Care Home: Frocester Manor

What the care home does well As part of this inspection we sent questionnaires to parents and relatives of people living at the home. Comments received included: "My relative is happy and safe". "I would recommend Frocester Manor to anyone". "It provides a caring environment that allows my relative to lead a fulfilling lifestyle." "My relative is able to choose what they want to do". Person centred Plans make good use of photos and pictures to support people with communication difficulties. People living in the home lead active lifestyles supported by the staff as required. People said that the food is nice and that they are able to choose what they eat. People living at the home benefit from warm, comfortable and homely accommodation that meets their current needs. The re-development of the annex shows the organisation`s forward thinking to meet people`s future potential needs. Health and safety across the site is thoroughly assessed and monitored minimising potential risks. What has improved since the last inspection? The accommodation across the site has improved since the previous site visit through the re-development of existing accommodation, and the ongoing maintenance programme being completed in other areas. File management has improved since the previous site visit and this makes it simpler to access information. Person Centred Plans provide the reader with extensive information about what the person wants to achieve. What the care home could do better: Some of the records examined as part of this site visit were in need of review to ensure that people`s needs were still being met. Progress towards people`s goals was well recorded in a number of examples seen on the day. Unfortunately this was not consistent and it was impossible to judge whether some people`s goals were being achieved. CARE HOME ADULTS 18-65 Frocester Manor Frocester Nr Stonehouse Glos GL10 3TF Lead Inspector Mr Paul Chapman Key Unannounced Inspection 12th December 2007 09:00 Frocester Manor DS0000016443.V344749.R01.S.doc Version 5.2 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 Frocester Manor DS0000016443.V344749.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 Adults 18-65. 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. Frocester Manor DS0000016443.V344749.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Frocester Manor Address Frocester Nr Stonehouse Glos GL10 3TF 01453 822342 01453 791781 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.hft.org.uk Home Farm Trust Miss Clare Linda Seeley Care Home 43 Category(ies) of Learning disability (43) registration, with number of places Frocester Manor DS0000016443.V344749.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27/07/06 Brief Description of the Service: Frocester Manor is a large manor house situated in substantial grounds in Frocester, nr Stroud. It is owned by The Home Farm Trust and can provide accommodation for up to 43 people with learning difficulties. The accommodation is made up of four buildings across the site (inc. the manor house) and provides people with large communal areas including a wellmaintained garden. All of the people have individual bedrooms, and some have small flats with cooking facilities. The home has access to a number of vehicles that allows people to make use of facilities in Stroud and other surrounding towns. Frocester Manor DS0000016443.V344749.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This site visit took place in December 2007. The registered manager was not on duty and staff in each of the units and the service manager supported us to complete the inspection. An AQAA (Annual Quality Assurance Assessment) was completed by the registered manager prior to the site visit being completed. Questionnaires were supplied to people living in the home, relatives and other professionals involved in people’s care. Time was spent observing the care of people and their interactions with staff. A number of people living in the units across the site were spoken to and several people’s rooms were inspected on their invitation. The care of six people was looked at in depth that included looking at their financial, medication and personal records. A new member of staff was spoken with about their recruitment process and induction/training. Other staff were spoken with across the site about the care they provide. Other records examined included staff files, health and safety information and quality assurance records. What the service does well: As part of this inspection we sent questionnaires to parents and relatives of people living at the home. Comments received included: “My relative is happy and safe”. “I would recommend Frocester Manor to anyone”. “It provides a caring environment that allows my relative to lead a fulfilling lifestyle.” “My relative is able to choose what they want to do”. Person centred Plans make good use of photos and pictures to support people with communication difficulties. People living in the home lead active lifestyles supported by the staff as required. People said that the food is nice and that they are able to choose what they eat. Frocester Manor DS0000016443.V344749.R01.S.doc Version 5.2 Page 6 People living at the home benefit from warm, comfortable and homely accommodation that meets their current needs. The re-development of the annex shows the organisation’s forward thinking to meet people’s future potential needs. Health and safety across the site is thoroughly assessed and monitored minimising potential risks. 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. Frocester Manor DS0000016443.V344749.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Frocester Manor DS0000016443.V344749.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 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 may wish to live in the home have access to information about the service and are fully assessed before deciding whether to move in. EVIDENCE: The home has an admissions policy and procedure that involves obtaining an assessment from a person’s placing authority and information from their previous placement. People are also invited to visit the home and provided with information about the service they will receive. No new admissions were examined on this occasion. Frocester Manor DS0000016443.V344749.