CARE HOMES FOR OLDER PEOPLE
Fair Havens Christian Home 468 Winchester Road Southampton Hampshire SO16 7DD Lead Inspector
Ms Jan Everitt Unannounced Inspection 11th January 2006 09:30 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 Fair Havens Christian Home DS0000011425.V254756.R01.S.doc Version 5.1 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. Fair Havens Christian Home DS0000011425.V254756.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Fair Havens Christian Home Address 468 Winchester Road Southampton Hampshire SO16 7DD 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) 02380 790874 02380 777478 Fair Havens Christian Home Mrs Christine Newman Care Home 23 Category(ies) of Dementia - over 65 years of age (23), Old age, registration, with number not falling within any other category (23), of places Physical disability over 65 years of age (8) Fair Havens Christian Home DS0000011425.V254756.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. A maximum of 8 service users may be accommodated in the PD(E) category that are in receipt of personal care only. A maximum of 10 service users in the OP category may be accommodated who are in receipt of nursing care. 14th June 2005 Date of last inspection Brief Description of the Service: Fair Havens Christian Care Home is a small homely care home with nursing that accommodates twenty-three service users. The age range for admission to the home is 65 years and over. Fair Havens is registered to accommodate up to eight service users who are physically disabled but are in need of personal care only and up to ten service users in the old age category who are in need of nursing care. The home is registered to care for twenty-three service users over 65 years of age with dementia. The home is managed by Keychange, a nationally registered charity and has a strong Christian ethos, which is reflected in the atmosphere of the home and the delivery of care. The name of the home remains Fair Haven. The home consists of a two-storey building with a newer purpose built ground floor extension. Seventeen of the twenty rooms are single occupancy accommodation and three rooms are double occupancy. Eight of the twenty rooms have en-suite facilities. The home has a well maintained landscaped garden and patio areas for sitting in. Fair Havens Christian Care Home is situated in a residential area on the outskirts of Southampton city and has easy access to all of the local amenities. Fair Havens Christian Home DS0000011425.V254756.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection of Fair Havens Christian Care Home took place on the 11 January 2006 and lasted 5 hours. It was undertaken by one inspector who was assisted throughout by the senior nurse on duty that day. The registered manager was off duty on this day. Ten standards were assessed on this occasion, six of which are the core standards. Of the ten standards assessed, six were found to have minor shortfalls. The inspector toured the building and spent a considerable time talking to a large number of the service users and three visiting relatives. Speaking with the service users the inspector concluded that the service users were very happy with their choice of home and that relatives reflected this when speaking to the inspector. The inspector assessed that given the number of the service users who were unable to verbalise their opinions, from observations of the care practices and interactions between service users and carers, the care and services received by the service users was of a good standard. Three staff were spoken with individually and from these conversations the inspector concluded that there was a high level of motivation and job satisfaction within the staff group. All communal areas were seen and a number of the service users’ rooms. Care records were examined. What the service does well:
The premises are both well maintained and well decorated and provide a welcoming, homely environment within which service users live, one service user described their life as being ‘very comfortable here’. The cleanliness and hygiene around the home is maintained to a high standard. The care records are well maintained and carers are participating in the documentation of reporting the service users day- to-day activities. They are well respected by the service users and demonstrated a good knowledge of service users’ needs. The staffing levels are high enough to enable staff to spend time with service users and service users have described the staff as being part of a ‘big family’. Fair Havens Christian Home DS0000011425.V254756.R01.S.doc Version 5.1 Page 6 The service users spoken with, highly praised the staff group and said they were ‘kind and responsive to their wishes’ The home has an activities programme advertised on the notice board. The service users reported that they are satisfied with the variety of activities that are available. They reported to the inspector that they particularly enjoyed the speakers that attend the home and the church group that attend the home weekly to lead singing and prayer services. The activities advertised were varied and appropriate for the service user group. The home supports staff training and is supporting a number of carers to undertake their NVQ level 2 and 3 qualification. A training matrix identifies the training undertaken by the staff and training needs. Staff reported to the inspector that the manager and senior staff are very supportive and appreciative of the work they do. What has improved since the last inspection? What they could do better:
Service users should be nutritionally risk assessed on their admission to the home and appropriate care plans written if a risk has been identified. Bedrails should be risk assessed and bumpers purchased to cover those bedrails in use. There must be evidence that there has been agreement from the service user/representative for the use of bedrails. A service users satisfaction questionnaire and survey should be implemented to form part of the quality assurance system and to ensure that service users and their relatives/representative have the opportunity to consult on suggestions and comments they may have. Although a satisfaction survey has not been distributed, a relative requested to speak to the inspector and she wanted to express her gratitude and satisfaction with the care her frail mother was receiving and praised the home highly. A risk assessment of the environment has been discussed with the manager and organisation in the two previous inspection reports and is required in this report. Staff supervision has commenced but is not fully operational to date, but staff spoken with during the inspection consider they are well supported and valued by the manager, who they report, is always available to talk to. Staff supervision should continue to be developed by the manager to achieve the standard of six sessions per year. The carpet identified in the main body of the report must be cleaned or replaced to eliminate unpleasant odours.
