs are considered through an ongoing training and development plan. As identified at the last inspection further National Vocational Qualification (NVQ) training is required to meet the National Minimum Standard of minimum 50% care staff with level 2 in care. CARE HOMES FOR OLDER PEOPLE Frintondene 4 Third Avenue Frinton On Sea Essex CO13 9EG Lead Inspector Pauline Dean Unannounced Inspection 10th September 2008 09:40 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 Frintondene DS0000017825.V371137.R02.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. Frintondene DS0000017825.V371137.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Frintondene Address 4 Third Avenue Frinton On Sea Essex CO13 9EG 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) 01255 679635 01255 679635 frintondene@hotmail.com Mrs Elizabeth Lambert Mrs Elizabeth Lambert Care Home 8 Category(ies) of Old age, not falling within any other category registration, with number (8) of places Frintondene DS0000017825.V371137.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 8 persons) 16th October 2007 Date of last inspection Brief Description of the Service: Frintondene is a family run residential care home for eight older people. There is one twin bedroom and the remaining are single bedrooms. All have en-suite facilities of a bath or shower, wash hand basin and toilet, with the exception of two single rooms, which have an en-suite wash hand basin and toilet. Communal accommodation comprises of a lounge/dining room at the front of the house. Under the previous regulatory authority, the temporary use of the dining room as a bedroom had been agreed on the basis that this was to cease and return to a dining room by 2007. Fees are £525.00 - £575. 00 per week. Hairdressing, chiropody, some toiletries and newspapers are included in the fees, with outings, clothing, alcohol and perfumes and creams charged at cost. The property is situated in a quiet residential road, close to the seafront at Frinton on Sea. It is a three-storey, detached house with residents’ accommodation on the ground and first floors, with the second floor being a staff flat. A passenger lift is installed to operate between the residential floors and there are other aids and adaptations suitable to the needs of the resident group. The care home has small rear and side gardens and a paved area at the front house where some residents like to sit. Frintondene DS0000017825.V371137.R02.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 unannounced inspection of Frintondene took place on 10th September 2008 over an 8¼-hour period. The inspection involved checking information received by Commission for Social Care Inspection (CSCI) since the last key inspection in October 2007. At the site inspection, records and documents were inspected and we spoke to the registered manager, care staff and the people living at the home. In addition the Annual Quality Assurance Assessment (AQAA) completed in May 2008 was considered as part of the inspection process and a tour of the premises was completed. Surveys were sent to the home prior to the inspection. Four surveys were completed by the people living at the home, four surveys were completed by staff and one by a health professional. Their comments are reflected in this report. During the inspection four people who live at the care home and a carer were spoken with. What the service does well: The outcome for the section entitled – ‘Choice of Home’ continues to be rated as excellent. Whilst there have been no new admissions to the home since the last inspection, the procedure and recorded practice with regard to admission and entry to Frintondene were detailed and comprehensive. As highlighted at the last inspection health care issues are well managed within both record keeping and care practice. A health professional had responded positively regarding the health care arrangements in the home. The home was clean, bright and welcoming on the day of the inspection visit. Decoration and maintenance tasks are completed to a high standard, with ongoing maintenance tasks identified and actioned. There was a relaxed and homely atmosphere in this family-run care home, which has an established staff group. People living in the home spoke of being able to make choices around what they wished to eat, what they wished to do and where they liked to spend their Frintondene DS0000017825.V371137.R02.S.doc Version 5.2 Page 6 time. Within the survey work completed, residents were complimentary regarding the way they were supported to maintain their independence. What has improved since the last inspection? 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. Frintondene DS0000017825.V371137.R02.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Frintondene DS0000017825.V371137.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 6. People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who come to live at the home can be confident that their needs will be fully assessed and these will be met. EVIDENCE: On the day of the inspection there were seven people living at Frintondene. Since the last inspection no new residents have moved into the home. The home is currently using all of the bedroom accommodation for the double room is used as a single room. The most recent admissions to Frintondene had been in December 2006. As noted at the last inspection an initial assessment was completed with Frintondene DS0000017825.V371137.R02.S.doc Version 5.2 Page 9 supporting evidence of assessments completed by a social worker. Records had been completed of planned visits and copies of information (Service User Guide) were noted as being sent to the prospective residents and their relatives for them to make an informed choice when moving into the home. The planned admission had taken place in December 2006 and the new residents had been admitted to the home for a one-month