CARE HOMES FOR OLDER PEOPLE
Fair Haven 23 Knyveton Road Bournemouth Dorset BH1 3QQ Lead Inspector
Jo Palmer Unannounced 27 September 2005 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 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. Fair Haven D55 S3937 Fair Haven V243577 270905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Fair Haven Address 23 Knyveton Road, Bournemouth, Dorset, BH1 3QQ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01202 553503 01202 319003 Bethany Guild (Christadelphian Homes) Mrs Wendy Avril Gibbs PC Care Home only 30 Category(ies) of OP - 30 registration, with number of places Fair Haven D55 S3937 Fair Haven V243577 270905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 15 December 2004 Brief Description of the Service: Fair Haven is registered to provide personal care and support for up to 30 older people. The home is owned and managed by Christadelphian Care Homes, a registered charity that exists solely to provide accommodation to persons requiring residential and nursing home accommodation. Fair Haven is not registered to provide nursing care. The home accommodates mainly members of the Christadelphian community although non-Christadelphians can be cared for with permission of the Trustees. Fair Haven is situated in a residential street of Bournemouth within easy walking distance of the town centre, cliff top walks and parkland. Accommodation is provided in 24 single rooms and 3 shared rooms, all rooms have en-suite facilities. There are two lounge areas, a dining room and conservatory for resident use, the conservatory leads on to well maintained mature gardens that are readily accessible to residents and where there are two summer houses A lift provides access between floors and a chair lift has recently been installed on one of the two stairways. Fair Haven provides a good level of pastoral care and support along with 24 hour staffing, all catering and laundry services and access to local community health services such as GPs, opticians, dentisits etc.
Fair Haven D55 S3937 Fair Haven V243577 270905 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection on 27th September 2005 lasted for four and half hours. Wendy Gibbs registered manager, the trainee manager and staff on duty assisted with the inspection process. The purpose of this inspection visit was to review practices in relation to some of the National Minimum Standards and this inspection concentrated on the outcomes of care and services for residents. The inspector spoke with six residents, seven members of staff, the manager and trainee manager; took a tour of the home and examined relevant records. Registered to accommodate 30 residents, twenty-four were accommodated at the time of inspection. The Commission sent comment cards to the home to be provided to relevant persons to obtain their views on the care and services provided at Fair Haven, at the time of writing the report the following had been returned: • 13 from residents • 3 from relatives • 1 from a visiting public figure. Comments from these are included in the next sections of this report. What the service does well:
Residents responded positively to comment cards confirming that they like living in the home, feel well cared for and are treated well by staff, all confirmed that their privacy is respected and that they feel safe. Twelve of the thirteen respondents think there are sufficient activities and nine like the food. All three relatives who responded to comment cards confirmed that they are made to feel welcome and that they can visit their relative in private at any time and there are sufficient numbers of staff on duty. Two confirmed they are kept informed about important matters affecting their relative and they are consulted as necessary about their relative’s care. Two respondents confirmed that they have access to the home’s complaints procedure and have access to the home’s inspection report. All indicated that they were satisfied with the level of care provided. Whilst less favourable responses should not be disregarded, it was evident during this inspection that both the complaints procedure and the last inspection report were prominently displayed in the home’s entrance and are available for any visitor to the home. One comment card was returned from a public figure who had occasion to visit Fair Haven
