Care Home: Frome Care Village

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What the care home does well Staff at the home gave first aid and acted appropriately following the incident. At the last key inspection which was conducted in December 2009 it was reported "Some people who live at the home commented "staff are lovely" and "food is good". The manager and staff at the home maintain regular contact with visiting health professionals to support the needs of people living at the home. A health professional said `the staff treat residents with respect and as individuals`. We observed some good interactions between some members of staff and people who live at the home. The home provides a good induction to all new staff to ensure that they are confident in their role and feel well supported. All staff have attended all necessary mandatory training. Visitors to the home are encouraged and made welcome by staff and are now invited to attend events. The home has a clear complaints policy that residents and visitors are aware of. Policies and procedures are in place to protect residents from the risk of abuse, including staff training and robust recruitment policies." What the care home could do better: On the 2nd March 2010 we were informed of an incident which had occurred at the home. This incident involved a person living at the home trapping their fingers in the bedroom door resulting in a serious injury and admission to hospital. This incident occurred at night. The purpose of this visit was to review the circumstances around this incident. As a result we viewed the staff statements which had been taken by the home manager following the incident, the care plans and risk assessments for the individual, the bedroom and staffing rota`s for the night of the event. In addition we have discussed the incident with the Health and Safety Executive for their consideration.The statements from staff confirm that the incident was not observed. The home manager described to us an individual who was "quite slight" in build and who was at risk and who had indeed fallen on several occasions. This individual was mobile with a frame and was someone who did not ring the bell to summon staff assistance. The conclusion of the homes investigation in conjunction with the staff statements was that the individual had opened the bedroom door to go in to the corridor. The door had then closed on to her back and as a result of the individual being of slight build and unsteady had placed her fingers in the door frame to steady herself. The fingers had then become trapped resulting in the injury. We and discussions at the subsequent safeguarding meetings have no evidence to suggest that this was not the course of events and that the injury was a result of an accident. As part of our visit to the service we reviewed the care plans and risk assessments for this individual. It was clear from the plans that the individual as at risk of falling and was unsteady on her feet. The accident records for the individual showed that 16 falls had occurred since admission in September 2009. A number of these falls had occurred at night. The home manager told that they had recently increased the night time checks for all people at the home from two hourly to hourly. These checks are now documented. The documentation showed that this individual had been "checked" at periods throughout the night. Despite these checks however the care plans and associated risk assessments did not consider increasing the level of checks for this individual despite the frequency of the falls. Despite a number of the falls occurring at night and evidence that the individual did not use the bell to summon staff assistance consideration had not been given to using other methods of alerting staff that the individual had got out of bed. Equipment such as pressure mats could have been used. This would have prompted staff to go and offer assistance and may have reduced the frequency of falls. The home agreed to supply this equipment for this individual at the subsequent safeguarding meeting. As result of this incident the home should review the care plans and risk assessments for all people at the home who are at risk of or who have fallen to ensure that appropriate equipment is in place to meet their needs. The individual has now returned to the home. On reviewing the file for this service as a result of this incident it is still noted that the home manager is yet to submit an application to become registered with us. Random inspection report Care homes for older people Name: Address: Frome Care Village Styles Hill Frome Somerset BA11 5JR one star adequate service 08/12/2009 The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Justine Button Date: 0 4 0 3 2 0 1 0 Information about the care home Name of care home: Address: Frome Care Village Styles Hill Frome Somerset BA11 5JR 08702869464 Telephone number: Fax number: Email address: Provider web address: riverview@psphealthcare.com www.aalenhouse.com Name of registered provider(s): Name of registered manager (if applicable) PSP Healthcare Ltd Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 60 Number of places (if applicable): Under 65 Over 65 0 0 60 0 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category physical disability Conditions of registration: 60 60 0 24 The maximum number of service users who can be accommodated is 60. The registered person may provide the following category of service only: Care home with Nursing - Code N to service users of either gender whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (Code OP) Physical disability (Code PD) - maximum of 24 places Dementia (Code DE) Mental disorder, excluding learning disability or dementia (Code MD) Care Homes for Older People Page 2 of 10 Date of last inspection Brief description of the care home 0 8 1 2 2 0 0 9 Frome Care Village was purchased by PSP Healthcare LTD in 2008. Frome Care Village can be found just off styles Hill road, set in its own grounds. It is situated on the outskirts of the town of Frome near to Asda superstore. Shops, banks, pubs and restaurants are near by however transport would be needed to reach these facilities from the home. The home is currently situated in two separate buildings (although both are situated on the same site) The Parsonage and Woodlands. The Parsonage is an older building with facilities situated over two floors. The upper floor being accessed by staircase and lift. There are 34 bedrooms spread over the two floors. Both floors have a range of living and dining spaces. The parsonage currently provides care and support predominantly for people who have dementia. The woodlands has 24 single en-suite bedrooms again spread over two floors. This building was constructed in 2000. Again there are a range of living and dining facilities on both floors. The lower floor being accessed by stairs or a passenger lift. Woodlands provides care and support for those people with nursing needs. The two homes share some facilities such as laundry and kitchens. There are accessible gardens surrounding both homes. The home is currently has an interim a manager, Ms Jill Holmes . In addition both The parsonage and Woodlands have a head of care who is responsible for the day to day running of both buildings. The current fee levels range from 518 pounds per week to 1200 Pounds per week. This information was given to us on the 26/02/09. Care Homes for Older People Page 3 of 10 What we found: This random inspection was conducted in response to an incident which occurred at the home. The incident resulted in the serious injury of