Inspection on 14/12/06 for Fairburn Mews

This inspection was carried out on 14th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Fairburn Mews 30/08/06

Fairburn Mews 31/10/05

Fairburn Mews 16/05/05

Similar services:

Snydale Care Home

Whiteley House

Staveley Birk Leas Nursing Home

Fairmount Nursing Home

Currergate Nursing Home

Tyndale Avenue

Brookfield

Castlethorpe Care Home

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

CARE HOME ADULTS 18-65 Fairburn Mews Wheldon Complex Wheldon Road Castleford WF10 2PY Lead Inspector Gillian Walsh Key Unannounced Inspection 14th December 2006 10:00 Fairburn Mews DS0000062960.V319124.R01.S.doc Version 5.2 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 Fairburn Mews DS0000062960.V319124.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 Adults 18-65. 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. Fairburn Mews DS0000062960.V319124.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fairburn Mews Address Wheldon Complex Wheldon Road Castleford WF10 2PY 01977 521784 01977 521785 fairburnmews@exemplarhc.com 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) Fairburn Health Care Ltd Kim Elaine Jackson Care Home 20 Category(ies) of Dementia (10), Mental disorder, excluding registration, with number learning disability or dementia (10), Physical of places disability (10), Terminally ill (5) Fairburn Mews DS0000062960.V319124.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Each of the two units within the home will be staffed with a minimum of two carers at all times; and staffing levels will be increased, using the Residential Forum staffing model, in accordance with assessed care needs. Each unit will have a RMN, Level 1, on duty at all times. The home`s full-time manager will be supernumerary to the care and nursing rota. Can provide accommodation and care for two named service users over 65 years of age 30th August 2006 2. 3. 4. Date of last inspection Brief Description of the Service: Fairburn Mews is a new, purpose built facility offering nursing and social care, within dedicated units, to 10 people aged 18-65 suffering from Huntington’s Disease in the downstairs Lowrie Suite, and 10 people aged between 18-65 with mental health problems on the upstairs Hulme Suite. The home shares a site with two other care homes situated on the outskirts of Airedale village and Castleford town centre. There are limited local facilities although this is partly compensated for by the home having access to a minibus which is used to take residents to nearby shopping and activity centres. Secure garden areas have been developed and residents have use of patio areas accessed from the home. All bedrooms are single, ensuite, well equipped and several of the rooms on Lowrie Suite have double beds. Communal areas are spacious and comfortable. In December 2006 the scale of charges at the home are £1274.38 - £3114.91 per week with extra charges being made for hairdressing, toiletries, chiropody and some trips out. Information about the home is available from the home in the Statement of Purpose and Service User Guide. All current and prospective residents are given copies of these documents and the Service User Guide contains the summary of the last inspection report. Fairburn Mews DS0000062960.V319124.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit to the service made on 14 December 2006 that occurred within a full inspection. For this inspection, the views of residents and relatives were sought by way of questionnaires. Healthcare professionals, including General Practitioners and involved social workers, views were sought prior to the inspection made in August. The outcome of this, at the time of writing this report, was as follows: Of the 11 resident questionnaires sent out, none were returned. Of the 11 relative questionnaires sent, 4 were returned, all of which were favourable with two people commenting on the “excellent care” and “extremely helpful” staff. Of the 5 health care professional questionnaires sent in August 2006, 5 were returned; these were favourable but did not contain specific comments. Of the 14 social worker questionnaires sent in August 2006, 3 were returned, all were favourable with one person commenting “the home appeared very organised”, “It was also very comfortable and welcoming”. In writing this report, information and evidence was not only obtained by way of visiting the home but also from notifications and information sent to CSCI and from the last CSCI inspection reports. In gathering evidence, CSCI undertook case tracking, reviewed documentation, sought feedback from residents and their families, staff, the home’s manager and registered person and other relevant stakeholders, and undertook relevant observations and discussions appropriate to needs of the residents, taking into account their needs and communication needs. The inspector would like to thank residents, their relatives and staff for their time and assistance during this inspection. What the service does well: Fairburn Mews DS0000062960.V319124.R01.S.doc Version 5.2 Page 6 Some of the good things about this service are: • • • • • • The home offers a well-designed, comfortable and spacious environment. Residents are supported and encouraged to live with as much independence as possible. Staff are available in sufficient numbers to dedicate one to one time to each resident on a daily basis. Individual activity plans are developed on a weekly basis to meet the needs of residents. Care planning is developed in partnership with the resident concerned and staff take a holistic view in their approach to care. Staff work hard to develop therapeutic relationships with residents and their families. One resident said staff are “Bloody fantastic”. What has improved since the last inspection? What they could do better: Plans are already in place to develop a sensory garden, sensory room and improved activities room. Staff are also looking at ways in which residents’ independence can be improved, such as the introduction of a dedicated postal address for each person. Fairburn Mews DS0000062960.V319124.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Fairburn Mews DS0000062960.V319124.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fairburn Mews DS0000062960.V319124.