Fair Haven D55 S3937 Fair Haven V243577 270905 Stage 4.doc Version 1.40 Page 6 recently, whilst this person had completed the relatives comment card where some questions were not applicable, an additional comment was made that included: “All the residents were happy, warm and comfortable, the house and grounds were a credit to the staff and all the residents spoke well of their care”. Of the National Minimum Standards inspected, the following was identified during this inspection: Information is available to prospective residents and those living at the home in the form of a Service User Guide that details the aims, objectives and philosophies of Christadelphian Care Homes. Specific information regarding services and facilities provided at Fair Haven are included along with a copy of the home’s terms and conditions of residency. Resident’s needs are assessed and care plans are produced detailing how assessed needs are to be met by staff, inconsistencies in the care planning approach need to be addressed. Records evidenced that resident’s health care needs are met by visiting health care professionals; residents confirmed they felt their needs are met and they are able to make their own appointments if able. Fair Haven provides a comprehensive social, recreational and activities programme for residents through which their emotional, cultural and support needs are met. Resident’s families, a committed staff group and the home’s welfare committee assist with arrangements for residents to maintain their faith and attend various religious events and services. There is a good provision of meals in the home and residents confirmed that meals provided meet their individual requirements, a range of fresh, wholesome meals are served and special diets can be catered for. Any complaints, concerns or grumbles raised by residents are addressed sensitively and are well managed by staff; all are recorded with evidence of outcomes to satisfaction of the complainant. The complaints procedure is contained in the Service User Guide and Terms and Conditions of Residence document. Procedures are in place to direct staff should any concerns be raised or incidents reported. Fair Haven is clean and well maintained; the home provides good facilities for residents to enjoy their own rooms, communal space and the gardens. Although a large home, there is a homely feel in the lounge areas and in resident’s own rooms where they are at liberty to bring items of their own furnishings and items to decorate their rooms. The home provides adequate bathing and toilet facilities. There are sufficient numbers of well-trained staff on duty that are committed to the care they provide, the inspector was impressed by the staff group’s loyalty to, and respect for the residents individuality, and dignity.
Fair Haven D55 S3937 Fair Haven V243577 270905 Stage 4.doc Version 1.40 Page 7 Management systems at Fair Haven are well organised and managers are supported by Christadelphian Care Homes trustees in policy development and quality assurance processes. Staff and residents spoken with confirmed that communication is good regarding developments, changes or any significant matter affecting their lives and work in the home. Records are held in accordance with accepted procedure, records relating to management of some residents finances are well organised and accurate. What has improved since the last inspection? What they could do better:
The system of care planning at Fair Haven is changing to develop a computerised system that will provide more consistency in approach. Managers and staff must however ensure that care plans identify all aspect of care need and how these are to be met. Systems for management and administration of medication require attention; current methods do not provide sufficient information in order to assess proper medication usage and calculate whether residents are receiving prescribed medicines at prescribed times. All resident areas must be provided with emergency alarm call points in order that residents can summon assistance. Of thirteen residents who returned comment cards prior to this inspection, four indicated that they would ‘sometimes’ like to be more involved in decision making in the home and one answered ‘yes’ to the question about being more involved. Seven were content not to have further involvement. Whilst this inspection has evidenced that residents are consulted regularly with regard to menu planning and to quality assurance surveys, the registered persons could consider ways in which residents are more involved in the day-to-day decision making in the home. Three returned cards answered ‘sometimes’ to the question ‘do you like the food’ and one answered ‘no’. Residents confirmed during this inspection that the food was good although one commented that sometimes the meat and vegetables were sometimes a ‘bit too hard’, the registered persons therefore, should consider ways of ensuring that meals are provided that meet individual tastes and preferences.