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 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. All people have Person Centred Plans (PCP) that highlight what is important to them and what they would like to achieve. Recording what had been achieved was inconsistent making it impossible to confirm that all people’s goals are being achieved. People are enabled to make decisions about their lives and staff provide them with support to do this where it is required. Completed and regularly reviewed risk assessments enable people to take acceptable risks as part of their day-to-day lives. EVIDENCE: Across the site the home is split up into five separate units. On this occasion three of the five units were visited and the care and support of two people in each of those units was examined in detail. The home has a person centred approach to peoples’ care. The documents examined by us were well designed making good use of photos and symbols to Frocester Manor DS0000016443.V344749.R01.S.doc Version 5.2 Page 10 support people’s communication difficulties. The plans identify important people in their lives, places they like, health needs, activities, likes and dislikes, dreams and fears and other items. In addition to this each person has a personal file that contains all other relevant information like financial details and records of medical appointments. All documents are stored securely. In two of the units people sat with us and explained their plan. They went through the plan explaining which goals had been achieved and who had supported them. It was clear from the comments made by these people that they had been involved in developing their plan and this was supported by the fact that some of the plan had been written by them. Where we were not able to sit and go through people’s plans with them documents showed their input. The Annex The detailed examination of two people’s files showed the following: • • Both of the PCP’s provided a good level of detail and made good use of photos and pictures to support communication. 1 PCP provided good evidence of the person’s goals being achieved; the other PCP provided limited evidence of goals being achieved. The manager and staff should ensure that the reviews provide evidence of people’s goals being achieved. If they are not being achieved the reason should also be recorded. A number of documents in each person’s file were not dated and this made it difficult to judge their value. The manager and staff should ensure that all documents are dated when they are created. Some documents were blank (for example: - communication support, specific agreed practices). If people do not have needs in these areas then the form should state this. • • Speaking with one person living in the annex they explained that their key worker had sat with them and asked them what they wanted to write. They said that they thought the PCP was a good idea as “things written in it get done”. They gave an example of wishing to have a garden outside their window. This had been completed. The person said that they were happy living in the home. The Bungalow The detailed examination of two people’s files showed the following: • One person sat with us and explained their PCP. They explained that they keep it in their bedroom. They stated that they had helped their key worker to put it together. Like others seen it made good use of photos and pictures to document goals and achievements. The person said that each month they complete a review with their key worker. The person stated that their goals were being met; other written evidence seen supported this. DS0000016443.V344749.R01.S.doc Version 5.2 Page 11 Frocester Manor • • • The other PCP examined was significantly out of date and need of review. The manager must ensure that this is addressed. Each person’s file was well organised and this made it easy to find information. Since the previous site visit was completed all of the personal files for people living in the home have been standardised. This is good practice and makes it easier to find information. One of the personal files showed a number of documents in need of review. This was brought to the attention of the staff on duty. The Lodge The detailed examination of two people’s files showed the following: • • • Both of the PCP’s provided a good level of detail. Again one person volunteered to sit and explain their PCP to us. From their comments they were really proud of their PCP and the input they had into developing it. The information contained in both of the personal files had been regularly reviewed by staff. A shortfall brought to the attention of the staff on duty related to the plan to support a person with their personal care. The information was limited and it was felt that this might affect the staff’s ability to provide a consistent approach to meet the person’s needs. Some other minor shortfalls noted were staff not signing and dating documents. Speaking to people during the day of the site visit provided examples of people being able to make decisions about their lives. Examples included the activities they completed, the food they choose and the people they spend time with. Where required staff support people to make decisions. All but one of the files examined contained numerous risk assessments completed by the staff that are trained appropriately. It is the home’s practice that once the assessments have been written the registered manager reads and approves them, or returns them to staff for revision. All risk assessments were reviewed regularly. HFT use a programme called Assessnet for completing risk assessments. The only concern highlighted was in the lodge where the only risk assessment found for one person related to their financial management. Staff must ensure that risk assessments are written that look at all areas of the person’s life. The CSCI supplied surveys to people in the home. Six people responded and this makes it impossible for the findings to be representative of all of the people living in the home. The majority of the responses received were very positive about the home; people were able to confirm that their needs are being met. Frocester Manor DS0000016443.V344749.