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made from evidence gathered during the visit to this service. The work of the staff and the systems operated at the home make sure that people only move into the home once assurances have been given that their assessed needs can be appropriately met. EVIDENCE: Prior to admission, all potential residents are assessed either by the home’s manager or by the clinical nurse manager. Completed copies of the assessment tool used were seen in the four files inspected and contained all of the information necessary to complete a full assessment of need. Copies of assessments completed by health care professionals previously involved in the individuals’ care are also obtained. Fairburn Mews DS0000062960.V319124.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents know that their assessed and changing needs are reflected within their individual care plan. Residents are supported to take risks, which are managed through agreed risk assessment procedures. EVIDENCE: Care plan files for three residents from the upstairs unit and one from downstairs were looked at. All contained comprehensive assessments of needs and care plans which had been developed in line with the results of the assessments. Care plans covered areas such as mood, behaviour and cognition as well as physical, recreational and some social needs. Fairburn Mews DS0000062960.V319124.R01.S.doc Version 5.2 Page 11 Where appropriate, care plans had been developed with the involvement of the resident or their representative and signatures had been obtained to confirm this. One person said that they had gone through their care plan with staff on the day of the inspection visit and had signed it to say that they agreed with what it said. Documentation demonstrated that care plans are being appropriately reviewed to meet the residents’ changing needs, this again is done with the involvement, where appropriate, of the resident or their representative. Some care plans include long and short-term goals to demonstrate how effective the care plan is and whether a review would be appropriate. One person spoken with said that they had asked for some changes to their care plan and that this would be discussed later. Care plans and other documentation held within the file contained details of residents’ decisions and choices about their everyday lives and how they are supported and encouraged to maintain, wherever possible, independence and individuality. In conjunction with assessments undertaken and care plans developed, comprehensive risk assessments had also been developed to demonstrate that residents are enabled to take risks but that plans are in place to manage and minimise the risk to the resident and others who may be concerned. Fairburn Mews DS0000062960.V319124.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Residents are given support and encouragement to access education and leisure activities, both within the home and the local community. Relationships with family and friends are supported and residents’ rights are fully respected by staff. Meals are nutritious and are enjoyed. EVIDENCE: The home employs a full time activities organiser and all of the residents on Hulme Suite have individual, weekly therapeutic and leisure activities programmes in place which are facilitated by the key worker, in conjunction with the resident and the activities organiser. The individual programmes cover morning, afternoon and evening activities and are planned the preceding week to make sure that proper arrangements such as transport, escorts, extra staff and any expenditure can be organised in good time. Staff said that these programmes are flexible depending on how the resident feels and other things Fairburn Mews DS0000062960.V319124.R01.S.doc Version 5.2 Page 13 that may come up. In addition to this, group activities are held which residents have the choice of attending. During the visit, the inspector spent some time playing a board game with one person who said that they enjoyed doing such an activity and that it helped with their concentration. Residents are encouraged and supported to attend local colleges, gyms and other educational and leisure centres wherever this is appropriate to their needs and wishes. Other local facilities are used by residents on a regular basis such as trips to shopping centres and local pubs. Although similar activities are available for residents on the Lowrie Suite, it is very much up to the individual how they choose to spend their time depending on how they are feeling and their abilities. Staff said that they are in the process of developing a sensory garden and are about to develop the games room to offer a wider range of activities including a sensory room. Residents’ bedrooms are viewed as their private area and those who wish to, and are able to, have a key to their own room. Two residents said that staff always knock on their door before entering the room. From observations made during the inspection visit, it is clear that staff are respectful of residents’ rights to take responsibility for their lives. Families and friends are welcomed to the home and encouraged to participate in the lives of their friend or relative subject to the individual’s choice. Residents are also supported to visit friends and relatives or to spend time socially with them. Care plans clearly evidence that individuals’ rights to privacy and independence are recognised and respected at the home. Meals and mealtimes are flexible to meet the needs of the residents. Special diets and personal preferences are incorporated into the provision of a healthy and nutritious diet. One person said, “we can choose what we want and it’s always nice”. Fairburn Mews DS0000062960.V319124.