Care Home: Frithwood Nursing Home, The

What the care home does well The home is managed well with residents and visitors being satisfied with the care and support provided in the home. The meal provision in the home is nutritious and varied to meet individual preferences. The quality of the care provided in the home is reviewed on an ongoing basis and the views of residents and visitors are welcomed. Overall the staff team are trained and have the skills and information they need to appropriately care for the residents. Residents can make choices and decisions, where able, on a daily basis. What has improved since the last inspection? Care plans were detailed and up to date. The home had worked to address the heating problems. A new boiler had been fitted and this had eliminated the previous heating issues. Several bedroom carpets had been changed and all wardrobes now locked. The laundry room had now been provided with adequate ventilation. CARE HOMES FOR OLDER PEOPLE Frithwood Nursing Home, The 21 Frithwood Avenue Northwood Middlesex HA6 3LY Lead Inspector Sarah Middleton Key Unannounced Inspection 2nd September 2008 09:45 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 Frithwood Nursing Home, The DS0000010931.V371412.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. Frithwood Nursing Home, The DS0000010931.V371412.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Frithwood Nursing Home, The Address 21 Frithwood Avenue Northwood Middlesex HA6 3LY 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) 01923 820 955 01923 842 684 fnh@mdhomes.co.uk MD Homes Carolyn Estabilla Care Home 20 Category(ies) of Physical disability (20) registration, with number of places Frithwood Nursing Home, The DS0000010931.V371412.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 categories: 2. Physical disability - Code PD The maximum number of service users who can be accommodated is: 20 31st July 2006 Date of last inspection Brief Description of the Service: Frithwood Nursing Home is a converted detached house situated in a residential area of Northwood. It has a well-maintained private garden at the rear of the property. The accommodation consists of fourteen single and three double rooms. There are two bathrooms and two shower rooms plus toilet facilities throughout the home. There is a day room and a dining room for residents to utilise. Local transport facilities are available in the form of buses and Northwood Underground Station. The Registered Manager deals with the care management for the home. The Operations Manager deals with the financial and personnel management of the four homes within MD Homes. The homes fees are £735-£850 per week, subject to assessment. Frithwood Nursing Home, The DS0000010931.V371412.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. This was an unannounced inspection carried out between 9.45am-7.45pm. We viewed various documents, such as, resident’s files, health and safety records and staff training records. One postal survey was returned and we spoke with two staff, two visitors and four residents. “We” refers to the Inspector who carried out the inspection. The Registered Manager and the Operations Manager were present for the inspection. The Registered Manager will be referred to as the Manager in this report. The Manager had completed the Annual Quality Assurance Assessment, which is a self-assessment that focuses on how outcomes are being met for the residents. There were nineteen residents in the home at the time of the inspection. The home had met all the previous eight requirements and one requirement were made from this inspection visit. All of the key National Minimum Standards were inspected. What the service does well: The home is managed well with residents and visitors being satisfied with the care and support provided in the home. The meal provision in the home is nutritious and varied to meet individual preferences. The quality of the care provided in the home is reviewed on an ongoing basis and the views of residents and visitors are welcomed. Overall the staff team are trained and have the skills and information they need to appropriately care for the residents. Residents can make choices and decisions, where able, on a daily basis. Frithwood Nursing Home, The DS0000010931.V371412.R01.S.doc Version 5.2 Page 6 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. Frithwood Nursing Home, The DS0000010931.V371412.R01.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 Frithwood Nursing Home, The DS0000010931.V371412.R01.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 is N/A. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are assessed prior to admission to the home to ensure that the home can meet their needs. EVIDENCE: The Annual Quality Assurance Assessment stated that the home has a detailed pre-admission assessment to decide if a resident can move into a home. This was confirmed as copies of Social Services needs led assessments were seen along with the home’s pre-admission assessments. Frithwood Nursing Home, The DS0000010931.V371412.R01.S.doc Version 5.2 Page 9 Documentation for three pre-admission assessments was viewed. These provided clear information such as the prospective resident’s health and personal care needs. Either the Operations Manager or the Manager completes the pre-admission assessments. We discussed also involving the newly appointed Deputy Manager during the pre-admission process. Prospective residents and their relatives are also invited to visit the home and to spend time meeting other residents and members of staff. Relatives are encouraged to bring personal possessions into the home so that when the new resident moves into their new bedroom they can see familiar items around them. Frithwood Nursing Home, The DS0000010931.V371412.R01.