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 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 lead active lifestyles supported by the staff. People have choices about what they would like to eat. EVIDENCE: Frocester Manor DS0000016443.V344749.R01.S.doc Version 5.2 Page 13 The home has been part of the local community for in excess of thirty years and continues to have a good relationship with the neighbours. People spoken to during the day stated they feel they are part of the local community. A range of opportunities are available, including attending the day centre on site, or day services in the community and Colleges in Stroud. Speaking to a member of staff during the site visit they explained that they will be managing the day service in the future and spoke with enthusiasm about some changes that will be made. A range of personalised activities are accessed by each of the units across the site. Activities are recorded in people’s personal files, monthly reviews and daily notes. Leisure activities that take place off site included: horse riding, attending various local social clubs, bowling, going to pubs, eating out, theatre, cinema, shopping and swimming. Speaking with people from the different units across the site they gave us examples of the holidays they had been on since the previous inspection was completed. Each person spoken with was able to give a good account of their holiday and what they enjoyed. A number of the people attend the local church, and staff support somewhere it is appropriate. Anybody can attend church when they wish. We received 14 completed questionnaires from parents and relatives. All of the comments were positive about the service being delivered at the home. 1 parent spoke about the support staff provide to enable them to see their son/daughter. All of the people spoken to at the site visit stated that they were able to see parents and relatives, whether this is at the home or visiting them. The different menus across the site were seen to provide people with a varied and nutritious diet. Each of the people spoken with were happy with the food. All of the people stated that snacks and drinks were available when they wanted them, and that they choose what meals are prepared. The annex now has its own kitchen where they prepare the majority of their own meals. Staff spoke about how this has enabled people living in the unit to become more involved in food preparation. The AQAA completed by the registered manager states that an aim for the next 12 months is to develop more pictorial menus for people with communication difficulties. This will support people to have more choices. Frocester Manor DS0000016443.V344749.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 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. Personal care needs are highlighted and plans are in place to enable staff to address those needs. The home make good use of other professionals to meet people’s needs where they are unable to. The shortfalls identified with the Medication administration is putting people at unnecessary risks. EVIDENCE: As identified earlier in this report a shortfall in the unit called The Lodge related to the detail in 1 person’s guidelines for their personal care. Other guidelines seen provided a good level of detail. The manager should ensure that where anyone requires support with their personal care detailed guidelines are available to ensure a consistent approach by staff. A review of peoples’ needs should be completed to ensure that appropriate guidelines are in place for all people. The files examined gave numerous examples of where other professionals were involved in meeting peoples needs. In addition to this appointments with Doctors, Dentists, Opticians and Chiropodists were recorded. The staff show a Frocester Manor DS0000016443.V344749.R01.S.doc Version 5.2 Page 15 good awareness of people’s changing needs due to increased mental and physical frailty. Care files provided good evidence of working with other professionals to meet people’s needs in this area. Medication administration was assessed in each of the units. The Annex • The documents signed by staff to confirm they have given people their medication were examined. Records for 3 people showed gaps in recording for December. This was brought to the attention of the senior staff member on duty. Some topical creams had been opened but not labelled with the date making it impossible to judge whether they were still fit for safe use. The temperature of the medication fridge had not been recorded for the 3 days before this site visit. Medication to be returned to the pharmacist must be must be stored securely. Medication changes were being hand written by staff. Where this happens the staff member making the change must sign the alteration. • • • • The Bungalow • The documents signed by staff to confirm they have given people their medication were examined. Records for 2 people showed gaps in recording for December. This was brought to the attention of the staff member on duty. One container of topical cream had been opened 3 months ago and should be disposed of. • Cotswold House • The documents signed by staff to confirm they have given people their medication were examined. Records for 1 person showed 2 gaps in recording for December. This was brought to the attention of the senior staff member on duty. Medication changes were being hand written by staff. Where this happens the staff member making the change must sign the alteration. Medication stock was being managed appropriately. • • The shortfalls identified above become requirements and recommendations of this inspection report. The AQAA completed by the registered manager states that over the last 12 months they have addressed medication errors. Although medication administration has improved the manager must continue to monitor this area as this inspection shows that shortfalls are still present. Frocester Manor DS0000016443.V344749.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 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 are able to make a complaint if they are not happy with the service they are receiving. The home’s policy and staff training minimises the risk that issues will not be addressed appropriately. EVIDENCE: The home has a complaints policy. The management team of the home have dealt with previous complaints appropriately, following the procedure detailed in the home’s policy file. The Commission for Social Care Inspection have received no complaints about the home. The AQAA completed by the registered manager states that 4 complaints have been made in the previous 12 months. 