Fair Havens Christian Home DS0000011425.V254756.R01.S.doc Version 5.1 Page 7 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 Havens Christian Home DS0000011425.V254756.R01.S.doc Version 5.1 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 Fair Havens Christian Home DS0000011425.V254756.R01.S.doc Version 5.1 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): The standards in this section were not assessed on this occasion. EVIDENCE: Fair Havens Christian Home DS0000011425.V254756.R01.S.doc Version 5.1 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 The service user’s health, personal and social care needs are set out in individual plans of care, however, some of the health care risks are not documented. EVIDENCE: A sample of care plans was viewed. Information required to be recorded and stated in Schedule 3 of the Care Home Regulations were, in general, in place. The care plans identified problems and risk assessments were undertaken for moving and handling and tissue viability. In general the care plans were well recorded and evaluated appropriately. The inspector observed that a full assessment had not been undertaken for one gentleman who had been admitted for respite care some months previously. Nutritional risk assessments are not recorded. The inspector observed that for one gentleman, with a neurological disorder and whose wife reported that he being given supplementary drinks, there was no evidence of a nutritional risk assessment and a strategy plan documented to rationalise why he needed supplementary drinks. However, it was also noted that he is being weighed weekly and this was recorded, and that his weight was increasing. The service
Fair Havens Christian Home DS0000011425.V254756.R01.S.doc Version 5.1 Page 11 users spoken with reported that they felt well and were well cared for. There were a number of relatives visiting the home at the time of the inspection and they reported that they were very pleased with the care and services their relative was receiving in the home. From conversations and observation the inspector concluded that the home is delivering a high standard of care that the care plans do not always reflect adequately enough. Fair Havens Christian Home DS0000011425.V254756.R01.S.doc Version 5.1 Page 12 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 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. EVIDENCE: The inspector spoke with approximately fifteen residents and four visiting relatives. Relatives and friends visit the home frequently and this is evidenced in the visitor’s record book. The service users and relatives gave high praise for the ‘wonderful’ Christmas that the home had given them. The chef received many compliments from the residents and the relatives about the Christmas fayre that he had prepared and reported to the inspector that he had made all the Christmas puddings and cakes himself. One relative reported that she was invited to share Christmas day at the home to be with her mother and that it had been a splendid affair. There was particular praise for the carol concert that took place the week before Christmas. The home has a strong Christian ethos and the church visit weekly to sing hymns and say prayers. The home has an activities programme displayed on the wall of the dining room and a service user informed the inspector that there was a list of speakers that come once a week to talk on various subjects and that she finds
Fair Havens Christian Home DS0000011425.V254756.R01.S.doc Version 5.1 Page 13 this very interesting. There are a number of residents that enjoy reading the daily papers and these are delivered to the home daily. The inspector observed one lady resident reading her paper. Another resident reported that there were lots of activities going on and that she enjoyed the craft afternoons. The inspector spoke to all the relatives that were visiting and a service user’s daughter reported being thrilled at receiving a Christmas card that her mother had made at the craft activity. A service user was also observed to be knitting and reported that she is always knitting something. The inspector observed a new large screen television had been installed in the lounge and when service users were asked what they thought of it, nearly all replied that it was easy to watch from any of the chairs in the lounge. The home has another two lounges one being a quiet lounge. Service users social histories are recorded in their assessments and many of the residents have chosen to come to this home because of the Christian ethos and they have heard about it through their church. Those that are able, continue to go out into the community to socialise with friends and family. The home continues to be supported on a regular basis by the group of people who were once committee members for the home before it was taken over by the Keychange Charity. The physiotherapist visits the home weekly to practice gentle exercise with a number of service users and one service user reported that she looks forward to this visit as the physiotherapist accompanies her on a walk down the road when she feels she is ‘set free’. Fair Havens Christian Home DS0000011425.V254756.R01.S.doc Version 5.1 Page 14 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): 18 Service users are protected from abuse, however the use of bedrails as restraint is not risk assessed. EVIDENCE: The inspector observed that there were bedrails in use. Only one set of bedrails had bumpers to cover them to avoid entrapment. For the other bedrails in use, there was no risk assessment or care plan to identify why they were being used and no evidence documented in the care plans of conversation or agreement for their use, from the service user or their relative. This was discussed at the last inspection and no action has been taken. A requirement will be made from these findings. Fair Havens Christian Home DS0000011425.V254756.R01.S.doc Version 5.1 Page 15 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): 21 & 26 Service users have sufficient and suitable lavatories and assisted bathing facilities. The home is clean, pleasant and hygienic. EVIDENCE: The home has sufficient bathrooms to meet the service users in residence needs. The inspector observed that the newly refurbished wet/shower room is out of order owing to problems with the flooring being lifted by the water. This is under investigation and until the problem can be resolved this is out of use. The staff reported that this was disappointing for some of the service users who found it difficult to get in and out of baths, but that it was not deterring any of the residents from being able to bath. The home is very clean and a separate housekeeping staff maintains hygienic and high standards. The inspector did detect a slight offensive odour in a double ground floor room and noted the carpet to be stained. This was discussed with the nurse in charge and she reported that the resident was prone to accidents. A requirement will be made from these findings.
