CARE HOMES FOR OLDER PEOPLE
Fair Haven 23 Knyveton Road Bournemouth Dorset BH1 3QQ Lead Inspector
Jo Palmer Key Unannounced Inspection 10:15 9 & 10th August 2006
th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000003937.V307652.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000003937.V307652.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Fair Haven Address 23 Knyveton Road Bournemouth Dorset BH1 3QQ 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) 01202 553503 01202 319003 Christadelphian Care Homes Mr Stephen John Webb Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places DS0000003937.V307652.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. One named person (as known to CSCI) under the age of 65 may be accommodated to receive care. 26th January 2006 Date of last inspection 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 provides access between floors 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, dentists etc. DS0000003937.V307652.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over two days, 9th and 10th August, the first day was unannounced, the second date was pre-arranged. The inspection took six hours and forty-five minutes in total. Mr Steve Webb, has been appointed as Registered Manager since the last inspection, Mr Webb was present and assisted with the inspection. The inspector also spoke with five residents and four members of staff, examined relevant records and took a brief tour of the home and grounds. This was a ‘key’ inspection where the home’s performance against the key National Minimum Standards was assessed along with progress in meeting requirements of the last inspection. A pre-inspection questionnaire was sent to the manager in order that certain information could be provided, questionnaires were also sent to the home prior to the inspection to be distributed to residents, relatives and visiting health care professionals. Information provided in the pre-inspection questionnaire will be used to inform parts of this report. At the time of writing the report, fourteen questionnaires had been received from residents, two from GP’s and one from a health care professional, their comments are included throughout this report. What the service does well:
Fair Haven offers residents a good service on admission ensuring they have all the information readily available about the care and services on offer and ensuring that their needs are assessed prior to moving in so they can be confident that the home is able to meet those needs. Following assessment prior to admission, a plan of care is written detailing how the care is to be delivered by staff, care plans in the main are informative, respectful and evidence the residents acknowledgement of the identified care outcomes. Attention is needed however to ensure all needs are appropriately assessed as they change and care plans are reviewed. Residents can be assured that their medication needs will be managed accordingly as systems have developed to ensure safe practice and that all medicines are given as prescribed. Staff observed in their interaction with residents showed an inherent level of respect and residents spoken with confirmed that they are treated kindly and their rights to privacy is supported. DS0000003937.V307652.R01.S.doc Version 5.2 Page 6 Social care at Fair Haven is provided in accordance with individual resident expectations; assessments identify resident’s basic social, cultural, leisure and recreational preferences and all residents are supported in maintaining their Christadelphian faith. Meals are provided in a sociable environment and from a menu that meets their individual dietary requirements and tastes. Complaints are managed well in the home and the manager views complaints as a positive monitoring tool whereby any difficulties can be resolved with careful negotiation and sensitivity; residents are provided with a complaints procedure should they have any concerns they wish to raise. Residents are also protected by policies in the home laying down procedural guidance for staff should any incidents occur or allegations be made, staff have also received training in issues relating to protection of vulnerable adults and prevention of abuse. The premises are safe, clean and well maintained, residents benefit from comfortable private rooms where they can have some of their own belongings around them and shared, communal space where social events and bible readings take place. A pleasant dining room is available where residents can enjoy their meals together. There are sufficient bathing and toilet facilities in the home and staff areas, laundry, kitchen and utility areas are sited on the ground floor. Mature gardens to the rear of the home are accessible to residents and seating is provided in the shade and in two summer houses. Care staff are on duty in the home in sufficient numbers to meet residents needs although consideration is being given to increasing staffing numbers in the evenings. Throughout the day, care staff are supported by domestic and catering staff and the home’s administrator. Staff training programmes are good to ensure staff have, and maintain the skills to meet the needs of the resident group, some further training is needed to update staff knowledge in health and safety issues. All staff are recruited safely using appropriate vetting procedures to ensure all applicants are suitable to work with older people. Since the last inspection, the management arrangements for the home have changed with the retirement of the previous manager and appointment of Mr Webb. The inspection evidenced that eh home is being managed effectively and Mr Webb is taking steps to ensure practices are developed and improved. Christadelphian Care Homes carry out a monthly, six monthly and annual audit of care and service provided at Fair Haven and Mr Webb has plans to supplement this with internal surveys of residents and staff views. Residents are safeguarded by good procedures for managing their personal financial affairs with support of the home and their families. General Health and Safety is promoted in the home by ensuring that all equipment, installations and the premises are safe and well maintained, further training is needed for staff in some areas of health and safety however. DS0000003937.V307652.R01.S.doc Version 5.2 Page 7 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. DS0000003937.V307652.