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ care plans are well maintained and detailed, thus providing information as to the residents’ needs and how these are to be met. The medication shortfalls identified could place the residents at risk. Residents are treated in a respectful and caring manner. EVIDENCE: We viewed three residents’ plans. Currently the Manager completes the care plans and risk assessments. Those viewed were comprehensive and recorded the residents’ needs, such as their mobility, personal care needs and social interests. Religious needs had also been assessed and noted on the care plan. Each file had a photograph of the resident and there was information about the resident’s previous occupation, which could be informative and useful for the Frithwood Nursing Home, The DS0000010931.V371412.R01.S.doc Version 5.2 Page 11 staff team. There was some evidence that residents had been involved or made aware of the care plan. Risk assessments were in place for identified risks on all the files viewed. The Annual Quality Assurance Assessment recorded that various risk assessments are in place so that potential risks are considered and minimised. This was confirmed during the inspection as those risk assessments seen covered areas such as risk of falls, developing pressure sores and bedrail assessments. The Manager had updated the care plans and risk assessments on a monthly basis. There were no residents with pressure sores or wounds at the time of the inspection. Pressure relieving equipment is in the home and the Manager was aware of the need to carefully document if a resident has a pressure sore and to make a referral to the Tissue Viability Nurse. Moving and handling dependency, nutritional and continence assessments had all been completed. Where bedrails are used, risk assessments and consent forms had been completed, to ensure these are used safely and appropriately. All residents have a GP and can have access to other health professionals, such as dentist, optician and chiropodist. Each file records appointments so that it is easy to monitor health visits. We viewed a sample of medication records. A registered nurse administers medication. Nurses receive training and information on medication. No residents self-medicate. We viewed the book outlining returned medicines and the home disposes of medication in line with current legislation. Any allergies are noted on the medication administration record (MAR). The list of staff signatures able to administer medication was out of date and brought to the attention of the Manager who will update this. The majority of medication is delivered in a sealed blistered pack. Liquid medicines seen had dates of opening written on them. Controlled drugs were stored in a separate locked cupboard. The controlled drugs in the home were counted and were correct at the time of the inspection. The controlled drugs register was viewed and evidence that one nurse administers this medication and another signs to witness this medication has been administered. All medicines are stored safely and appropriately. We counted three residents medication. It was noted that for one resident there was too much medication. We checked the current medication administration record and the previous month’s record but could not ascertain where the error had occurred. The home carries forward medication from the previous month and this is recorded. Errors can occur when there is an overstock of medication in the home. Although the Manager stated that the medication is checked there was no written evidence of this and therefore it was not clear when the last audit had occurred. A requirement was made for regular medication checks and full counts of the loose medication, in boxes and bottles to be carried out. Regular checks can pick up on medication errors quickly. Evidence of these checks need to be available for inspection. Subsequent to the inspection the Manager carried out a full medication check and no other errors were identified. Frithwood Nursing Home, The DS0000010931.V371412.R01.S.doc Version 5.2 Page 12 Personal care is given in private and those residents asked commented positively on the care they receive from staff. We saw staff regularly interact with the residents in a caring and gentle manner. Residents were appropriately dressed and most items of clothing are labelled with each resident’s name. Overall the residents looked well cared for and supported in a professional way. Frithwood Nursing Home, The DS0000010931.V371412.R01.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall residents are encouraged to take part in activities to suit their individual interests. Residents can see family and friends as they so wish, thus maintaining social relationships. Residents’ rights are respected and promoted within the home. The food provision is good and residents can have a choice of the meals they eat. EVIDENCE: We were informed that the activities co-ordinator had left the home and currently there was not a designated member of staff in charge of ensuring activities take place. Frithwood Nursing Home, The DS0000010931.V371412.R01.S.doc Version 5.2 Page 14 This was discussed with the Operations Manager and Manager as it is crucial that someone takes a lead in organising regular activities and where possible outings. We were informed that in the past when transport had been arranged for a trip out of the home, residents, who had initially agreed to go out, then refuse to do so on the day. Although this issue was acknowledged, the home has its own form of transport and can take out a few residents at a time. Therefore trips out could be offered on an ongoing basis to encourage residents to have a change of routine. The Annual Quality Assurance Assessment stated that outings are organised each month but as stated above this could not be evidenced. The Annual Quality Assurance Assessment also noted that plans for improvement would be to produce an activities timetable to keep the residents informed. This is seen as good practice and would enable residents to clearly know what is going to happen each day in the home. One resident enjoys going out with staff and is supported to attend their preferred place of worship. One visitor commented that the home could offer more activities. The Manager should ensure there are sufficient numbers of staff working in the home so that, along with the everyday tasks and jobs to do, staff have the time to provide a stimulating home for the residents to live in. This will need to be monitored by the Manager to ensure this Standard is met and will be looked at again at the next inspection visit. Two visitors were seen and spoken with during the inspection. They visit daily and can visit at anytime. One resident