trail period. Following this period a contract was completed and copies were seen on file. The entire process had been managed in a meticulous and careful manner to ensure that the residents’ move into the home was as smooth and painless as possible. In addition, the registered manager had completed a Client Personal Profile record and an ‘Observation on Admission’ record sheet for each of the residents and this covered mobility, eyesight, hearing, mental state, history of falls, sleeping, hygiene, diet and fluid intake and aids and adaptations needed. These provided information for the creation of care plans. Within the survey work conducted by the Commission, all four residents who had completed the survey had said that they had received enough information about the home before the moved in to make an informed choice and they had all received a contract. One resident said ‘I called and looked over several homes including this one and, when the time came, I had no difficulty in choosing Frintondene.’ Within the AQAA it was stated that Frintondene is full at the moment and they hold a waiting list. It went on to say that the home has ‘a group of people living together, but individually they are happy and contented with their choices that they have made.’ This was with regard to choosing a home. Frintondene does not offer intermediate care. Frintondene DS0000017825.V371137.R02.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at the home can be assured that their care needs will be met through their individual plan of care and they can be assured that their medication will be administered in a safe and secure way. EVIDENCE: Three care plans were sampled and inspected as part of case tracking of the care offered at the home. The format allowed consideration of all aspects of the health, personal and social care needs of the resident. The records kept, detailed the care required, although we did raise with the registered manager the need to add more detail regarding caring for a resident who woke up in the night. Whilst the manager was able to clearly detail the action taken it was not evident in the care planning records. However, by the end of the inspection, the registered manager had reviewed this care plan and additional Frintondene DS0000017825.V371137.R02.S.doc Version 5.2 Page 11 action points had been added. They agreed that this would be considered as they conduct their monthly review of the care plans. One care plan inspected was due for review and this would be dealt with immediately. A further example of where more detail is needed was with regard to medication. Currently carers are referred to the individual’s Medication Administration Record (MAR) sheet. This does need to be detailed within the care plan. The registered manager agreed to review this at the planned monthly review. Within the care plans seen there was evidence of some changes in care and these had been recorded in the care plan and changes made to care required. An example of this was seen around mobility and the action taken and measures in place had been noted. All four residents who had completed the Commission‘s surveys said that they ‘always’ receive the care and support they needed and four staff members said that they are ‘always’ given up to date information about the needs of the people they support and care for. It is acknowledged that Frintondene has an established staff group who have worked with the residents for some time and they are therefore familiar with their care needs. Within the AQAA it was stated ‘We treat each resident’s needs individually. Personal health and care is obviously very important for their daily living, wellbeing and health.’ All four residents spoken to at the inspection told us that they were well cared for. Three people said that carers enable them to maintain as much independence as they are able. They spoke of being assisted with bathing and supported to go out for short walks in the locality. Alongside the care plans individual risk assessments have been developed. Risk assessments around going out alone, management of medication, bathing, washing and dressing and mobility around the home were seen. An example was seen for a resident around their mobility in the home and outside and aids and advice had been given to support them to maintain this degree of independence. Records were seen on the care-planning files of visits of health professionals such as GPs, chiropodist and the Diabetic Nurse. Three residents confirmed that they were supported and assisted to access their GP who would be called if they needed them. The registered manager said that she would not hesitate to call for a doctor should a resident need one. Evidence of visits by health professionals was to be found in the daily records for each resident. During the inspection, the registered manager decided that these records would be more accessible if they were kept separate. They decided to introduce a separate record sheet for health professionals. It was felt that this would encourage staff to produce more detailed records of these Frintondene DS0000017825.V371137.R02.S.doc Version 5.2 Page 12 visits. The current entries were varied as to the detail and content and whilst they may be sufficient this was not always evident. Within survey work conducted by the Commission, a GP had completed and returned a health professional survey. They were very positive regarding the health care of the residents. They said that they felt that the health care needs of the residents were ‘always’ met and care staff ‘always’ supported residents in the management of their medication. They said that the care service respected individuals’ privacy and dignity and the home would seek advice and act upon it manage and improve the individuals’ health care needs. Three out of four of the residents who had completed the Commission‘s survey work said that they ‘always’ received the medical support they needed and one person said that they ‘usually’ received the medical support they needed. Medication administration, record keeping and storage was sampled and inspected for the three people living at Frintondene. All seven residents were said to have medication, with one resident able to self-medicate. As at the last inspection, the home takes on the responsibility of ordering their medication following a review of the medicines held in their room. Secure storage is provided for the store of these medicines. The remainder of medication is held in a metal medication storage cabinet with a Controlled Drug cupboard. A monitored dosage system is used, with the majority of medication held in blister packs. Records and medication for three residents was sampled and inspected and overall this was found to be in good order. A recommendation was made regarding detailing a change to PRN for a medication. Whilst it was noted in the individual’s note it did need to be further detailed on the Medication Administration Record (MAR) sheet. The registered manager completed this during the inspection. The registered manager told us that the home had had a change in the branch of chemist dispensing their medication and there had been a few problems. They are hoping that this will be rectified and they will receive an improved service. All six carers had completed medication training in June 2008. Both the registered manager and a carer said that they felt this was a very good course for questions had been used to assess the competency of participates. They said that they felt this refresher training ensured that they were updated with regard to current practice. People living at the home are treated with respect and dignity. During the day, staff were seen to speak clearly and attentively to individuals and as they entered their room they waited for permission to enter. As noticed at the last inspection residents at Frintondene are addressed by their title, as is their wish. Frintondene DS0000017825.V371137.R02.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service People who live at the home can expect to be given choices about how they spend their time, visiting arrangements and meals. EVIDENCE: Within the AQAA it was stated that ‘The group of residents we have do not wish to partake in set activities together, they generally follow their own pursuits, hobbies and outings. Their daily life is fairly full, reading the paper, doing crosswords, going out and having visitors. Life is their choice and staff follow their routine needs and wants.’ This was confirmed from our conversations with four residents. All were able to tell us what they enjoyed doing in the home and when they went out. All four said that they enjoyed sitting in their room either reading their paper, doing the crossword, writing letters or watching television. One person said that they did not want a television preferring to listen to the news on the radio. Another person said that they enjoyed watching the ‘soaps’ on the television, watching DVDs and Frintondene DS0000017825.V371137.R02.S.doc Version 5.2 Page 14 reading their paper and a third resident said that they enjoyed watching television and reading their paper in their room. Activities and events, which take place in the locality, are promoted in the home. One resident said that continued to enjoy the productions put on by the local Summer Theatre and they are able to transport themselves to and from this event on their mobility scooter. They had attended some productions this year. Another resident continues to go to church each Sunday and regularly visits the Greensward or shops in the local shopping centre at Frinton on sea. All four residents spoken to at the inspection have some contact with their relatives. We were told that they could receive their visitor in private either in their room or in the newly created small lounge. Three out of the four residents who had completed the Commission‘s surveys said that they did not wish to join in any group activities and one added that most of the residents ‘receive family visits, which are welcomed by the staff.’ Three of the four residents spoken to at the inspection confirmed that they have contact with relatives and when they visit they are made very welcome. The registered manager said that residents are encouraged and supported to manage their own financial affairs for as long as they wish. They were able to give examples of how they had supported a resident to change from using a cheque to paying their fees by a standing order. It was evident that residents are able to bring in some of their personal possessions. Within each bedroom, residents had their own radio and/or television as they wished and residents told us they had brought in small pieces of furniture such as an armchair, bookcases and tables. Within their rooms we were able to see evidence of books, tapes, DVDs, videos and photographs and ornaments were on display. At this inspection I was able to speak with a carer who regularly cooked for the residents. They told us that menus are planned weekly. This was confirmed by the registered manager who said that food supplies are purchased weekly online from a local supermarket. Seasonal fresh fruit and vegetables are included in the menu planning and a local butcher and farm shop supply some fresh foods. Each day there are two main choices at the lunchtime meal. On the day of the inspection the majority of the residents chose cottage pie with fresh vegetables of carrots, greens and potatoes. Dessert was an apple crumble and cream. Normally four residents chose to have their meal in the lounge/dining room, but unfortunately the lift broke down, as the residents were about to come downstairs for lunch. Those who were able come down to have their meal and Frintondene DS0000017825.V371137.R02.S.doc Version 5.2 Page 15 we were able to join them. This was a pleasant occasion, for the food was attractively presented with residents being served. All four residents spoken to during the inspection complimented the home of the meals served and with the survey work completed two residents said they ‘always’ liked the meals served, whilst two residents said they ‘usually’ liked the meals served. Nutrition records were kept of food eaten and it was evident that the residents have a varied, nutritious diet. Frintondene DS0000017825.V371137.R02.