2 of these have been resolved, while 2 others remain open. Throughout the day of this site visit where possible we spoke to people about how they would go about making a complaint if they were unhappy with something. All of the people spoken with were aware of the complaints procedure and believed that if they were unhappy the staff would listen to them. The questionnaires completed by people living in the home confirmed that they are aware of the complaints procedure and have access to it. Frocester Manor DS0000016443.V344749.R01.S.doc Version 5.2 Page 17 During the site visit we spoke to new staff about their induction and specifically about safeguarding adults. They confirmed as part of their induction they received training in the safeguarding of adults. Where people are unable to manage their own money it can be held securely in each unit. Where this is the case people stated that they could have their money whenever they wish. Records of income and expenditure were examined for 2 people in each of the units visited. No errors were found. The AQAA completed by the registered manager states that over the next 12 months they intend that staff will attend all available training in safeguarding adults. The training records seen during this site visit confirmed that the majority of staff had completed training in safeguarding adults. Frocester Manor DS0000016443.V344749.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 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. The home provides people with a comfortable, homely and friendly environment that meets their current needs. The organisation have a good awareness of people’s potential future needs and accommodation has been designed to fit them. EVIDENCE: Since the previous site visit the redevelopment across the site has been completed. The Annex – The biggest changes have been made to the annex unit. It is now separated from the main house with a locked door, has its own kitchen, and the communal area and bedrooms have been re-furbished. The unit has a homely, warm and friendly atmosphere. All of the bedrooms are en-suite and the rooms seen were decorated to a high standard and personalised with people’s Frocester Manor DS0000016443.V344749.R01.S.doc Version 5.2 Page 19 possessions. 1 bedroom has a lounge area. One person who spoke to us said that they had been able to choose the colour of their bedroom. There are 2 assisted bathrooms in the annex, 1 has been renewed within the past 12 months. 1 person has an assisted shower room as an en-suite. In addition to the assisted bathrooms in the Annex overhead tracking has also been fitted (although not in use at present), this is planning ahead for the future as people in the annex may require more support with their physical needs. Staff explained that to the front of the annex they are going to develop a garden with the people living in the annex. The Bungalow – Visiting the bungalow the staff on duty explained that the unit was due to be decorated throughout in the New Year, and a new 3-piece suite had been ordered. The unit provides the people living there with a lounge and kitchen/diner and separate bedrooms. 1 person invited us to see their bedroom, it was decorated to a high standard and they explained that they had recently had a new carpet fitted (which they had chosen). The member of staff explained that all of the people living in the unit had agreed on a joint PCP to create a sensory garden outside the unit. Unfortunately due to the poor summer in 2007 they had not been able to complete this goal, but it was their hope that this would happen in the near future. 1 person stated that they were really looking forward to this being completed. It is recommended that the carpet in the lounge be replaced. The bungalow is a warm, comfortable and homely. The Lodge – The Lodge has been decorated throughout since the previous site visit was completed. Staff on duty showed us around the home, and 2 bedrooms were seen. Cotswold House – This unit has also been decorated. All of the people spoken with during the day were happy with their accommodation. This was further supported by the completed questionnaires received by us. All of the units were clean and hygienic and are decorated and maintained to a good standard throughout. The quality of the accommodation has greatly improved over the past 5 years. Comments from the completed staff questionnaires received by the CSCI confirm that since the re-development people’s needs are being better met. Frocester Manor DS0000016443.V344749.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 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. The home’s robust recruitment process ensures that people living in the home are not put at unnecessary risks. With appropriate training people living in the home are empowered to be actively involved in the recruitment by staff. A comprehensive training programme is available for new and established staff that enables them to meet people’s needs. EVIDENCE: All staff have job descriptions and contracts of employment. 1 member of staff that we spoke to had only been employed for a month. They explained that people living in the home were involved in the interview process and showing them around the site. The member of staff explained that the interview panel was made up of 2 staff and 2 people living in the home (who lead the interview). This practice has been discussed with the manager at the previous site visit. They explained that before people are involved in staff recruitment each person receives training in an interview skills group where Frocester Manor DS0000016443.V344749.R01.S.doc Version 5.2 Page 21 they discuss questions, methodology, confidentiality and practice techniques. This is excellent practice that enables people living in the home to have a valuable input into the recruitment of staff. Recruitment records was examined for 2 new staff that have started since the previous inspection was completed. No shortfalls were found which minimises potential risks to people living in the home. All new staff receive a comprehensive induction when they start at the home, and one staff member has responsibility for supporting them through this process. All elements of the induction process are signed by both parties to confirm the element has been completed and understood. In addition to this new staff complete the mandatory training required by the regulations. This induction process is excellent as it ensures that new staff have the skills required to start supporting people with learning disabilities. Training records for each member of staff are well organised and reviewing the previous 12 months showed that staff members had completed training in dementia, PCP facilitator, food safety, fire safety, safeguarding adults, supervisory management, moving and handling, first aid, infection control, safe handling of medication, risk assessment and a continuing programme of staff completing their NVQ’s (National Vocational Qualification) in care and management. Since the previous inspection was completed HFT have introduced a “professional passport” that provides clear lines of expectations within roles through a capability matrix. The AQAA completed by the registered manager highlights that HFT have successfully renewed their Investors in People Award. Frocester Manor DS0000016443.V344749.