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000003937.V307652.R01.S.doc Version 5.2 Page 9 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 the following standard(s): 1, 3 & 4. Standard 6 is not applicable Quality in this outcome area is good; this judgement is made using available evidence. The home’s Statement of Purpose and Service User Guide provide detailed information about the care and services provided at Fair Haven. The admissions process is such that it ensures resident’s needs are assessed prior to admission and residents are assured that their needs can be met by the home prior to agreeing to move in. EVIDENCE: A handbook for residents is available detailing all relevant information about the care and services provided at Fair Haven. The handbook provides information for prospective residents prior to them making a decision to move to the home and provides useful information for current residents about the home and local community. Prior to moving to Fair Haven, the needs of the resident are assessed using a prescribed format that has been developed to encompass all a person’s health and welfare needs. This assessment uses a scoring system to help determine a
DS0000003937.V307652.R01.S.doc Version 5.2 Page 10 person’s level of dependency and the aim is to ensure these are regularly reviewed. Records of care provided demonstrated that resident’s needs were being met as assessed and as identified on care plans (see standard 7). Care records were written plainly and in a manner that supported resident’s dignity by staff demonstrating an understanding of the care delivered. DS0000003937.V307652.R01.S.doc Version 5.2 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 the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate; this judgement is made using available evidence. Care plans provide sufficient detail for staff to be aware of resident’s health and welfare needs and how to meet them although are let down by the infrequency of reviews. Medicines are given as prescribed and recording processes have improved; further attention is needed to ensure all medicines are supported by an effective audit system. Resident’s rights to privacy are supported through care delivery, relationships with staff and confidential record keeping practices. EVIDENCE: Mr Webb is introducing a new assessment format that will ensure all resident’s needs are identified and supported by a written plan of care. This format is in its infancy and although some residents care records demonstrate the extent of the care required, some do not. Care plans available for staff providing instruction for care to be delivered were clear, concise and evidenced that residents are consulted regarding the process showing clear respect for
DS0000003937.V307652.R01.S.doc Version 5.2 Page 12 individual choices, decisions and preferences. For those residents whose care needs are yet to be reviewed, care plans were not based on comprehensive, up to date assessment criteria. Although it is recognised that Mr Webb is making progress in addressing this issue, the requirement of the last inspection is repeated that care plans are reviewed regularly based on findings from detailed assessments. It was evident that resident’s health care needs were being met by community based health care professionals, records examined detailed contact by doctors, chiropodists, dentist and optician and where necessary, district nursing services. A requirement of the last inspection is however repeated as where a district nurse is in attendance for a resident who needs wound care, staff at Fair Haven must have clear instruction about the wound site. The plan of care must detail how to manage the site between the nurse’s visits and procedures for bathing and personal care must address methods of reducing the introduction of infection to the wound and the in-house management of MRSA. A new system of medication management has been introduced since the last inspection. Fair Haven now uses a system of monitored dosage where some medicines are dispensed by the supplying pharmacist into dossette boxes. This system is well managed in the home with records supporting an audit trail of medicines prescribed, received into the home, administered on behalf of residents and disposed of when no longer required. Some anomalies were noted where medication had been supplied in boxes or bottles rather than the monitored dosage dispensing packs, a review of these medicines demonstrated that their use was not supported by an audit trail, administration records confirmed however that these were given as prescribed. All staff at Fair Haven with responsibility for handling medicines have undertaken appropriate training and new recording formats have been introduced to ensure effective audit of all medicines that enter the home. Medicines storage is appropriate being secure and well organised, caution is needed to ensure that liquids are stored at the right temperature; a medicines fridge is available. Five residents were spoken with; all confirmed that staff were kind, helpful and respectful and they felt their care needs were being met, they said they felt comfortable during personal care routines and their privacy and dignity were supported. Of 14 responses to questionnaires sent to residents, 8 confirmed that they always receive the care and support they need, 4 that they ‘usually’ receive this care and support and one said they ‘sometimes’ receive the care and support needed. Eleven confirmed that staff listen and act on what they say and one that staff do not listen, two respondents declined to answer this question. Ten stated that staff are always available when needed, three stated that staff are ‘usually’ available and one that staff are ‘sometimes’ available. 9 of the 14 respondents ‘always’ receive medical support needed, 4 ‘usually’ receive this support and one ‘never’. Whilst this could be perceived as a damaging comment, there was no other evidence to support this although the registered persons could consider canvassing residents further for their views on the support of the community health care staff.
