Inspection on 15/01/08 for Fair Havens Christian Home

This inspection was carried out on 15th January 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Fair Havens Christian Home 23/12/08

Fair Havens Christian Home 19/02/07

Fair Havens Christian Home 11/01/06

Fair Havens Christian Home 14/06/05

Fair Havens Christian Home 09/02/05

Fair Havens Christian Home 03/08/04

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Winton House

Newbeech House

Treloar College

Rush Court

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Fair Havens Christian Home 468 Winchester Road Southampton Hampshire SO16 7DD Lead Inspector Jan Everitt Key Unannounced Inspection 15th January 2008 09:00 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.V355003.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. Fair Havens Christian Home DS0000011425.V355003.R01.S.doc Version 5.2 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 matroncan1@aol.com 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.V355003.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A maximum of 8 service users may be accommodated in the PD(E) category who 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. 19th February 2007 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 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. The current fee charged is £490-£690. Fair Havens Christian Home DS0000011425.V355003.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating of this service is 1 star. This means that the people who use this service experience adequate quality outcomes. The site inspection visit to Fair Haven Christian Home, which was unannounced, took place over a one-day period on the 15th January 2008 and was attended by one inspector. The registered manager, Mrs Newman was in attendance to assist the inspector throughout the visit. The visit to the home formed part of the process of the inspection of the service to measure the service against the key national minimum standards. The manager had returned the Annual Quality Assurance Assessment (AQAA) to the CSCI within the stated timescales and the focus of this visit to the home was to support the information stated in this document and other information received by the CSCI since the last fieldwork visit, which was a key inspection, made to the home on 19th February 2007. Documents and records were examined and staff working practices were observed where this was possible without being intrusive. The inspector spoke to most of the residents, staff and visiting relatives in order to obtain their perceptions of the service the home provides. Those spoken to were very happy and complimentary about the care and services that are provided. Surveys had been distributed to service users, relatives, care managers, GP and other visiting professionals. One service user survey, one relative/carer surveys, three staff, one GP and the visiting chiropodist surveys were returned to the CSCI. The outcome of the surveys returned indicated that there was a high level of satisfaction with the service and that generally residents and relatives were pleased with the care the home provides and staff were very committed to the service. There were 21 residents accommodated in the home and we were unable to communicate effectively with a small number of residents to gain their views of the service. There were no residents from an ethnic minority group. What the service does well: The home has a warm welcoming atmosphere and provides a safe, wellmaintained homely environment for the service users. The service users and relatives say: ‘The home does everything well for my parents’. Fair Havens Christian Home DS0000011425.V355003.R01.S.doc Version 5.2 Page 6 ‘We are all agreed that Fair Haven is the best of all the places we have visited people in’. ‘The home always responds to questions or concerns’. Service users spoken to and the survey returned said: ‘Excellent information given before admission to the home’. ‘ A friendly and caring home and staff are respectful and meet individual needs with patience’. ‘I would like more activities’. ‘The staff are wonderful’. ‘I am very happy living here’. ‘The food is very good’. ‘Matron is wonderful’. The home has a range of training opportunities for staff and those spoken with told us and comments on surveys returned said: ‘I have been well supported and was put with an experienced carer for a month when I first started the job’. ‘Matron encourages all staff to do training’. ‘We see matron at least six times a year and have appraisals so any problems can be bought up’. ‘Staff know they can see matron at any time if there is a problem’. ‘All information about the residents is put down in the daily report and we are kept up to date with their care’. ‘Staff give excellent care to support residents, their families and other staff. ‘ The home is like a second family to me and this is down to the matron’. ‘ The service provides a caring environment which is sensitive to the various needs of individuals’. ‘We get plenty of training opportunities’. ‘I would like to have more activities for the residents to stimulate their minds’. ‘The standard of care given to residents is high’. The home ensures that residents’ healthcare needs are met and refer to appropriate professionals when necessary. The GP survey returned indicated that Fair Haven is a good service. The podiatrist commented that: ‘I have always been impressed by the attitude of staff concerning the dignity of the clients’. ‘I have seen the staff responding to the needs of individuals especially those with age related confusion’. ‘They are certainly able to treat the residents as individuals and have time for them. The impression of the home is that it is very caring with excellent staff’. The meals at the home are well managed and offer the service users choices and variety and met with their satisfaction. The home has a dedicated staff group. What has improved since the last inspection? Fair Havens Christian Home DS0000011425.V355003.R01.S.doc Version 5.2 Page 7 The pre-admission assessment is now comprehensive and detailed and is undertaken by the manager. The medication policy and procedures have been reviewed and a new system put in place for the management of medication. The home has a designated senior member of staff that co-ordinates all medication. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Fair Havens Christian Home DS0000011425.V355003.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 Fair Havens Christian Home DS0000011425.V355003.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Standard 6 is not applicable to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The pre-admission process has improved and service users are thoroughly assessed prior to being admitted to the home to ensure the home can meet their needs. EVIDENCE: The previous inspection identified a requirement to improve the pre-admission assessment of prospective service user’s needs. We case tracked four service users records, three of which were the most recently admitted residents. The pre-admission assessment format has been reviewed and covers all aspects of both physical and emotional care needs. The assessment is undertaken by the manager and is completed by her when she visits the service users in their own homes or in a clinical setting. She Fair Havens Christian Home DS0000011425.V355003.R01.S.doc Version 5.2 Page 10 said that she is given good information from some clinical settings who are willing to share information. A transfer letter from a hospital, detailing the needs of a resident on discharge from them, was observed in a resident’s admission records and contributed to the assessment process. The manager said she does receive a care needs assessment from care managers if they are involve with the admission, otherwise she gains information at the time of assessment from the prospective service user and/or relatives, if they are available, which she reports is not frequent. The manager said that for those who are able, the service users are offered the choice of visiting the home prior to admission. One of the service users spoken with said that she had visited the home with her family before admission and said that: ‘I am very happy with the home and yes, the manager visited me at home and talked to me and asked questions about how I was managing at home and about my problems with my walking’. The AQAA confirmed that the service does not provide intermediate Fair Havens Christian Home DS0000011425.V355003.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service user’ risk assessments and care plans must be developed further to identify and describe all care needs of the service users. Service users are able to take responsibility for their own medication. The system for the management of medication is now safe and effective. The home’s ethos and staff working practices ensure that residents’ privacy and dignity is promoted. EVIDENCE: A sample of four care plans were case tracked. Service users are assessed on admission and this together with information gathered prior to admission contributes to the formation of the care plans of how clients’ needs are to be met. Fair Havens Christian Home DS0000011425.V355003.R01.S.doc Version 5.2 Page 12 The system of care planning used by the home is comprehensive and identifies risk assessment formats for moving and handling, nutritional status, tissue viability and dependency profiles and an assessment tool that covers all aspects of care needs. The care plans viewed demonstrated that residents have moving and handling profiles with care plans describing how their moving and handling needs are managed. The physiotherapist that attends the home every week undertakes these assessments and care plans. The care planning system is not being used effectively and therefore does not always demonstrate a completed risk assessment and care plans associated with risks. It was noted at assessment that one service user was recorded as ‘at risk of weight loss’. There was no evidence of a nutritional assessment or weights being recorded. Another resident’s care plan said ‘feed with pureed diet and thickened fluids’, and although this was documented as an action on the care plan, there was no associated nutritional risk assessment undertaken to monitor the resident’s nutritional status and weight. One of the recently admitted residents is a diabetic and manages their own medication, which was described in a care plan, but there was no record of regular monitoring of blood sugars to evaluate the effectiveness of her treatment. This was discussed with the manager, who said that this is monitored and the results of the blood sugar tests are recorded in the daily notes and not in the care plan. The daily notes are recorded in detail and specific important information gets lost in the notes among general information. The care planning system was discussed with the manger. The assessments and care plans in place for some residents that have been at the home for some years need to be reviewed and re-written as they do not document all current information. The manager agreed that the care plans must be reviewed and each service user’s identified problem/need have a care plan to describe how that need can be met and be evaluated and reviewed at appropriate intervals. It was observed also that although previous hobbies and likes and dislikes were recorded in the assessment there were no social care plans written to identify how resident’s recreational and social care needs are