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive care and support to meet their physical and emotional needs in a manner entirely appropriate to their individual preferences and personal goals. Very robust systems for managing medications are in place to ensure the safety of residents. EVIDENCE: Residents said that staff give them the support they need and in the way they want it. When asked about how staff give support, one resident said “they’re bloody fantastic”, another person said “I listen to what they say, they give me good advice”. This person also said that due to “great staff” they now realised that “life is worth living”. The care plans seen detailed the support residents need and how the individual wished to receive this support. Two residents spoke of the involvement they Fairburn Mews DS0000062960.V319124.R01.S.doc Version 5.2 Page 15 have with developing and reviewing their care plans and one person said that, by following the care plan they had agreed with their nurse, they were now feeling much better. Staff at the home are supported in meeting residents’ physical and emotional needs by community and hospital based healthcare professionals. The home also has strong links with the Huntington’s Disease Society to ensure that staff and residents on Lowrie Suite are kept informed about any new developments and best practice. A physiotherapist based at Fairburn Mews sister home, on the same site, is available to residents who may need this type of intervention. Systems relating to management of medications were checked during the inspection visit. Very robust procedures have been put in place since the last inspection and maintained to ensure a safe and well-managed system. This includes allocated staff being given supernumery hours to dedicate to managing medications. Fairburn Mews DS0000062960.V319124.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives are confident that their views are listened to and acted upon. Policies, procedures and staff training are in place to protect residents from abuse and harm. EVIDENCE: No complaints about the service have been received, either by the home or by the Commission, since the last inspection. Residents and relatives said, in questionnaires sent out prior to the previous inspection, that they would know who to speak to if they had any concerns; they also indicated that staff listen to what they have to say. The complaints procedure is included within the Service User Guide, a copy of which is in each resident’s bedroom. Training records indicate that staff are receiving training in adult protection and abuse. Staff spoken with during the inspection visit knew how to recognise and report suspicion of, or actual, abuse under local policies and procedures. The home’s own policies and procedures now include details of Wakefield Council’s adult protection procedures. Fairburn Mews DS0000062960.V319124.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a spacious, clean and comfortable home with furniture and equipment available, both communally and individually, to meet their needs. EVIDENCE: The communal areas were clean and comfortable, and furnishings are modern and suitable for the needs and lifestyles of the residents. This includes an area for residents to make their own drinks and snacks and an activities room. Bedrooms are spacious, nicely furnished, personalised and include equipment as needed by the individual resident which, in some instances, particularly on the Lowrie Suite, includes double beds. All rooms have fittings to enable people to have their own telephone and computer. All areas of the home appeared clean and hygienic and several rooms have recently been redecorated and refurbished in colours and materials chosen by residents. The Fairburn Mews DS0000062960.V319124.R01.S.doc Version 5.2 Page 18 planned sensory garden, sensory room and improved activities room will greatly enhance an already very pleasant environment. Fairburn Mews DS0000062960.V319124.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by an effective and appropriately trained staff team, all of whom have been properly checked to protect people in care. EVIDENCE: Observations made during the inspection visit, and residents’ comments, evidence that residents are supported by a team of staff with a range of skills appropriate to the needs of the residents. On employment, all staff undertake a period of induction training arranged by the company, which is in line with the Skills for Care Council’s induction standards. All staff then follow a training programme which incorporates mandatory and specialist training relevant to the care needs of residents at the home. The training programme, with details of when staff have received or are due to receive training and updates, was seen during the inspection visit. Fairburn Mews DS0000062960.V319124.R01.S.doc Version 5.2 Page 20 NVQ training in care is ongoing for all care staff. Records show that six staff hold the level 2 award, with a further four currently studying for it. Four people have also gained the level 3 award, with one person studying for it. During the inspection visit, personnel records for four members of staff were seen. All of the documentation and checks required by regulation to protect residents had been obtained. Records show that all staff receive regular supervision from their line manager. Fairburn Mews DS0000062960.V319124.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a well run home with an effective staffing structure where quality monitoring is ongoing to ensure that resident views underpin the running of the home. EVIDENCE: The registered manager is a qualified nurse with many years’ experience of managing residential care and is currently in the process of completing the registered managers award. A system for monitoring all aspects of care provision and quality monitoring has been established with questionnaires sent out to residents, relatives and professionals concerned with the care of residents. The report completed to Fairburn Mews DS0000062960.V319124.R01.S.doc Version 5.2 Page 22 demonstrate the results of this process was seen and covered all aspects of the home, including such areas as reception, housekeeping and maintenance as well as care and safety issues. Records relating to health and safety including fire alarm testing, water temperatures, emergency lighting and environmental risk assessments were seen to be up to date and in good order. A maintenance man attends to any running repairs and scheduled safety checks on a daily basis. Records show that fire drills are held on a regular basis to ensure that all staff familiar with the process. Fairburn Mews DS0000062960.V319124.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 Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 4 13 3 14 4 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 4 X 3 X 3 X X 3 X Fairburn Mews DS0000062960.V319124.R01.S.doc Version 5.2 Page 24 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 Fairburn Mews DS0000062960.V319124.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 Fairburn Mews DS0000062960.V319124.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!