Inspection on 30/08/06 for Fairburn Mews

This inspection was carried out on 30th August 2006.

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 1 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 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 30th August 2006 10:00 Fairburn Mews DS0000062960.V310608.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.V310608.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.V310608.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.V310608.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 31st October 2005 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 August 2006 the scale of charges at the home are £900 - £1700 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.V310608.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 30th August 2006 that occurred within a full inspection. As part of this inspection the views of residents, relatives, healthcare professionals including General Practitioners and involved social workers were sought by way of questionnaires. The outcome of this was as follows: Of the 11 resident questionnaires sent out, none were returned. Of the 11 relative questionnaires sent, 2 were returned, both of which were favourable but did not contain any specific comments. Of the 5 health care professional questionnaires sent, 5 were returned; again these were favourable but did not contain specific comments. Of the 14 social worker questionnaires sent, 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 offers a well-designed, comfortable and spacious environment in which 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 which one resident said they really appreciated. Care planning is developed in partnership with the resident concerned and staff take a holistic view in their approach to care. Fairburn Mews DS0000062960.V310608.R01.S.doc Version 5.2 Page 6 Staff demonstrate good knowledge of those in their care and work hard to develop therapeutic relationships. 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 DS0000062960.V310608.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Fairburn Mews DS0000062960.V310608.R01.S.doc Version 5.2 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 the following standard(s): 2 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. Quality in this outcome area is good. This judgement has been made from evidence gathered during the visit to this service. 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 files inspected and contained all of the information necessary to complete a full assessment of need. Fairburn Mews DS0000062960.V310608.R01.S.doc Version 5.2 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 the following standard(s): 6, 7 and 9. Residents’ 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. Quality in this outcome area is good. This judgement has been made from evidence gathered during the visit to this service. EVIDENCE: Care plan files for two residents from each unit 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 social needs. One plan in particular demonstrated a holistic approach toward care, where a plan had been devised in respect of the resident’s family’s involvement in their life. Fairburn Mews DS0000062960.V310608.R01.S.doc Version 5.2 Page 10 Where appropriate, care plans had been developed with the involvement of the resident or their representative and signatures had been obtained to confirm this. Documentation demonstrated that care plans are being appropriately reviewed to meet the resident’s changing needs, this again is done with the involvement, where appropriate, of the resident or their representative. Positively, some care plans had been developed with both long and short- term goals to demonstrate how effective the care plan was and whether a review would be appropriate. Care plans and other documentation held within the file contained details of residents’ decisions and choices about their everyday lives and their plans for the future. In conjunction with assessments undertaken and care plans developed, 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 concerned. Fairburn Mews DS0000062960.V310608.R01.S.doc Version 5.2 Page 11 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 the following standard(s): 12, 13, 15, 16 and 17. Residents are encouraged and supported to take part in social, leisure and educational activities appropriate to their needs and choices either within or external to the home. Meals are appropriate to the needs and tastes of residents. Quality in this outcome area is good. This judgement has been made from evidence gathered during the visit to this service. EVIDENCE: None of the current residents are in employment or attending college, although one person said that they were being supported to access a literacy course via the local library. This person is also being supported to attend sessions at a local gym. The home employs a full time activities organiser and all of the residents on Hulme Suite have individual activities programmes in place which are facilitated by the key worker in conjunction with the resident and the activities Fairburn Mews DS0000062960.V310608.R01.S.doc Version 5.2 Page 12 organiser and one resident said how much they really appreciated the one to one time they have with staff on a daily basis. Although 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. 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, one person said that soon after admission they felt comfortable and “at 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 that the meals are “really good”. Fairburn Mews DS0000062960.V310608.R01.S.doc Version 5.2 Page 13 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 the following standard(s): 18, 19 and 20. Residents’ personal care and health needs are met appropriately although shortfalls in medication systems have potential to put residents at risk. Quality in this outcome area is poor. This judgement has been made from evidence gathered during the visit to this service and id directly as a result of the shortfalls in medication systems. EVIDENCE: Care plans reflect residents’ choices regarding the support and care they receive from staff at the home and speaking with residents confirmed that care plans are followed. Specialist healthcare support is accessed as required by the individual; examples of this were seen during the inspection. General healthcare needs are met through local GP, dental, optical services etc. None of the current residents wish to self-administer their medications and, therefore, systems for storing and administration of medications by staff were checked. Since the last inspection, during which a requirement was made about medications, a system for weekly auditing of medication has been put in place. However, this system does not appear to be being properly operated as errors were found. A box of Paracetamol for PRN use was in the trolley for a resident who had recently been admitted, although the MAR (Medication Fairburn Mews DS0000062960.V310608.R01.S.doc Version 5.2 Page 14 Administration Record) sheet for this person did not indicate that this person had been prescribed Paracetamol. No