met. The use of bedrails on service user’s beds was not being risk assessed and care plans did not demonstrate the reasons why they were being used. It was observed that bedrails bumpers were in position on all bedrails to ensure the safety of residents when in use. The staff spoken to say they are well informed about the service users care needs through their daily handover meetings and from the care plans, but added that they are very familiar with the residents’ daily routines. Fair Havens Christian Home DS0000011425.V355003.R01.S.doc Version 5.2 Page 13 Service users spoken with were complimentary regarding the care that they were receiving. Three service users said that they were assisted as required. Comments included ‘the staff are very good’. and said they were ‘wonderful and always at hand to help’. The manager reported that the home had developed and maintained good relationship with the local primary care trust and felt supported. All the service users are registered with the local surgeries. The GP visits the home on request. Advice was sought as required from external healthcare professionals, such as referrals to speech therapist for swallowing assessments and advice on nutrition. There was evidence in one of the service user’s rooms of guidance left by the speech and language therapist as to how staff could effectively communicate with this service user. The home has a good process for recording GP visits and other visiting healthcare professionals, and records any changes in treatment plan, which would inform the staff of any changes in their practice. The physiotherapist visits the home weekly to undertaken mobility and moving and handling assessments. The home has a medication policy and procedures in place. All medications were stored securely including those that should be kept in the fridge and controlled drugs. Staff reported that the registered nurses were responsible for the administration of medication. The previous report identifies shortfalls in the medication management and a requirement was made. This has been complied with and the manager is now using a new system for medication management, which is co-ordinated by the senior staff nurse and she checks the prescriptions before they are dispensed. We checked a sample of MAR sheets, which were observed to be completed appropriately. At the time of this site visit there were no controlled drugs prescribed. It was observed on care plans that the preferred choice of name had been recorded and staff were heard to speak to residents by the name they wished. It was evident from comments received and interaction observed that the staff have formed good relationships with the service users and were familiar with their daily routines, which were being respected. Service users said, ‘staff are very good and kind’, another service user said ‘The staff are respectful, thoughtful, patient and cheery’. A relative commented that the staff were very good and that her relative ‘had good care Fair Havens Christian Home DS0000011425.V355003.R01.S.doc Version 5.2 Page 14 the home does everything well’. We visit regularly and have a good picture of care’. Staff were observed to knock prior to entering the service users bedrooms and attended to the service users in a courteous and respectful manner. Fair Havens Christian Home DS0000011425.V355003.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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. The service users are supported to maintain links with the community and their family and friends. The service users autonomy and choices are respected in their activity of daily living. Meals are well-balanced offering choice and variety and are enjoyed by all service users. EVIDENCE: The home does not employ a person specifically for organising activities. The carers take on that responsibility on a day-to-day basis and visiting entertainers attend the home regularly. The home does not have a formal activities programme but there are flyers put on notice boards for forthcoming activities. One of the carers has taken a particular interest in activities and is Fair Havens Christian Home DS0000011425.V355003.R01.S.doc Version 5.2 Page 16 taking an active part in arranging special occasion celebrations and craft workshops. The AQAA states that the home’s activities have improved in the last year and that staff are now instigating short reminiscence interludes on a regular basis, given time. The manager says that the home would like to develop more person centred recreational time and allow for one to one interaction with those less able and who have diminishing mental capacity. The home has a supportive Christian ethos. Three service users spoken with said that they enjoyed the activities offered and the links with the people from the church. The home has a weekly service on Tuesdays and also monthly on Sunday evenings that the service users stated they took part in and enjoyed. A visiting physiotherapist attends the home on a weekly basis and undertakes group and one–to one exercise session with service users. Daily newspapers are available and a mobile library visits the home every three months when the service users can select/ exchange a variety of books. The manager reported that the home has introduced music for health programme and other activities to include external entertainers, musical afternoons, quizzes, and a relative comes in once a week to play scrabble or do crosswords. There was no evidence of social care plans in the records and although there are activities happening there is no record of who participates and their level of participation. This was discussed with the manager as to records being maintained of social histories and what service users like to do for their recreation and the outcomes