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): 16 & 18. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at the home can expect their concerns to be taken seriously by the care home. EVIDENCE: Frintondene has a complaints procedure, which had been reviewed in March 2008. It was detailed and easily understood and stated that all complaints would be responded to within 28 days. The registered manager said that the home had had no complaints since the last inspection and should they have a complaint there were systems for recording and logging a complaint. Three residents spoken to at the inspection said that should they have a complaint they would raise their concern with the registered manager. All four residents who had completed the Commission ‘s surveys said that they did know how to make a complaint and one person said that ‘so far, I have had no reason to complain.’ Within the AQAA the registered manager had confirmed that the policy had been updated and staff were asked to read and sign to say that they have understood the policy. They went on to say ‘There is a very open policy for Frintondene DS0000017825.V371137.R02.S.doc Version 5.2 Page 17 complaints. All concerned are encouraged to speak their mind about anything. All complaints are treated with confidentiality and put right as soon as possible.’ They went on to say – ‘Residents and relatives speak about how safe and protected they all feel and they know they can speak to me anytime.’ This was borne out by our conversations with the residents and ensured that residents are safeguarded. Within the home there were policies on Protection and Abuse, which covered Whistle blowing, Missing Persons Incidents, Restraint and Identifying Abuse. Within this paperwork there were the details of the local Safeguarding Unit and the registered manager was able to outline the procedure should they need to make a referral. A member of staff who was spoken to at the inspection was also aware of the policies on Protection and Abuse and had some understanding of how to make a safeguarding alert. The registered manager said that whilst they have made use of the local authority training and publications on Safeguarding, they are looking to further Safeguarding Adults training in December 2008. Frintondene DS0000017825.V371137.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at Frintondene have homely, surroundings, which are kept clean and tidy. comfortable and safe EVIDENCE: Within the AQAA it is stated that – ‘The home is well maintained, light, airy and very homely. The residents are given a choice as to what colour schemes they may like in their rooms. They can bring in their own furniture and things to make the rooms more homely for them. The home is a safe, inviting place to be, as we are always being told.’ This was evident on our inspection, for residents had been able to personalise their rooms as they wished and told us that they were happy with their rooms. Frintondene DS0000017825.V371137.R02.S.doc Version 5.2 Page 19 Within the Commission‘s survey work completed by residents all four residents said that they found the home to be fresh and clean and this was the position on the day of the inspection. A maintenance and decoration programme is ongoing and tasks are identified and completed in a timely manner. Some remedial work is planned with regard to the carpeting on the 1st floor landing and staircase and the registered manager said that this is planned and to be completed in the immediate future, before the carpet is worn and becomes a hazard. On the day of the inspection the passenger lift broke down. The registered manager contacted the service engineer and the lift was back in operation the following day. The registered manager telephoned and confirmed that the repair work had been completed and the lift was fully operational. The ground floor bedroom has reverted to a small lounge/dining room and whilst the registered manager said that it is used only occasionally it is available for residents and their visitors as they wish. Residents continue to use both the rear garden and the front garden to sit out in the summer months. One resident told us that they enjoyed sitting out in the front garden where they were able to see people walking to the promenade. Frintondene has a laundry/utility room, which has one washer and one dryer. Both have been replaced in the last year. The laundry room has been decorated too. There is an outside hanging area for drying clothes and laundry duties are completed by day and night carers. One resident commented that the laundry is completed speedily and it was an efficient service. Frintondene DS0000017825.V371137.