had been referred to Age Concern for an advocate, as they spoke little English. They had met with an advocate once and the Manager is hopeful this will become a regular form of support for this particular resident. Staff have learnt some words in the resident’s language and there is one member of staff who can fully communicate with this resident. The lunchtime period was observed. Those residents needing assistance with feeding were supported in an appropriate manner. We viewed the kitchen, which is a large room suitable for catering for the residents. Menus were seen and these evidenced the variety in meal provision offered in the home. Those residents asked said they enjoyed the meals. The cook was aware of special diets, for example those residents who needed food to be pureed. Family members can also inform the cook of the resident’s preferences and evidence was seen of this. The cook also confirmed that she prepares cultural meals for some residents, when they do not always want to eat the more traditional food that is usually on offer. Frithwood Nursing Home, The DS0000010931.V371412.R01.S.doc Version 5.2 Page 15 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. Residents or visitors can feel confident that issues raised would be addressed by the home. The system in place for protecting the residents is robust and therefore safeguards the residents. EVIDENCE: There had been no complaints since the last inspection. Residents spoken with said they would feel able to speak with staff if they had any concerns. The home would follow the Hillingdon Safeguarding Adults procedures. Staff spoken with said they would report any concerns they had to the Manager. There have been no safeguarding referrals or investigations about any residents since the last inspection. Frithwood Nursing Home, The DS0000010931.V371412.R01.S.doc Version 5.2 Page 16 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, 24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall residents live in a safe, clean and welcoming home. EVIDENCE: We carried out a tour of the home and were informed that the home is still hoping to expand and build an extension to the side of the home, once planning permission is granted. This would provide the Manager with a separate office and six additional bedrooms. The home had worked hard to address the previous shortfalls identified at the last inspection. The damaged bathroom lock had been fixed. Lockable wardrobes were seen in a sample of bedrooms, so that residents could lock their personal possessions. Frithwood Nursing Home, The DS0000010931.V371412.R01.S.doc Version 5.2 Page 17 Several bedrooms and the main hallway had new carpets fitted. The laundry room had additional ventilation in this room so that was no longer too hot. The heating was now working, with a new boiler fitted. However in bedroom ten it was noted that there was still a portable heater that was not covered. This had been noted in the 2006 inspection, as there had been heating problems at that time and several portable appliances had been seen that did not have low surface temperatures. This issue was discussed with the Operations Manager and Manager and this portable radiator was removed at the time of this inspection. Although it was acknowledged that it was at the far end of the bedroom next to the existing covered radiator, if used it could pose a risk to the resident. If residents are cold with the current heating systems in the home then the home should consider obtaining more suitable and safer additional heating appliances. We were satisfied that the home will not use the uncovered portable heating appliances again and that they were aware of the potential risks. Bedroom ten’s carpet had stains on it and it is recommended that this is cleaned or replaced. The ongoing maintenance of the home needs to be a priority for the Manager to ensure the home continues to look welcoming and appealing for both residents and visitors. Frithwood Nursing Home, The DS0000010931.V371412.R01.S.doc Version 5.2 Page 18 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was sufficiently staffed to meet the needs of the residents. Staff had received appropriate training so that they were equipped and informed about how to care for the residents. Robust recruitment procedures are in place to safeguard the residents. EVIDENCE: We viewed the rota and were satisfied that there were good staffing levels for the residents. Five staff work in the mornings and three in the afternoon. There is always one nurse working on a shift. Some staff work a long day but we were informed those staff would receive a break during the day. No agency staff are used and when extra staff are needed then staff are sought from another local MD Home. The home did not have any students working in the home at the time of the inspection. It was discussed with the Manager the benefits in reviewing staffing levels on an ongoing basis, as the residents needs can change and when this occurs, staffing levels might then need to be looked at and possibly increased at certain times. Frithwood Nursing Home, The DS0000010931.V371412.R01.S.doc Version 5.2 Page 19 Those staff asked said the staff team work well together and that there is good communication within the team. Staff meetings are held on a regular basis and there is a handover every day. The home encourages the staff, who do not hold a professional qualification, to study for an NVQ. The cook is currently studying for an NVQ in catering and other care staff have applied to start with an NVQ level 2 in the near future. The home supports new staff to attend English classes so that they can improve both their understanding of the spoken and written language. The Operations Manager confirmed that the home would not employ a member of staff who had no understanding of English. Four staff employment records were viewed. These contained the information required, such as two references, Criminal Record Bureau checks and details of employment history. We discussed with the Operations Manager and Manager the need to ensure that the references match with the details of the referrers on the application forms and that is made clear as to why there might be times when another reference might need to be sought. Furthermore we also discussed