Fair Haven D55 S3937 Fair Haven V243577 270905 Stage 4.doc Version 1.40 Page 8 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. Fair Haven D55 S3937 Fair Haven V243577 270905 Stage 4.doc Version 1.40 Page 9 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 Standards Statutory Requirements Identified During the Inspection Fair Haven D55 S3937 Fair Haven V243577 270905 Stage 4.doc Version 1.40 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 & 4. Standard 6 is not applicable. The home’s Statement of Purpose and Service User Guide provide detailed information about the care and services provided by Christadelphian Care Homes including information regarding Fair Haven. EVIDENCE: A copy of the home’s Statement of Purpose and Service User Guide are held on file with the Commission, the trainee manager confirmed that these were the up to date copies that are provided to residents and other interested parties. The trainee manager indicated that he was working on producing a Service User Guide in a format that is more specific to Fair Haven and is presented in a format that is more suited to the needs of the resident group. Residents are assured as part of the admissions process prior to and on admission that based on the findings of assessment, Fair Haven is suited to meet their needs, pre admission assessments were not examined. Fair Haven D55 S3937 Fair Haven V243577 270905 Stage 4.doc Version 1.40 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 & 10. Inconsistencies in the care planning process do not enable staff to readily identify what residents needs are or how they are to be met. Resident’s health needs are met through visits to doctors and other health professionals as required. The systems for the management and administration of medication are poor and not in the interest of residents. Residents perceive their care needs as being met by a kind and respectful staff group. EVIDENCE: The current care planning process at Fair Haven is being changed, the trainee manager confirmed that Christadelphian Care Homes have introduced a computerised system of care management across it’s homes; the aim is to train all staff to become computer literate in order that residents records can be held on computer file. The objective is to provide more comprehensive and reliable information to enable staff to identify how they should meet resident’s needs. Currently, whilst this process is being implemented, the system of ‘paper’ care plans remains in use. One computerised recorded care plan was seen briefly and two hand written care plans were examined. Of all three, it was evident that efforts have been made to address all the health and welfare needs of each resident although
Fair Haven D55 S3937 Fair Haven V243577 270905 Stage 4.doc Version 1.40 Page 12 there were some anomalies. For example, where a care plan identifies a need for pressure area care, this must be cross-referenced to, and included in, the care plans for toileting, mobility (moving and handling) and bathing. Some care plans needed reviewing in light of the changing needs of residents; one care plan identified a level of independence with personal care although it was evident from reviewing daily records and discussion with the manager that this persons care needs had increased as full attention was required for personal care to be given. Of those records reviewed, it was evident that medical care and attention is provided as required by other health care professionals such as GPs, district nurses, chiropodists etc. Residents spoken with confirmed that they are at liberty to make their own arrangements for appointments or staff will assist if necessary. Residents also confirmed that they felt their care needs were being met, many residents retain high levels of independence and as such require little staff intervention, some require more staff input for their personal care needs to be met. Systems for the management of medication for residents require attention. Medicines are ordered for differing lengths of time dependent on the GP prescription, some GPs prescribe for one month, some for two, three or more. Medicines are supplied, in the quantity prescribed through a local pharmacy; they are stored securely in their original containers in a locked cabinet, in a locked room. Records relating to the supply of medicines are unclear, a senior carer keeps a record of the amount of tablets ordered and the number received from the pharmacy although in order to see an audit trail of medicines received and administered requires tracing back through past records as stocks held were inconsistent with current recorded information. Each morning, medicines for each resident for both day and night are removed from their original container and placed in a named pot. At the correct time for administering the medicines, another carer will take the pots to the residents and sign the record indicating that the medicine has been given. This system of double dispensing is not a satisfactory system of managing medication as there is no one person accountable for correct administration and storage of unidentifiable medicines in pots is not in line with Royal Pharmaceutical guidelines. There were two pots containing unidentified medicines, these pots were not named for individual residents. In the home’s diary where night staff keep a record of significant matters affecting residents, one entry stated that a resident had “requested 2 pain killers”, the residents daily records held in a kardex format did not specify whether these had been given, the residents medicine chart indicated that painkillers were prescribed although had not been given. Fair Haven D55 S3937 Fair Haven V243577 270905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 15 A committed staff group ensure that residents are able to enjoy the social, cultural, and recreational activities provided by the home, by resident’s families and by the welfare