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 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. The home is well managed which ensures that the quality of the service provided is of a high standard. The home’s health and safety procedures and policies ensure that people are not put at unnecessary risks. EVIDENCE: The registered manager has been in post for the previous 5 years. They have extensive experience of working with this client group and have completed the appropriate qualifications to manage the service. Comments from the completed staff questionnaires confirm that the home is well run. The only negative comment in the completed questionnaires was about staff sickness. Staff stated this regularly causes staff shortages that sometimes affects the service provided to people living at the service. Frocester Manor DS0000016443.V344749.R01.S.doc Version 5.2 Page 23 All of the units across the site have regular meetings where people are able to express their views. Minutes from a number of these meetings were available for examination and showed people were given choices and asked for their opinions. The assistant regional director completes an annual quality audit of the home where they will highlight shortfalls that need to be addressed. Regular health and safety meetings are held with representatives from each unit in attendance. These meetings allow staff to bring issues to the attention of the health and safety representative on site. To support this process a qualified health and safety consultant completes an annual health and safety audit. When completing the inspection across the site evidence was seen of regular health and safety checks, other relevant health and safety regulations being adhered to: Portable appliance testing had been completed in February 2007. A qualified engineer had serviced fire equipment in August 2007. Fire safety checks are completed weekly/monthly by external contractors. Across the site records showed that this was being done correctly although records in The Lodge did not show that the emergency lighting was being tested monthly. This must be addressed by the manager and becomes a requirement of this inspection report. Across the site fridge and freezer temperatures were recorded twice a day. Whilst visiting the lodge the team leader went through the health and safety file for the unit. (All of the units across the site have these files). Each of the files are collated in the same way and cover the following topics: • Recorded accidents and incidents within the unit. • Copies of the monthly health and safety audit completed by staff in the unit. Evidence showed that where a shortfall was identified it was addressed. • COSHH (Control of Substances Hazardous to Health) risk assessments. • Copy of the annual health and safety audit completed by an external consultant. • Portable Appliance Testing documentation. • Evidence of first aid boxes being checked monthly. • Evidence of smoke alarms being cleaned monthly. • Evidence of water temperatures being checked monthly. • Evidence of the food probe being used to test cooked meats. • Evidence of door alarms being checked monthly. This is good practice and the manager audits each unit’s file every 6 months to ensure that staff are using it correctly. Frocester Manor DS0000016443.V344749.R01.S.doc Version 5.2 Page 24 The records seen during the inspection were well organised and stored securely. Frocester Manor DS0000016443.V344749.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 3 X 3 X X 2 X Frocester Manor DS0000016443.V344749.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES 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 YA6 Regulation 15 Requirement People’s notes must provide greater evidence of their goals being achieved, or not. Staff must ensure that information contained in people’s personal files and Person Centred Plans (PCP) are up to date and regularly reviewed. 2. YA9 13(4) b, c Risk assessments must be completed to cover all areas of a person’s life. The manager must ensure that guidelines for the service users requiring support from staff to complete their personal care are detailed and up to date. This requirement has been repeated from the previous inspection report – Timescale for action 29/09/06 Medication administration sheets must be signed by staff to confirm that people have received their medication. Medication changes that are hand written by staff must be Frocester Manor DS0000016443.V344749.R01.S.doc Version 5.2 Page 27 Timescale for action 28/03/08 29/02/08 3. YA18 15 29/02/08 4. YA20 13(2) 29/02/08 signed. 5. YA42 23(4) c iv The emergency lighting in the lodge must be tested monthly. 29/02/08 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. Refer to Standard YA6 Good Practice Recommendations All documents in people’s files should be dated when they are written, or reviewed. Blank documents should not be left in people’s files. If they are not relevant staff should make that clear on the document. 2. YA20 Topical creams and ointments should be labelled with the date they are opened. Medication due to be returned to a pharmacy should be stored securely. 3. 4. YA24 YA34 The carpet in the bungalow should be replaced as part of the ongoing maintenance programme. The manager should ensure that recruitment records are maintained. Frocester Manor DS0000016443.V344749.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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