one person living at the home. The incident was referred to Somerset Adult Social Care to be considered under the safeguarding policy. Following this inspection subsequent meetings have been held under the safeguarding policy to review the incident and to discuss any actions required. As this inspection visit was conducted to review specific concerns relating to this incident not all the standards were reviewed on this occasion. People who require additional information about the home should refer to the key inspection report dated December 2009. As this inspection was conducted as a result of this specific incident the requirements and recommendations from the previous key inspection were not reviewed on this occasion. What the care home does well: What they could do better: On the 2nd March 2010 we were informed of an incident which had occurred at the home. This incident involved a person living at the home trapping their fingers in the bedroom door resulting in a serious injury and admission to hospital. This incident occurred at night. The purpose of this visit was to review the circumstances around this incident. As a result we viewed the staff statements which had been taken by the home manager following the incident, the care plans and risk assessments for the individual, the bedroom and staffing rotas for the night of the event. In addition we have discussed the incident with the Health and Safety Executive for their consideration. Care Homes for Older People Page 4 of 10 The statements from staff confirm that the incident was not observed. The home manager described to us an individual who was quite slight in build and who was at risk and who had indeed fallen on several occasions. This individual was mobile with a frame and was someone who did not ring the bell to summon staff assistance. The conclusion of the homes investigation in conjunction with the staff statements was that the individual had opened the bedroom door to go in to the corridor. The door had then closed on to her back and as a result of the individual being of slight build and unsteady had placed her fingers in the door frame to steady herself. The fingers had then become trapped resulting in the injury. We and discussions at the subsequent safeguarding meetings have no evidence to suggest that this was not the course of events and that the injury was a result of an accident. As part of our visit to the service we reviewed the care plans and risk assessments for this individual. It was clear from the plans that the individual as at risk of falling and was unsteady on her feet. The accident records for the individual showed that 16 falls had occurred since admission in September 2009. A number of these falls had occurred at night. The home manager told that they had recently increased the night time checks for all people at the home from two hourly to hourly. These checks are now documented. The documentation showed that this individual had been checked at periods throughout the night. Despite these checks however the care plans and associated risk assessments did not consider increasing the level of checks for this individual despite the frequency of the falls. Despite a number of the falls occurring at night and evidence that the individual did not use the bell to summon staff assistance consideration had not been given to using other methods of alerting staff that the individual had got out of bed. Equipment such as pressure mats could have been used. This would have prompted staff to go and offer assistance and may have reduced the frequency of falls. The home agreed to supply this equipment for this individual at the subsequent safeguarding meeting. As result of this incident the home should review the care plans and risk assessments for all people at the home who are at risk of or who have fallen to ensure that appropriate equipment is in place to meet their needs. The individual has now returned to the home. On reviewing the file for this service as a result of this incident it is still noted that the home manager is yet to submit an application to become registered with us. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 5 of 10 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 7 15 The care plans need to 26/02/2010 adequately reflect the needs of people living at the home. This will ensure that all people at the home recieve the correct care and support from staff. 2 8 12 The management need to ensure that all staff are aware of the care needs of the individuals living at the home. This should include knowledge of wounds and pressure ulcers. This will ensure that people living at the home recieved the correct support and care from staff. 12/02/2010 3 8 12 The management need to 11/02/2010 continue to monitor the care and support provided at the home to ensure that an adequate level of care is given at all times. This should include continence care, wound care, moving and handling systems and personal hygiene needs. This will ensure that the needs of people living at th ehome are met to an Care Homes for Older People Page 6 of 10 Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action adequate level. 4 18 12 It is required that the 08/11/2010 management team investigate the concerns with regard to the removal of the call bell from one indivdual. The management must inform The Care Quality Commssion of theactions they have taken in response to these concerns This will ensure the health and safety of people living at the home 5 19 16 The management need to 26/02/2010 ensure that the environment remains fit for purpose. This should include the decor, fixtures and fittings. This is particularly relevant to the Parsonage. This should include the accessible hot water pipes and torn flooring. To ensure that people live in a safe and pleasant place. 6 26 13 The management must ensure that there is an adequate supply of liquid soap, paper towels and aprons at all times To reduce the risk of the spread of infection. 7 27 18 PSP healthcare must ensure 12/02/2010 that there are adequate numbers of registered nurses on duty at all times including Page 7 of 10 11/02/2010 Care Homes for Older People Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action nights to meet the needs of all people living at the home. To ensure the health and well being of people living at the home. 8 33 26 Regulation 26 visit reports should be forwarded to CQC on a monthly basis until further notice This will help us monitor the care and support provided at the home and monitor any improvements 9 38 37 The management will inform 26/11/2009 the Care Quality Commission of any events which adversely effects the well being or safety of any person living at the home. This will ensure that appropriate action is made by the management team to any issues identified at the home 27/01/2010 Care Homes for Older People Page 8 of 10 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 22 13 The home should review the 01/04/2010 care plans and risk assessments to ensure that all people at the home have any required equipment. This should include the use of equipment such as pressure mats for those people who have or who are at risk of falling This will ensure the health, safety and well being of people living at the home Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Older People Page 9 of 10 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for noncommercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. Care Homes for Older People Page 10 of 10 - 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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