Fair Havens Christian Home DS0000011425.V254756.R01.S.doc Version 5.1 Page 16 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): 28 & 30 Service users are in safe hands at all times. Staff are trained and competent to do their jobs. EVIDENCE: At the time of the inspection one registered nurse was in charge of the home. A large percentage of the care staff have achieved their NVQ level 2 and 3 in care and a further two are undertaking at the present time. The staff spoken with are very enthusiastic about their jobs and are motivated by their training. One member of staff is undertaking her NVQ level 3 and said she gets so much job satisfaction from caring for the clients and that it is the best job she has ever done. Most of the staff have been in post for a considerable amount of years and are very familiar with the needs and preferences of the residents. From observation of how the staff and service users interact, this would suggest that the carers are well trained and have good relationships with the service users and each other and work well as a team and support each other at busy times. The home has a training matrix that identifies the training staff have undertaken. Staff spoken with reported that they receive annual moving and handling training and two fire lectures from the fire officer and two training sessions in-house. The registered nurse reported that she has undertaken more clinically based training from various sources and this includes male catheterisation, infection control and first aid. The inspector observed a variety of training being advertised on the notice board in the manager’s office.
Fair Havens Christian Home DS0000011425.V254756.R01.S.doc Version 5.1 Page 17 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): 33, 36 & 38 The home is run in the best interests of the service users, however, there is no documented feedback from the service users/relatives to ascertain the level of satisfaction with the service. Staff are not formally supervised. The health, safety and welfare of service users and staff are promoted and protected. EVIDENCE: The organisation has no quality control system in place. The manager does audit the care plans and MAR sheets and internally audits the services provided. The home does not distribute service users surveys to ascertain the level of satisfaction with the service and to involve service users and relatives in suggestions of ways to improve the service. This was discussed at the previous inspection with the manager but no results of a survey have been published to date. The service users and relatives spoken with speak highly of
Fair Havens Christian Home DS0000011425.V254756.R01.S.doc Version 5.1 Page 18 the manager and her team and there was nothing but praise from everyone about the care they receive. One service user did say that she does not like it when agency staff attend the home as they are not familiar with the home and the way things are done. A relative visiting her very sick mother, requested to speak with the inspector. She wished to tell me how impressed she was with the care and kindness her mother was receiving since her admission to the home nearly a year ago and that although her mother was very ill she highly praised the care and attention her mother was receiving and that she would not wish her to be anywhere else in her final days. She praised the professionalism of all staff from the manager to the chef and said she could find no fault with anything in the service provision. She reported that she is always made welcome in the home and is made to feel comfortable and is pleased to be able to participate in her mother’s care. From observation and conversations with both service users, relatives and staff, there is no doubt that the home is providing a good standard of care and services. The monthly regulation 26 visit reports are received by the CSCI regularly from the nominated person visiting the home. The inspector could not evidence that formal supervision takes place 6 times a year. The registered nurse reported that the manager is her appraiser and that she is not formally supervised between appraisals. A requirement will be made from these findings. The inspector could not evidence a risk assessment for the environment and the nurse on duty was unaware if one existed and if it did, where it was stored. A requirement will be made from these findings. A sample of servicing certificates for systems and equipment were viewed and found to be current. All mandatory health and safety training is undertaken at appropriate intervals by staff. Fair Havens Christian Home DS0000011425.V254756.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X X 3 X X X X 2 STAFFING Standard No Score 27 X 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X 2 X 2 Fair Havens Christian Home DS0000011425.V254756.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation Reg 15(1) Requirement Nutritional assessments must be undertaken for service users at the time of admission to identify those at risk of malnourishment. Nutritional assessments must be reviewed at appropriate intervals. Bedrails bumpers must cover all bedrails in use to prevent entrapment. This was a requirement from the last inspection with a timescale of 30/08/05 and has not been complied with. Bedrails must only be used following a risk assessment and permission sought from the service user as to their use. If the service user is not mentally able to participate in this decision- making, the use of bedrails must be discussed with their relative/representative. You are required to ensure that the carpet in the room identified as having an offensive odour is cleaned thoroughly. The manager must establish a system to improve and review
DS0000011425.V254756.R01.S.doc Timescale for action 28/02/06 2. OP18 12(4)(a) 28/02/06 3. OP18 Reg 15(1) 28/02/06 4. OP26 Reg 16(2)(k) Reg 24 (1)(2) 28/02/06 5. OP33 31/03/06 Fair Havens Christian Home Version 5.1 Page 21 6. OP36 Reg 18(2) 7. OP38 13(4) the services delivered in the home, by seeking the opinions and views of the service users and/or their representatives. The registered manager must ensure that staff are supervised 6 times a year and this is documented as having taken place. An environmental risk assessment must be undertaken and recorded. This was a requirement from the last inspection report with a timescale of 30/09/05 and has not been complied with. 30/04/06 15/02/06 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 Good Practice Recommendations Fair Havens Christian Home DS0000011425.V254756.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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