Inspection on 16/05/05 for Fairburn Mews

This inspection was carried out on 16th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fairburn Mews 14/12/06

Fairburn Mews 30/08/06

Fairburn Mews 31/10/05

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 Unannounced 16 May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 J51J01_s62960_Fairburn Mews_v227238_130505.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Fairburn Mews Address Wheldon Complex Wheldon Road Castleford WF10 2PY 01977 521784 01977 521785 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Fairburn Health Care Ltd Care Home with Nursing 20 Category(ies) of Dementia - 10 places registration, with number Mentally Disabled - 10 places of places Physically Disabled - 10 places Terminally Ill - 5 places Fairburn Mews J51J01_s62960_Fairburn Mews_v227238_130505.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Conditions of this registration are listed on the registration certificate displayed at the service. Date of last inspection N/A 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 Huntingtons 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 are being 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. Fairburn Mews J51J01_s62960_Fairburn Mews_v227238_130505.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection of Fairburn Mews since its registration with the Commission for Social Care Inspection. The homes manager is new to the position and as she is not yet registered with the commission is referred to in the report as the acting manager. The inspection was unannounced and lasted seven hours. Currently there are 4 residents in the downstairs unit and 1 resident in the upstairs unit but only 2 residents were able, or chose to speak to the inspector on this occasion. The inspector spoke with the acting manager and several members of nursing, care and support staff. Since registration there have been changes in management personnel, which appears to have resulted in a lack of clarity of some staffs rolls and responsibilities within the home and within the wider company. Since the inspection the inspector has spoken with the responsible individual and the acting manager who have confirmed that actions have and are being taken to remedy this situation. Although there are some minor maintenance problems caused by the settling of the building, the environment offers a high standard of accommodation to residents, with all required aids and adaptations in place to meet individual needs. There are no external signs to indicate that Fairburn Mews is on the site with two other Nursing Homes and there are no signs to indicate which building is Fairburn Mews and where the entrance is. The responsible individual said that arrangements had been made to put appropriate signage in place. Problems were identified in relation to the issuing of residents terms and conditions, medication systems and recruitment practices. The inspector would like to thank residents and staff for their time and assistance during this inspection. What the service does well: Fairburn Mews offers a well-designed, comfortable and spacious environment in which residents are supported and encouraged to live with as much independence as possible. Staff enable residents to exercise choice in all areas of their daily lives. Fairburn Mews J51J01_s62960_Fairburn Mews_v227238_130505.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Fairburn Mews J51J01_s62960_Fairburn Mews_v227238_130505.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection Fairburn Mews J51J01_s62960_Fairburn Mews_v227238_130505.doc Version 1.30 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4 and 5 Procedures are in place to ensure that proper assessments are completed prior to people being offered care at the home. EVIDENCE: The Statement of Purpose and the Service User Guide both need updating so that residents know the names of the current staff involved in the management of the home. The acting manager said that before any new residents come to live at Fairburn Mews, staff go out to meet them and assess whether the home has the appropriate staff and facilities to meet the prospective residents needs. Assessments completed by other professionals are also obtained. Following this assessment, the prospective resident and their family are invited to Fairburn Mews for a look around and the prospective resident can arrange a trial visit to help them decide whether they would like to live there. The acting manager writes to the prospective resident to confirm that the home can offer the right level of service to meet their needs. None of the current residents have been given a statement of terms and conditions. Fairburn Mews J51J01_s62960_Fairburn Mews_v227238_130505.doc Version 1.30 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 and 7 Care plans reflect assessed needs and decisions residents have made about their care and their chosen lifestyle. EVIDENCE: Care plans seen reflected the needs of the resident and individual preferences and choices were included in the care plan. One resident said that staff had told them about their care plan, as they were unable to read it. Another resident indicated that their next of kin would do this on their behalf. Care plans are being reviewed but no indication is made, either on the care plan or the review, that the resident or their family have been involved in the process. Daily records reflected the decisions and choices made by residents and one resident said that they were able to decide how they wished to spend their time and staff were observed to be offering residents these choices. Fairburn Mews J51J01_s62960_Fairburn Mews_v227238_130505.doc Version 1.30 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 and 17 Residents take part in activities of their choice. Meals are well managed and appropriate to the individual needs. EVIDENCE: The acting manager said that activity staff are employed within the company but there has not yet been one assigned to work exclusively at Fairburn Mews. At the moment activity staff visit approximately twice a week. This is not a problem at the moment as there is a large number of care staff on duty in relation to the number of residents and therefore activities are being carried out by care staff. Very little is available within the local community for residents to become involved with but they do go to the local pub and shopping centre and have been to watch the local rugby team. The acting manager said that meals are served when and where the residents choose and that a large amount of choice is available. She is currently working with the cook to devise menu’s and meal planning suitable to the very specific needs of the residents. One resident said that they could choose their meals and that they liked them. Fairburn Mews J51J01_s62960_Fairburn Mews_v227238_130505.doc Version 1.30 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 and 20 Residents receive personal support in private and according to their needs and wishes. Shortfalls in medication systems have a potential to put residents at risk. EVIDENCE: Only two residents chose to speak with the inspector