DS0000003937.V307652.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good, this judgement is made using available evidence including a visit to this service. Social care assessments provide staff with basic information concerning individual social and leisure choices and residents were content with the homes social arrangements. Residents are supported in maintaining contact with their friends and family and in making decisions about their lives in the home. Residents are provided with a varied menu and choices of meals that meet their dietary needs. EVIDENCE: Fair Haven provides a good level of social, religious and recreational support to residents and Mr Webb discussed his plans to develop this further. There are weekly exercise classes and shopping trips supplemented by games afternoons including word games and bingo. Outings are arranged regularly to local places of interest, the local library visit the home and a ‘shop’ organised by volunteers visits weekly. Residents are supported in maintaining their faith through daily readings, ‘breaking of bread’, visits to, and from the local churches and members of the Christadelphian community. The welfare committee support
DS0000003937.V307652.R01.S.doc Version 5.2 Page 14 residents with regular visits. Residents are supported in individual pursuits and activities such as embroidery, jigsaws etc and Mr Webb confirmed this was an area to be developed to ensure residents have access to tools, services and equipment to enable their hobbies and interests to be continued. Resident’s families and friends are encouraged to visit and welcomed into the home, Fair Haven has recently held coffee mornings and a ‘family day’ that was well attended and enjoyed by residents and their families. Residents records examined demonstrated the extent of their involvement with decision making about their care and residents spoken with confirmed that they are able to retain control over their lives in the home through self determined activity and social care arrangements and by establishing their own routines with regard to times of waking, retiring, going out etc. Meal times are set at Fair Haven and residents mainly take their meals in the dining room although can be served in their rooms if they prefer. Mr Webb stated that he would like to see meal times being more flexible to ensure residents have a choice of when to eat to fit in around their preferred daily routines. However, residents spoken with confirmed that the meals provided were good, appetising and plentiful although of 14 responses to questionnaires, 5 confirmed that they ‘always’ like the meals and 7 stated that they ‘sometimes’ like the meals. 2 declined to comment. One resident added that they would ‘like to be more involved in menu making’. A full time cook is employed who prepares all meals in the home, discussion with the cook confirmed that the kitchen is well appointed with a good range of equipment and that foods are available in good supply. A brief look at stocks and supplies evidenced that a good range of healthy options are available for meals to be prepared from including fresh, frozen, dried and tinned goods. The cook confirmed that many dishes are home made including cakes, pastries and some savoury dishes. Menu’s provided with pre-inspection information demonstrate a variety of meals for breakfast, dinner and tea. Mr Webb confirmed that care staff have access to the kitchen ‘out of hours’ to make drinks and snacks for residents. DS0000003937.V307652.R01.S.doc Version 5.2 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good, this judgement is made using available evidence including a visit to this service. Any person wishing to complain is directed through a written procedure detailing how their concerns will be addressed, they can therefore be confident that their complaints will be listened to and taken seriously. Procedures for responding to suspicions of abuse are held in accordance with Department of Health guidance, meaning that any allegations of abuse can be managed effectively. EVIDENCE: The complaints procedure has been reviewed since the last inspection and now informs complainants how to contact the Commission. Documented evidence was reviewed demonstrating that two complaints received by the home had been effectively managed and resolved to satisfactory conclusions. A policy document is available for staff reference directing them through appropriate procedures to be followed in the event of any suspicion of abuse; all staff have received training in adult protection issues and two staff spoken with demonstrated a knowledge of procedure. DS0000003937.V307652.R01.S.doc Version 5.2 Page 16 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24 & 26 Quality in this outcome area is good. This judgement is made using available evidence including a visit to this service. Accommodation at Fair Haven is safe and well maintained. Residents are able to benefit from comfortable, well furnished, clean and hygienic surroundings with some of their own belongings around them. EVIDENCE: A written schedule of completed and planned maintenance of the premises forms part of the home’s quality audit and indicates repairs and refurbishment. There was also evidence of regular servicing of equipment (see standard 38) There are sufficient bathing and toilet facilities sited around the home which are provided with appropriate aids and adaptations to meet residents needs. Resident’s rooms are comfortable and furnished appropriately and residents are able to benefit from having some of their own belongings around them. The lounge and sun lounge areas of the home provide a sociable meeting place for residents and a dining room is available where most residents can enjoy