committee. Residents are supported in maintaining contact with their friends, family and the local community and in making decisions about their lives in the home. Dietary needs of residents are well catered for with a balanced and varied selection of home cooked food that meets their individual tastes and choices. EVIDENCE: The home’s social calendar was not examined although it was evident from discussion with the manager and residents that there is a high level of stimulation provided through varied individual or group activities. The local ecclesia play a big part in assisting with social, religious and recreational activities which residents spoken with confirmed they are able to enjoy, residents also confirmed that they are able to make decisions regarding their lives in the home and their daily routines. Cook are employed to provide meals from a centrally located kitchen, a set menu is available and residents are asked at the beginning of each week to make their choices. If residents choose not to have the set main meal of the day, a range of alternatives is offered. A buffet style breakfast is provided in
Fair Haven D55 S3937 Fair Haven V243577 270905 Stage 4.doc Version 1.40 Page 14 the dining room with a range of cereals, toast, fruit and a cooked breakfast. The evening meal offers a variety of light meals including soup, sandwiches, salads and cakes. Residents in the main complimented the food although one stated that on the day of inspection, the potatoes were not cooked and another said that sometimes the meat is too hard. Residents are consulted at resident meetings with regard to menu planning. Fair Haven D55 S3937 Fair Haven V243577 270905 Stage 4.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 A written complaints procedure leaves residents in no doubt that steps will be taken to deal with any complaint or concern they may have. Staff knowledge and understanding of Adult Protection issues helps provide a safe environment to protect residents from abuse. EVIDENCE: The home’s complaints procedure is contained within the Statement of Purpose and Service User Guide, a copy is also posted in the entrance hall. A record is held of all complaints received; several complaints were logged from residents, all of which had been appropriately managed. The outcome of these complaints was recorded separately as some information was sensitive; the complaints log is an open document available for all staff to record any significant concerns in. Receipt of complaints from residents or relatives is not an indication of a poor service; it demonstrates that the residents are comfortable raising concerns and that staff and management are open to criticism. An adult protection policy is in place with procedural guidance for staff to follow should any incident of abuse be reported or suspected. The trainee manager demonstrated an awareness of the reporting and recording mechanisms should any incidents be alleged. Staff spoken with confirmed their understanding of the home’s adult protection policy. Fair Haven D55 S3937 Fair Haven V243577 270905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 23, 24, 25 & 26 Residents live in a safe, comfortable, clean environment with their own belongings around them. Bedrooms, bathrooms and communal areas provide sufficient room for residents and communal space is sufficient for the size of the home. EVIDENCE: The location and layout of the home is suitable for its stated purpose, the home is well furnished, equipped and maintained, and residents are able to bring items of their own furnishings to their rooms. All rooms have en-suite toilets; some have showers. Additional assisted bathrooms and toilets are sited conveniently around the home. A ground floor fire escape is sited in a bathroom and as a result, the bathroom door cannot be locked although there is a small ‘vacant/engaged’ sign on the door. There was no emergency alarm call point in this bathroom. All other bathrooms and toilets are fitted with appropriate locks for resident’s privacy and emergency alarms are accessible to residents in all other parts of the home.
Fair Haven D55 S3937 Fair Haven V243577 270905 Stage 4.doc Version 1.40 Page 17 Resident accommodation is over three floors of the home; each floor is accessed by one of two stairways and a passenger lift. The trainee manager confirmed that the lift is due to be replaced and will be out of action for a while. In preparation for this, Christadelphian Care Homes have installed a chair lift on one of the stairways to ease access around the home for residents. Additionally, a refrigerator, a kettle and toaster has been provided for each floor in order that risks associated with carrying trays and hot drinks up stairs are reduced. Fair Haven D55 S3937 Fair Haven V243577 270905 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 & 30 The deployment and number of available staff is sufficient to meet the needs of the residents. The arrangements for staff training are good with the staff demonstrating a clear understanding of their roles. EVIDENCE: Residents spoken with and relatives who returned comment cards stated that they felt there are sufficient staff on duty. There are four care staff on duty during daytime shifts, with two care staff on duty in the evenings and overnight. In addition to care staff, the manager, trainee manager and assistant manager are present during the day shifts along with sufficient ancillary staff for domestic and catering duties. Of fourteen care staff employed, eleven have attained NVQ level 2 in care, two of these have gone on to attain level three and a further six are due to start level three shortly. Two housekeepers have attained their NVQ level 2 in housekeeping, Mrs Gibbs has level four in care and the registered managers award. The trainee manager has the registered managers award and is undertaking the NVQ level 4 in care. Induction and foundation training programmes are