during the visit. Both were happy with the way staff delivered personal support and said that they had choice in how this support was given. The inspector observed staff knocking on resident’s bedroom doors and ensuring that care was delivered in private. Aids and equipment are available to meet individual needs. Systems for storage and administration of medication were checked and several problems were identified. On one unit medications were not being stored safely and a large amount of liquid medication could not be accounted for. Unsafe procedures for recording the administration of medication were identified on both units. None of the nursing staff or the acting manager could explain these discrepancies. Fairburn Mews J51J01_s62960_Fairburn Mews_v227238_130505.doc Version 1.30 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 A clear complaints procedure is available within the home. EVIDENCE: The complaints procedure is given to all residents as part of the Service User Guide. The acting manager said that no complaints had yet been received at the home. During this visit the inspector looked into a concern which had been expressed anonymously to the commission but from speaking to the resident concerned and care staff, no evidence could be found to substantiate this concern. Fairburn Mews J51J01_s62960_Fairburn Mews_v227238_130505.doc Version 1.30 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,27 and 30 Residents live in a spacious, clean and comfortable home with furniture and equipment available, both communally and individually, to meet their needs. EVIDENCE: The home was built less than six months ago and there are some minor problems caused by the settling of the building. The most urgent of these problems is that some of the double fire doors are not closing properly. The acting manager said that the fire officer had anticipated that there would be some minor problems and had already arranged to visit the home to make a check. The communal areas were clean, comfortable and furnishings were suitable for the needs and lifestyles of the residents. Bedrooms contain furnishings and equipment as needed by the individual resident, including double beds in many of the rooms downstairs, and have fittings to enable residents to have their own telephone and computer. Toilet and bathroom areas provide the equipment and privacy required. Fairburn Mews J51J01_s62960_Fairburn Mews_v227238_130505.doc Version 1.30 Page 14 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,34 and 35. There is a lack of clarity of staff roles and responsibilities, which affects the running of the home. A qualified, well trained and competent staff team supports residents, although recruitment practices are not being followed to ensure their protection. EVIDENCE: The acting manager has only recently been appointed and, at the time of the inspection, was unclear about many of the staffing arrangements for the home, particularly with regard to activities, domestic and catering staff. A new responsible individual has also been appointed and, so far, has had little contact with the acting manager. Residents are supported by a team of nursing staff with relevant qualifications and experience, and care staff who have received training relevant to the needs of the client group. Residents spoken to said that the staff kind and considerate in their approach. The staff file of a recently appointed staff member indicated that the home had not undertaken all the necessary recruitment checks to ensure protection of residents, prior to commencement of employment, with no POVA or CRB reports having been received by the home. Fairburn Mews J51J01_s62960_Fairburn Mews_v227238_130505.doc Version 1.30 Page 15 Care staff said that they had received good and relevant training since starting at the home. Staff files showed that training is ongoing, this includes NVQ and NAPPI training. Fairburn Mews J51J01_s62960_Fairburn Mews_v227238_130505.doc Version 1.30 Page 16 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 and 39 There is a lack of clear direction from senior management, which could potentially affect the well being of residents. Resident’s views, which should underpin the development of the home, are not formally being sought. EVIDENCE: The acting manager has not yet made application to the Commission to be registered as the homes manager. For the purposes of the report she is referred to as the acting manager. The induction procedure for the acting manager has been poor and she is in need of support to assist her in enabling the home to meet its aims and objectives. No quality monitoring systems have yet been put in place at the home. Fairburn Mews J51J01_s62960_Fairburn Mews_v227238_130505.doc Version 1.30 Page 17 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 3 4 1 Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 x x 3 Standard No 31 32 33 34 35 36 Score 2 x 3 1 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Fairburn Mews Score 3 x 1 x Standard No 37 38 39 40 41 42 43 Score 2 x 1 x x x x J51J01_s62960_Fairburn Mews_v227238_130505.doc Version 1.30 Page 18 NA 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 YA5 Regulation 5(c) Requirement All new service users must be issued with a statement of terms and conditions at the point of moving into the home. Current service users must be issued with this document without delay. The registered person must make arrangements for safe systems of drug storage, administration and disposal within the home. All staff must have appropriate clearances including the POVA check before employment. The registererd person must establish and maintain a system for reviewing and improving the quality of care provided at the home.A report in respect of this review should be supplied to the commission and a copy made available to service users. Timescale for action From next admission. 2. YA20 13(2) From 13th May 2005 3. 4. YA34 YA39 19. Schedule 2 24(1)(2) From 13th May 2005 31 July 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Fairburn Mews J51J01_s62960_Fairburn Mews_v227238_130505.doc Version 1.30 Page 19 No. 1. 2. 3. Refer to Standard YA1 YA6 YA31 Good Practice Recommendations The Statement of Purpose and the Service User Guide both need updating to reflect current management and staff details. Care plans and reviews should be signed by the resident or representative. Where this is not possible an explanatory note should be made. The responsible individual should ensure that management support is in place to assist the acting manager and other staff to better define and organise staff roles and responsibilities within the home. The acting manager should receive a proper induction to the role of homes manager. 4. YA37 Fairburn Mews J51J01_s62960_Fairburn Mews_v227238_130505.doc Version 1.30 Page 20 Commission for Social Care Inspection Park View House Woodvale Office Park Woodvale Road Brighouse. HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Fairburn Mews J51J01_s62960_Fairburn Mews_v227238_130505.doc Version 1.30 Page 21 - 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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