DS0000003937.V307652.R01.S.doc Version 5.2 Page 17 their meals. Well-maintained, mature gardens are accessible and seating is provided. Safety is ensured in the garden with appropriate areas being fenced off including the pond to prevent accident and Mr Webb discussed plans for additional handrails to be provided for additional safety. All areas of the home visited were clean and well maintained and free from offensive odours, one questionnaire returned from a resident had the added comment that ‘we never have any unpleasant smells’. The laundry room was not specifically inspected although a brief visit showed it to be well organised and clean and it was evident from observations of residents dress and bedding that the laundry service is effective, residents spoken with confirmed that their laundry is done quickly and is returned in good condition. DS0000003937.V307652.R01.S.doc Version 5.2 Page 18 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement is made using available evidence including a visit to this service. There are sufficient numbers of staff on duty in the home each day and night to provide the level of care and support needed by residents. Staff training programmes are in place to ensure that the staff group has the skills and knowledge they need to meet resident’s needs. Staff recruitment practices are good and ensure resident’s safety with all staff being appropriately screened prior to taking up employment. EVIDENCE: Mr Webb submitted staff rotas with the pre-inspection information. These demonstrate the numbers of care staff on duty during the day and night and the numbers of ancillary staff in the home during the day. In discussion with residents all stated that they felt there were sufficient numbers of staff on duty to meet their needs and relatives who responded to questionnaires all confirmed that in their opinion, there were always sufficient staff on duty. However, during the evening shift, there are two care staff on duty; as some residents require two staff to attend to their needs due to high levels of dependency, whilst they are being cared for there would be no staff available to assist other residents. Mr Webb confirmed that he was aware of this problem and was in the process of negotiating additional staff cover.
DS0000003937.V307652.R01.S.doc Version 5.2 Page 19 Fair Haven has been very pro-active with staff training and development plans, 10 staff members currently have level 2 NVQ, one was, at the time of inspection, just finishing level 3 NVQ and one has level 3 equivalent qualification (an overseas nursing qualification). Five carers are currently studying for level 3 NVQ and one is due to commence level 2 shortly. All staff have attended training in adult protection in September 2005 and at the time of inspection 50 of staff had received training safe medication practices whilst the other 50 were due for their training that day. Staff files examined for two recently recruited staff demonstrated that all appropriate checks are undertaken including CRB and POVA* checks. References are taken up from previous employers and applicants are asked to provide identification and proof of eligibility to work in the UK. An induction programme for new staff is in place for which a workbook was seen; Mr Webb confirmed that new staff work through the induction programme, which is then assessed at each stage in order to measure the extent of their learning. The induction programme meets the criteria of the National Occupational Standards for care staff. Mr Webb is commended for developing an induction training package for agency staff, a copy of which has been sent to the agencies that the home use in order that staff can familiarise themselves with the expectations of the home and basic health and safety procedures prior to working there. *Criminal Records Bureau and Protection Of Vulnerable Adults - The CRB check includes a check against the POVA list to ensure the person applying for the position has not been excluded from working with vulnerable people. DS0000003937.V307652.R01.S.doc Version 5.2 Page 20 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 & 38 Quality in this outcome area is good. This judgement is made using available evidence including a visit to this service. Fair Haven is managed effectively and in the best interests of residents. Quality assurance programmes and audits are in place to ensure controlled measurement of care and services provided in order that the home meets its expressed aims and objectives, residents would benefit from access to a development plan devised from audits results. Residents are safeguarded by good procedures for managing their personal financial affairs with support of the home and their families. Staff are supervised to ensure they maintain good working practices. The health and safety of residents is protected by procedures ensuring that equipment is checked and maintained, the premises are maintained in a safe manner and most staff are trained in health and safety practices.