for service users if they do take part in activities. The home has an open visiting policy and it was evident from the records in the visitor’s book and observation on the day of this site visit that the home has no restrictions on visiting. During this site visit one resident was having a coffee morning with a group of friends in the quiet lounge. From talking to service users and comments in relative’s surveys suggests that the home has good relationships with relatives, which the manager says the staff and she nurture. Friends and relatives are invited to all the festive celebrations throughout the year. Photographs on the wall showed service users making Christmas decorations and another of the celebrations for a resident’s birthday. Visitors spoken to say they were made very welcome in the home at anytime and felt they could speak to the matron at any time. Comments on surveys say that ‘‘we visit regularly and are always made most welcome’. ‘The home is very friendly and welcoming’. The service users spoken with said that they have autonomy and choice with their daily living activities. A service user commented that the staff attend to him ‘whenever I need them’. Another service user said, ‘nothing is too much for the staff, they are good’. Screens were available in the shared rooms to afford privacy for those sharing. Fair Havens Christian Home DS0000011425.V355003.R01.S.doc Version 5.2 Page 17 One service user said they continue to go to church each week and another goes out in their electric buggy, weather permitting. The assessment documents service user’s preferences as to when they like going to bed and get up. The staff said that respecting their preferences can cause some problems in the evening when they all request to go to bed and staffing numbers are not sufficient to do this. The staff member said this has been discussed at the staff meeting and with the manager who is striving to recruit more staff currently. The home has a planned menu that is rotated on a four-week basis. Comments from the service users indicated that the meals are very good and hot and cold drinks are available at all times. The service users spoken to said they can have snacks during the day and one resident has sandwiches before her bedtime. Comments include ‘very good food’ and ‘always hot and plentiful, excellent food’. ‘Delicious food, just like home with lots of vegetables and choices’. Meals available include pureed diets and diabetics. The lunchtime meal was observed on the day of the visit, and meals appeared wholesome, appetising and balanced, and the service users told us that they were thoroughly enjoying the meal. Staff were available to offer support with meals as required. Fair Havens Christian Home DS0000011425.V355003.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A formal system for recording complaints has not been instigated although the manager maintains records of complaints. The complaint procedure contains current information of how people can complain. The staff have clear understanding of adult protection ensuring that the service users are protected EVIDENCE: The previous report made a requirement of the home to maintain records of all complaints and the outcome of the action taken to address complaints. The AQAA states that one complaint has been received and upheld in the last twelve months. This was discussed with the manager and she said that she has records of this complaint and how she dealt with it, but that she is awaiting a corporate formatted complaints log from the head office of the organisation. The AQAA further states that no serious complaints have been received, as the manager believes that issues are dealt with early and quickly to satisfy the service users. The CSCI has not received any complaints in the past twelve months. Service users spoken to were aware of who they speak to if they wished to complain or were worried about anything, but said they really had no complaints. Staff surveys and staff spoken with also said that they would go to ‘matron’ if any person complained. Fair Havens Christian Home DS0000011425.V355003.R01.S.doc Version 5.2 Page 19 The home has clear guidance and procedures in place about what to do if there are any allegations of abuse. Staff spoken with had good understanding of safeguarding issues and their responsibilities in reporting any such incidence. The home has the Hampshire Adult protection procedure and local procedure about action to be taken if abuse is suspected. The manager confirmed that the all staff are inducted into the policies and procedures when they first start at the home and further education is given to those who undertake the NVQ 2 training. Fair Havens Christian Home DS0000011425.V355003.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides the service users with a comfortable, homely and clean environment in which to live and that meets their needs. The infection control procedures at the home are satisfactory and ensure that the service users are protected. EVIDENCE: We looked around the building and visited a number of bedrooms, communal areas, bathrooms, and kitchen, laundry were viewed. The home was clean and homely. Furnishing was of satisfactory standard and appropriate to the needs of the service users. The service users are provided with ample communal areas where a variety of activities are undertaken. The service users’ bedrooms seen were personalised and a service user said that he was able to bring in items of personal belongings on admission to the service. Fair Havens Christian Home DS0000011425.V355003.R01.S.doc Version 5.2 Page 21 The laundry area was in satisfactory condition and washing machines were fitted with sluicing programmes. Hand washing facilities were available and information on infection