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at the home can expect to be supported by sufficient staff with skills and knowledge to meet their needs. They can be assured that appropriate recruitment practice has been followed to safeguard their welfare. EVIDENCE: Frintondene is a family run care home with members of the family working as carers at the home. Staff rotas were inspected and as at the last inspection the home runs with two carers on duty throughout the day and two carers on duty at night, one awake and one asleep/on call. The registered manager said that resident’s dependency levels remain much the same as previous and should it be needed staffing levels are adjusted to meet their needs. Three out of the four residents who had completed the Commission ‘s survey work said that staff are ‘always’ available when they needed them and they ‘always’ received the care and support they needed. The fourth resident said that ‘usually’ staff are available when they needed them and they ‘usually’ received the care and support they needed. Within the AQAA it was said that ‘the ratio of staff to residents is adequate at all times’ and at the inspection the registered manager said that they would bring in extra staff as was needed. Frintondene DS0000017825.V371137.R02.S.doc Version 5.2 Page 21 The registered manager said that the home is just short of the minimum ratio of 50 trained members of care staff with a National Vocational Qualification (NVQ) level 2 in care. One care worker has a NVQ level 2 in care, another carer hopes to complete their NVQ level 2 in care in October 2008 and a third carer will start their training in January 2009. On completion this will ensure the home has met the 50 minimum ratio. The staff recruitment files of two care staff were sampled and inspected. Evidence was seen of good staff recruitment practices with records and checks in good order. All staff are issued with a statement of terms and conditions and evidence was seen on each file of regular supervision sessions. These records detailed discussion on communication in the home, efficiency and time management and the care home’s philosophy. On each of the files inspected, evidence was seen of a programme of basic training courses. In 2008, care staff have completed Medication training, Basic Health & Safety training, Basic Food Hygiene and Appointed First Aider training. The registered manager said that the latter training course is to ensure that there is a trained First Aider on duty on each shift. In addition four carers including the registered manager have attended a course on the Mental Capacity Act in July 2008. The registered manager said that training in Infection Control, Manual Handling and Safeguarding Adults are planned for later in the year. All four staff members who had completed the Commission ‘s survey said that they were given the training relevant to their role and all said that the manager met with then to support and discuss their work. Frintondene DS0000017825.V371137.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home should be assured of good management with an ongoing quality and monitoring system in place and health and safety systems to ensure that the people living in the home are protected. EVIDENCE: The registered manager said that they had completed and were awaiting their certificate for the Registered Manager’s Award (RMA). They said that had one module to complete for the NVQ level 4 in care and they expected to complete that this year. Frintondene DS0000017825.V371137.R02.S.doc Version 5.2 Page 23 A quality assurance and quality monitoring system is ongoing. In June 2008 the home had surveyed their residents and their relative and local GPs. The questionnaire for the residents and relatives covered topics under the heading of Living in the Home. These questionnaires covered Catering and Food, Personal Care and Support, Daily Living, Premises and Management. All of the responses receive were positive. Health professionals had also been surveyed and these too were positive. One comment made by a health professional was that the home was – ‘Calm, warm, happy, welcoming and efficient.’ On completion of this survey work a quality assurance audit tool is completed and the results are published. The registered manager said that these are shared with the residents and their relatives either verbally or by letter if required. Within the AQAA it was stated – ‘We have so much positive feedback from our residents, relatives and people in the community.’ It went on to say – ‘Residents, staff and all who enter the home feel safe within their environment’. The registered manager said that the home does not hold any money or valuables for residents. Residents either manage their own money or their relatives assist them. The registered manager said that lockable storage facilities are available in each bedroom for the storage of valuables. Health and safety certification was sampled and found to be in good order. Hot water temperature checks and records of resident’s hot water taps in their bedrooms and in the bathrooms are kept and recorded. The temperatures were around 44° C. Monthly visual checks are completed of electrical equipment held in the home and an annual Portable Appliance Test (PAT) was completed on all appliances in July 2008. The registered manager said that home has a Waste Transfer Service Contract in place for collection of yellow bag waste. This had been renewed in 2007 to cover 2008. A Fire Service Inspection was completed in June 2008 and the registered manager said that some verbal recommendations were made. They told us that these are to be included in the maintenance tasks listed in the Maintenance Book. This was seen and found to be listed as work to do. Gas safety records were seen for March and April 2008. These covered servicing and work completed by the engineer. Frintondene DS0000017825.V371137.R02.S.doc Version 5.2 Page 24 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Frintondene DS0000017825.V371137.R02.S.doc Version 5.2 Page 25 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. Refer to Standard OP7 Good Practice Recommendations The home should ensure that full detail of the action to be taken by care staff is clearly noted with care plans to ensure that care staff are fully aware of the care needs of the resident. Frintondene DS0000017825.V371137.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Frintondene DS0000017825.V371137.R02.S.doc Version 5.2 Page 27 - 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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