record had been made that this Paracetamol was available for this person. Another person was prescribed Sodium Valproate, one tablet to be taken in the morning and two in the evening. The balance of medication in the trolley should have been 30 tablets but 33 were left. The only possible explanation for this, by the manager and registered person, was that staff had been incorrectly administering one instead of two tablets in the evening. Another MAR sheet indicated that the stock balance for the person’s Paracetamol was 60; the actual balance, when checked, was 70. This would indicate that, when stock checks are being carried out, staff are not actually counting the tablets. This then makes the system ineffective and poses a possible risk to residents. Fairburn Mews DS0000062960.V310608.R01.S.doc Version 5.2 Page 15 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 the following standard(s): 22 and 23. Residents are confident that their views are listened to and acted upon appropriately. Systems are in place to ensure that residents are protected from abuse but some amendments are needed to ensure that correct local policies are followed. Quality in this outcome area is adequate. This judgement has been made from evidence gathered during the visit to this service. EVIDENCE: No complaints have been received by the home or by the Commission about the home since the last inspection. A comprehensive complaints policy and procedure is in place and is made available to residents and their families via the Service User Guide. One resident said that staff do listen to what they have to say. Staff training records show that staff have received training in protection of vulnerable adults and awareness of abusive situations. One member of staff who spoke with the inspector was not fully aware of how incidents of suspected abuse should be referred to the Local Authority as an adult protection situation. The manager was aware of the Local Authority’s procedures but a copy of these could not be found in the home. In response to this the manager immediately acquired a copy of the procedures and has sent off for information pamphlets for all staff. The home’s own abuse policy does not include details of the Local Authority’s adult protection procedure and needs to be amended to include this. Fairburn Mews DS0000062960.V310608.R01.S.doc Version 5.2 Page 16 The home does not handle the financial affairs of any of the residents although the home’s administrator said that small amounts of money can be kept within the home’s safe if the resident wishes to use this service. Two signatures, including the residents’ where possible, are always obtained each time money is deposited or withdrawn. Fairburn Mews DS0000062960.V310608.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Residents live in a spacious, clean and comfortable home with furniture and equipment available, both communally and individually, to meet their needs. Quality in this outcome area is good. This judgement has been made from evidence gathered during the visit to this service. EVIDENCE: The communal areas were clean and comfortable. Since the last inspection a lot of the furniture in the communal lounges has been re-covered due to wear and tear. Bedrooms contain furnishings and equipment as needed and desired by the individual resident, including double beds in many of the rooms downstairs, all have fittings to enable residents to have their own telephone and computer and all have ensuite shower and toilet. Fairburn Mews DS0000062960.V310608.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Residents benefit from clarity of staff roles and responsibilities and are supported by a competent staff team. The home’s recruitment policies and procedures protect and support residents. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Since the last inspection there have been a number of changes and improvements within the staff team. Some of the staff on duty during the visit were from another home within the company but still demonstrated a good knowledge of residents and their assessed needs and a good understanding of the home and their responsibilities. A recently employed member of staff who had recently qualified as a nurse said that, after their induction period, they had also completed a preceptorship programme with the home’s clinical nurse manager. One resident said that they were very happy with the staff and appreciated the amount of time staff are able to spend with them. Evidence within staff training files, the daily rota and from speaking to staff, demonstrates that an Fairburn Mews DS0000062960.V310608.R01.S.doc Version 5.2 Page 19 appropriately trained staff team are available in sufficient numbers to meet the current needs of residents. A selection of personnel files were seen and evidenced that recruitment policies and procedures are being followed. Fairburn Mews DS0000062960.V310608.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. 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. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The registered manager is a qualified nurse with many years’ experience of managing residential care and is currently studying for 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 demonstrate the results of this process was seen and covered all aspects of the Fairburn Mews DS0000062960.V310608.R01.S.doc Version 5.2 Page 21 home, including such areas as reception, housekeeping, 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 new maintenance man has recently been employed who attends, on a daily basis, to any running repairs and scheduled safety checks. One member of staff said that fire drills are held on a regular basis and, on a recent occasion where staff had not responded appropriately during a fire drill, the procedure had been repeated shortly afterwards to ensure staff were familiar with the procedure. Fairburn Mews DS0000062960.V310608.R01.S.doc Version 5.2 Page 22 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 2 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 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 X 3 X X 3 X Fairburn Mews DS0000062960.V310608.R01.S.doc Version 5.2 Page 23 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 YA20 Regulation 13(2) Requirement The registered person must make arrangements for safe systems of drug storage, administration and disposal within the home. Previous timescale of 31/10/05 was not met. Timescale for action 30/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA23 Good Practice Recommendations Training should continue to ensure that all staff are familiar with local policies and procedures to protect residents from abuse. The home’s own policies and procedures for dealing with protection and abuse of vulnerable people should reflect the Local Authority’s procedures. Fairburn Mews DS0000062960.V310608.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Brighouse Area Office 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 DS0000062960.V310608.R01.S.doc Version 5.2 Page 25 - 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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