control was available to the staff. Practice observed indicated that they were aware of this and protective equipment such as gloves and aprons were available. Staff spoken with were aware of infection control principles and one carer said she had just attended training in infection control and considered this very valuable and that it underpinned the practices in the home and that it had been beneficial to her. The matron said that there is an ongoing maintenance programme for the home of redecoration and refurbishment and the head office is very good at providing equipment they need, should the home request this. The home is in the process of gradually replacing all beds with profile nursing beds. The AQAA states that the home has installed a new fire alarm system, installed a new bath and a new canopy is to be constructed for over the front door in the coming year. The home is surrounded by well-maintained gardens that the residents enjoy during the finer weather. Fair Havens Christian Home DS0000011425.V355003.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staffing numbers should reflect the assessed needs of the service users in residence, particularly at busy times of the day. The home has system in place to ensure that staff have the skills to deliver care safely. The recruitment process is adequate. References should be obtained prior to employment to ensure the safety of the service users. There is a good training programme in place to ensure that staff are supported in their work. EVIDENCE: The staff rotas demonstrate that there is one trained nurse on 24 hours a day. There are between 4 and 5 carers on in the morning and 3 in the afternoon. One carer is awake at night and one sleep-in carer also. The staff levels were discussed with the manager, as this had been an issue at the previous inspection, with care staff having to undertake laundry duties and the afternoon carers having to organise the evening meal. Staff spoken with reported that the afternoon shift could be busy and stressful when clearing up after tea and then trying to respond to service users requests to go to bed. Fair Havens Christian Home DS0000011425.V355003.R01.S.doc Version 5.2 Page 23 Staff spoken with said that the staffing numbers that day were sufficient but it was dependant on the dependency of residents and if agency staff were attending the home. The manager said that she acknowledges there are some gaps in the numbers of staff when dependency levels are high, but she attempts to fill these with agency staff who are familiar with the home. She reported that she is currently recruiting another trained nurse, carers and ancillary staff. Indeed on the day of this visit the administrator was heard to be making appointments for interviews for the various posts available. Service users spoken with were very positive about the response they receive from the staff if they request anything and say: ‘No matter how busy they are help is always available’ ‘Staff always come but sometimes they are busy and that is ok to wait because I know how hard the staff work all and day and night’.’ The home employs a cook and separate domestic staff to undertake the cleaning of the home. The home employs a mixed culture staff group. The AQAA states that currently 44 if care staff have achieved their NVQ level 2 qualification and two carers are undertaking their NVQ level 3. One carer spoken to at the time confirmed that she is undertaking her NVQ level 3 and is enjoying the challenge. Another carer said she had achieved her NVQ Level 2 and had enjoyed the course and hoped to go on to level 3. The senior staff nurse is about to commence her Registered Managers Award. The manager said that the care staff are very enthusiastic to undertake their training and that the organisation will support them through their NVQ training. Staff spoken with and staff surveys received by the CSCI said that they are encouraged and supported by the manager to undertake training especially their NVQ level 2. Fair Havens Christian Home DS0000011425.V355003.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is managed by a person who is fit to be in charge and is appropriately trained to undertake this role. The financial interests of the service users are safeguarded through good accounting. The home is run in the best interests of the service users, however quality assurance and monitoring systems needs to be developed further to evidence the service is meeting the aims and objectives of the home. There is a satisfactory procedure in place to ensure the health and safety of the service users and staff is promoted. Fair Havens Christian Home DS0000011425.V355003.R01.S.doc Version 5.2 Page 25 EVIDENCE: The home has a registered manager who is also a registered nurse. The staff service users and visitor spoken with all said that the manager is available when they needed her and that she operated an open door policy. The manager had developed good relationships with her staff and the staff were supportive of her. Staff spoken to said: ‘The matron is very good and she is always there for you’. ‘The matron is the best manager I have ever worked for’. ‘The matron is very encouraging and supports us to do any training’. ‘I have worked in three homes and this is far the best. It is like a second family and this is down to the matron and the way she runs the home’. The AQAA states the manager is undertaking a business skills development course and does receive good support from the organisation’s operations controller. The manager’s assessor attended the home the day of this visit and the manager said that the course was proving to be interesting. The home does not have a formal internal audit system in place that seeks the views of the service users/ relatives and other