that where possible, even if the previous job was not in social care, one reference should be from that previous employer. This can still provide the home with information about the potential member of staff, such as their sickness record, time keeping and character. The induction used by the home is in line with the Skills For Care core Standards. The Operations Manager and Manager will consider also reintroducing an in-house induction more specifically about the home. New staff also spend time shadowing existing member of staff. Overall staff had received training in the core subjects, such as fire awareness and moving and handling. The Manager has an overall training plan and this along with individual training records were seen. Some of the MD Homes staff are trainers and can therefore ensure the whole staff team are up to date with information and skills they need to care for the residents. Some of the training is via a video. This form of training should be reviewed on a regular basis to ensure it provides the most up to date information for staff. The domestic member of staff had not attended moving and handling training and the part time cook needed to attend a refresher course in food hygiene. It is recommended that the Manager monitors and maintains the training record on a regular basis so that all staff are up to date with the training they need. Specialist training is also provided on subjects such as Mental Capacity act and dementia care. The Manager and recently appointed Deputy Manager are to commence training on Palliative Care, known as the Gold Service Framework. Frithwood Nursing Home, The DS0000010931.V371412.R01.S.doc Version 5.2 Page 20 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed. Systems are in place for reviewing the quality of care offered in the home. Residents’ monies are recorded and checked thus protecting the residents’ financial interests. The health and safety checks in place protect the residents, staff and visitors. Frithwood Nursing Home, The DS0000010931.V371412.R01.S.doc Version 5.2 Page 21 EVIDENCE: The Manager is a registered nurse and has completed the Registered Managers Award NVQ level 4. The home has recently appointed a new Deputy Manager and the Manager is going to be spending time showing her how the home is managed. Those staff asked said they found the Manager to be supportive and approachable. We regularly receive the Regulation 26 reports that are carried out on the visits in the home. Surveys are sent to visitors and for residents to complete and the results are analysed. Relatives meetings are held on an ongoing basis and residents can speak with staff or the Manager if they have any issues they wish to discuss. Staff meet with health professionals on an ongoing basis and any issues are discussed at these meetings. The Operations Manager spoke about the recruitment of a new Quality Assurance Manager. Their role would be to monitor the homes and the care being provided. The Annual Quality Assurance Assessment notes that the home does not have a development plan and that this should be implemented. This would be seen as good practice as it could enable the home to focus on the main aims and objectives of the home. We discussed providing a short summary of the work the home has been doing to provide quality care to the residents. This short report could then be made available for the Commission and residents. The home manages three residents’ personal monies. Each resident has a named bank account and the home pays out initially for any expenditure and periodically this expenditure is totalled up and the money paid from the residents account to meet this total. Receipts are obtained and records of financial transactions are maintained. We discussed payments when residents go on holidays with staff. It is usual practice for the resident to fund the member of staff to accompany the resident on a holiday. This is agreed with the resident, however we advised that it should be made clear in the home’s Statement of Purpose and Service Users Guide, so that all residents, their relatives and the funding authority are fully aware that this would be the procedure when planning a holiday with staff support. The Operations Manager acknowledged this and would address this in the MD Homes documentation. Frithwood Nursing Home, The DS0000010931.V371412.R01.S.doc Version 5.2 Page 22 Servicing and maintenance records were viewed and those seen were all up to date. Fire drills are held weekly and the local fire officer had visited the home in July 2008 and made no recommendations. We viewed the fire risk assessment and the Operations Manager who completes some of this confirmed she had attended training on how to complete fire risk assessments. We recommended for the home to carry out individual fire risk assessments on each resident, as the home should be confident that all residents could be safely evacuated if a fire was to occur. Water temperatures are taken on a weekly basis with no noted areas of concern. Frithwood Nursing Home, The DS0000010931.V371412.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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Frithwood Nursing Home, The DS0000010931.V371412.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement To protect the health and safety of the residents, medication systems must be robust. Regular audits of all medicines must be carried out and evidence of this be made available. Timescale for action 05/09/08 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. 4. Refer to Standard OP12 OP19 OP30 OP38 Good Practice Recommendations It is recommended that daily activities and trips are made more available, thus enabling residents to lead a full and stimulating life. To ensure residents live in a welcoming and inviting bedroom ten must be painted where needed and the carpet cleaned or replaced. It is recommended for all staff to receive regular training for the work they are to perform. Individual fire risk assessments should be completed to ensure risk are recorded and known for each resident. Frithwood Nursing Home, The DS0000010931.V371412.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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. 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