in place for new staff although no new staff have been appointed since the last inspection, Mrs Gibbs stated that Fair Haven is currently recruiting for full and part time care staff, when appointed, these staff will undertake this training. Fair Haven D55 S3937 Fair Haven V243577 270905 Stage 4.doc Version 1.40 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35 & 37 The management arrangements of the home support good care practices for residents and are inclusive of resident and relative’s views and opinions on service provision. The home and Christadelphian Care Home trustee’s regularly review aspects of the home’s performance through a good programme of selfreview and consultation. Residents who request assistance are assured of sound management of their financial interests and procedures for record keeping and confidentiality are operated in the residents best interests. EVIDENCE: Mrs Gibbs has attained both the Registered Managers Award and an NVQ level 4 in care. The trainee manager has attained the Registered Managers Award and is currently completing the NVQ level 4 in care. Mrs Gibbs has been competently managing the home for 13 years; the trainee manager is due to
Fair Haven D55 S3937 Fair Haven V243577 270905 Stage 4.doc Version 1.40 Page 20 take over on her retirement next year. Christadelphian Care Homes are commended for ensuring that the home’s management retains consistency with this extended hand-over period. As a registered charity, a board of trustees along with a chairman and general manager manages Christadelphian Care Homes. This inspection evidenced that Christadelphian Care Homes provide a good support system for home managers along with sound management and administrative procedures, which ensure that Fair Haven is run in the best interests of residents. Residents and staff spoken with confirmed that management arrangements are inclusive and that their views are sought regularly on aspects of the home’s operation including menu planning, social and leisure activities and in relation to care routines. The trainee manager confirmed that Christadelphian Care Homes produces an annual report of the Quality Assurance Audit, the audit for 2005 was being prepared at the time of this inspection. Regulation 24(2) of the Care Homes Regulations 2001 states that the registered persons ‘shall supply to the Commission a report in respect of any review…’, the last review of quality of care was provided to the Commission in 2001. The registered persons are therefore advised to send a copy of the 2005 review of quality of care report as soon as it is finalised to the Commission. A quality assurance file held at Fair Haven holds detail of audit methods to date, these were noted to include questionnaires sent to residents and relatives, procedures for quality assurance, management meeting minutes, resident meeting minutes and welfare committee meeting minutes. The file provides comprehensive information and monitoring from which to measure the home’s success in meeting its aims and objectives as outlined in the Service User Guide. This inspection evidenced that the home manages money on behalf of some residents. Mrs Gibbs confirmed that most residents have representation with their affairs although some request the assistance of the home in managing personal allowances, the home is not responsible for cashing pensions or payment of any resident’s fees. Records seen relating to monies held showed accurate accounting methods in relation to income, expenses and balances held, all monies and associated records are held securely. Of those records examined for the purpose of this inspection, all were well maintained, up to date and accurate with the exception of anomalies noted in care planning and medication management. Records are currently held confidentially and in accordance with data protection legislation. Fair Haven D55 S3937 Fair Haven V243577 270905 Stage 4.doc Version 1.40 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x x 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3
COMPLAINTS AND PROTECTION 3 3 3 2 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 x 3 x 3 x Fair Haven D55 S3937 Fair Haven V243577 270905 Stage 4.doc Version 1.40 Page 22 No Are there any outstanding requirements from the last inspection? 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 7 Regulation 15 Requirement Timescale for action 30.11.05 2. 7 15 3. 9 13 4. 22 16 Care plans must consistently describe how a persons assessed needs will be met. Where a person has a specific need that impinges on other aspects of their care, this must be referenced in all relevant parts of of their care plan. For example, pressure area care must be part of a personal care routine and part of a moving and handling plan. Care plans must be reveiwed 30.11.05 regularly to ensure that identified needs remain current and that where a persons needs have changed, up to date information is avaialble to ensure staff have clear direction regaridng how to meet those needs. Medication must only be 30.11.05 administered to residents from original, marked containers. All medicines must be identifiably marked with the name of the medicine, the dose and the name of the person for whom it is prescribed. All administration records must be signed. Emergency call points must be 30.11.05
D55 S3937 Fair Haven V243577 270905 Stage 4.doc Version 1.40 Fair Haven Page 23 sited in all resident areas around home. 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 21 Good Practice Recommendations It is recommended that a larger vacant/engaged sign is fitted to the door of the bathroom that contains a fire exit. Fair Haven D55 S3937 Fair Haven V243577 270905 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection Unit 4, New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Fair Haven D55 S3937 Fair Haven V243577 270905 Stage 4.doc Version 1.40 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