healthcare professionals. This was discussed with the manager as this has been highlighted at two previous inspections. She says she has attempted to send out questionnaire surveys to relatives and other stakeholders but reports that she has little response from them. She also said that owing to the advance age and failing mental capacity of a number of residents it was difficult to gain a true picture of their views. The organisation does not undertake any separate audit to ascertain the level of satisfaction from the service users. The operational manager does undertake regular visits to the home, in line with Regulation 26 and records of these were evidenced in the home. We viewed a sample of these reports and there were positive comments from service users to the person undertaking the visit. The manager said that she audits care plans, MAR sheets and the environment but does not document results and therefore there was no demonstrated evidence that this takes place. AQAA states that the reports show that the general management of the home is good and service users contented. Staff meetings are held and there was evidence of these in the form of a record of what was discussed at that meeting. Fair Havens Christian Home DS0000011425.V355003.R01.S.doc Version 5.2 Page 26 Staff spoken to gave the impression that they were very dedicated to the home and that they strived to give excellent care to the service users, their families and care for each other. All sections of the AQAA were completed and the information gave a reasonable overview of the current situation within the service. The evidence to show the service does things well was satisfactory although there were areas that needed more supporting evidence and in the case of quality assurance there was little reference to how this was achieved to measure the outcomes for service users. A sample of three service user’s monies that are managed by the home was checked. This indicated that receipts of all transactions were maintained and records of invoices raised were also available. Random checks of the service users’ personal account were found to be accurate. All transactions undertaken with the service users were recorded accurately. The administrator said that the operational manager also undertook a random audit of the service users’ personal moneys maintained by the home. The home has a health and safety policies and procedures in place that all staff are made aware of at induction. The AQAA states that maintenance of equipment has been undertaken in the last 6-9 months. This was confirmed at the visit on viewing a sample of servicing certificates. A new fire alarm system has recently been installed. The fire log evidenced that staff attend regular fire training once a year and undertake regular drills. The fire alarm system was tested on the day of this visit and records confirmed that these are undertaken weekly. A fire risk assessment has been undertaken and was available at this site visit. The accident records were viewed and maintained appropriately. The manager does not audit these or analyse the accident occurrence. Substances that are hazardous to health (COSHH) were kept locked away. The staff spoken with reported that they were about to have a moving and handling update that they receive yearly, this was also seen to be advertised on the wall. The AQAA states that maintenance of equipment has been undertaken in the last 6-9 months. This was confirmed at the visit on viewing a sample of servicing certificates. A new fire alarm system has recently been installed. The fire log evidenced that staff attend regular fire training once a year and undertake regular drills. The fire alarm system was tested on the day of this visit and records confirmed that these are undertaken weekly. A fire risk assessment has been undertaken and was available at this site visit. Fair Havens Christian Home DS0000011425.V355003.R01.S.doc Version 5.2 Page 27 Fair Havens Christian Home DS0000011425.V355003.R01.S.doc Version 5.2 Page 28 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Fair Havens Christian Home DS0000011425.V355003.R01.S.doc Version 5.2 Page 29 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 OP7 Regulation 15(1)(2)( b) 13(4)( c) Requirement Timescale for action 28/02/08 2. OP33 Reg. 24 (1)(2) The registered person must ensure that care plans accurately describe the action to take to meet service users’ assessed needs/problems. Care plans for those who have been in the home for a considerable time must be reviewed and updated. Care plans must demonstrate a risk assessment for residents who have bedrails in use. The manager must establish a 20/04/08 quality assurance system to improve and review the services delivered in the home, by seeking the opinions and views of the service users and maintaining results of audits of records and systems. This was a requirement from the last inspection and timescale of 15/04/07 has not been fully complied with. The registered manager must ensure that there is a robust recruitment procedure in place. All checks including references must be obtained prior to DS0000011425.V355003.R01.S.doc 3. OP29 19(1) 28/02/08 Fair Havens Christian Home Version 5.2 Page 30 employment in order to safeguard the welfare of the service users. 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 OP12 Good Practice Recommendations It is recommended that a record be maintained of all the activities that take place in the home and the level of participation of each individual resident. Fair Havens Christian Home DS0000011425.V355003.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Fair Havens Christian Home DS0000011425.V355003.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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