DS0000003937.V307652.R01.S.doc Version 5.2 Page 21 EVIDENCE: As a large care provider, Christadelphian Care Homes has in place systems for management of their services, Mr Webb is appointed to manage Fair Haven on a day to day basis and has been in post since July 2006 when the previous manager retired. Mr Webb is supported by Christadelphian Care Homes management committee and by senior staff in the home. Mr Webb has attained NVQ level 4 in care and the Registered Managers Award and at interview for registration with the Commission, Mr Webb discussed his plans for development and improvement of the service. In discussion with staff and residents about the recent change in management in the home all confirmed it was a positive thing and that Mr Webb was approachable, open and inclusive ensuring that the views of staff and residents was taken into consideration in any plans for change. Some of the staff and residents spoken with spoke affectionately of the previous manager and how well the home had been managed although all accepted that ‘things change’ and that Mr Webb would ‘do a good job’. Of the 14 responses to comment cards, the following comments were received: • • • ‘I must commend Fair Haven for the way it is managed’. ‘We have a good manager’. ‘All concerned do a good job’. Quality assurance systems are in place in the home with regular auditing and monitoring of care and services. A representative from Christadelphian Care Homes visits the home monthly to carry out monitoring visits as required under regulation 26 and carries out an annual audit of services measuring against the National Minimum Standards and care outcomes for residents; from the audit an annual report is produced. Mr Webb aims to do additional satisfaction surveys for both residents and staff and plans to report his findings both verbally at meetings and in a written report for residents. Any resident requesting assistance with the management of their personal finances are able to have money held for safekeeping on their behalf. Records are computerised for individual residents and statements are available from the home detailing the income, including its source, any expenditure and the remaining balance. All money and valuables are held securely and balances checked were correct against records held. Mr Webb has ensured further protection of residents personal interests by ensuring that all personal documentation including bank statements, when thrown away by residents, are shredded to prevent any identity violations. Since taking up position as manager, Mr Webb has ensured that all staff have received one to one supervision, records of supervision were seen and
DS0000003937.V307652.R01.S.doc Version 5.2 Page 22 evidenced that all areas of practice, any employment issues and staff training needs were discussed, the supervision record was signed as agreed as accurate by both parties. Examination of records of testing and maintenance of fire fighting equipment, alarm systems and emergency lighting demonstrated that these are being undertaken at the required intervals. A service contract is in place demonstrating the required level of maintenance of alarm systems, lighting and fire fighting equipment. A record of fire drills demonstrates that these are carried out regularly and staff training in fire safety is held at the required intervals. Information sent to the Commission prior to the inspection detailed maintenance and service of equipment and installations including electrical wiring, gas safety, central heating system, water temperature checks, lift servicing and emergency call systems. An officer from the local environmental health office last carried out a general inspection in January 2005 and for food hygiene in January 2006. Staff training needs updating in relation to some health and safety areas, all staff have received training in safe moving and handling in May 2006 although the last training in infection control was provided in 2002 and Food Hygiene for care staff in 2004. 50 of staff have received first aid training. DS0000003937.V307652.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 1 DS0000003937.V307652.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Care plans must be reviewed regularly to ensure that identified needs remain current and that where a person’s needs have changed, up to date information is available to ensure staff have clear direction regarding how to meet those needs. Previous time-scales 30/11/05 and 31/03/06 not met, this requirement is repeated for the third time. Where a service user is in receipt of wound care from a district nurse, the home must establish a plan of care, based on advice from the district nurse, to identify the action necessary to reduce the risks of introducing infection should the dressing become damaged between the nurses visits. Previous timescale 31/03/06 not met, this requirement is repeated for the second time. All staff must receive regular training up dates in areas of health and safety practice including infection control and food hygiene.
DS0000003937.V307652.R01.S.doc Timescale for action 1. OP7 15 30/09/06 2. OP7 15 30/09/06 3 OP38 13 30/09/06 Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard OP9 Good Practice Recommendations Where medicines are supplied in boxed or bottled containers, these should be marked with the date and time of opening to enable effective audit of medicines held in the home. 1. DS0000003937.V307652.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Poole Office 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
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