Inspection on 31/10/05 for Fairburn Mews

This inspection was carried out on 31st October 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also 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 30/08/06

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 Unannounced Inspection 31st October 2005 10:15 Fairburn Mews DS0000062960.V253799.R01.S.doc Version 5.0 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.V253799.R01.S.doc Version 5.0 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.V253799.R01.S.doc Version 5.0 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 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 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.V253799.R01.S.doc Version 5.0 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 homes full-time manager will be supernumerary to the care and nursing rota. 16th May 2005 2. 3. 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 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 DS0000062960.V253799.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection made on 31 October 2005. The acting manager was on annual leave on the day of the visit but the care manager and the responsible individual were available. Only one of the seven residents at the home chose to speak with the inspector on this occasion, but they and some visitors indicated that they were very happy with the home and the care provision. The day following the inspection the acting manager completed the registration process with The Commission for Social Care Inspection and can now be referred to as the registered manager. The inspector would like to thank all of the residents and staff involved in the inspection for their hospitality and assistance. What the service does well: What has improved since the last inspection? What they could do better: Improvements are needed in the systems for the safe administration and storage of medication. Some adjustments are needed to the Statement of Purpose and Service User Guide to ensure that prospective residents have access to full information about the home. Fairburn Mews DS0000062960.V253799.R01.S.doc Version 5.0 Page 6 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.V253799.R01.S.doc Version 5.0 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.V253799.R01.S.doc Version 5.0 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): 1, 2 and 5 The Statement of Purpose and the Service User Guide do not give the prospective resident all of the information needed to make an informed choice about the home. Procedures are in place to ensure that proper assessments are completed prior to people being offered care at the home. All residents receive an individual statement of terms and conditions. EVIDENCE: The Statement of Purpose and the Service User Guide are both in need of some development to ensure that they provide sufficient detail to fully meet with standards. The care manager said that referrals to the home are received from a several different sources and often relatives of a prospective resident will come to view the home as an initial enquiry. The care manager also said that wherever possible, 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. In the rare event of an emergency admission, as much information as possible is obtained and the homes assessments are completed following admission. This situation has only arisen once and was for a person requiring emergency respite care. Assessments completed by other professionals are also obtained. Examples of the homes, the placing authority and other professionals’ assessments were seen within resident’s files. These were thorough and formed the basis of the initial care plan. Fairburn Mews DS0000062960.V253799.R01.S.doc Version 5.0 Page 9 On admission each resident receives a statement of terms and conditions from the home. Fairburn Mews DS0000062960.V253799.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 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. EVIDENCE: A selection of care plans was seen. All included a personal history and details of personal preferences, which included which friends and family they enjoyed spending time with. All Care plan files included completed relevant assessments, which had been used to form the basis of care plans. Care plans were clear and gave good detail of assessed needs and how these should be met taking into account the wishes of the resident. Some of the care plans see had been signed by the resident or their representative. A care plan audit file evidenced that all care plans are audited twice a month and any problems or omissions are highlighted as requiring action. Some of the required actions identified in the audit had not been taken but the care manager said that a new system was being implemented to resolve this problem. Fairburn Mews DS0000062960.V253799.R01.S.doc Version 5.0 Page 11 Daily records gave good detail of how residents’ needs were being met but tended to be a little clinical rather than giving an overview of how the resident had spent their time and any decisions and choices they had made. Risk assessments gave evidence that risks are accepted as part of the promotion of an independent lifestyle and are managed in a way acceptable to the resident and staff. Fairburn Mews DS0000062960.V253799.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 15 and 16. Available activities are appropriate to the needs of current residents. Residents are supported to maintain relationships with families and friends. Residents rights are respected. EVIDENCE: Details of activities programmes for each unit were available in the entrance hall. One of these programmes appeared to be very individual and the care manager explained that this was a programme individually devised for one of the two residents on the unit. A discussion took place about how individual programmes should be retained on residents’ files rather than on public display and until occupancy increases, it may be more appropriate to advertise a list of available activities. The care manager said that she was looking at nursing staff and key workers working with the activities organiser to ensure that activities programmes were person centred and therapeutic. Families and friends are welcomed to visit the unit as the residents’ wish and where necessary staff support residents to maintain relationships. Care plans, observation of staff and information from a resident all indicated that residents rights are respected at the home. Fairburn Mews DS0000062960.V253799.R01.S.doc Version 5.0 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): 19 and 20 Residents’ physical and emotional needs are considered and met through the care planning process. Shortfalls in medication systems have a potential to put residents at risk. EVIDENCE: Care plans had been developed giving consideration to residents’ physical and emotional needs. Care plan reviews and daily records indicated that these care plans are followed to ensure that assessed needs are met. The care manager said that, where necessary, appropriate professionals from outside the home would be accessed to give additional support to the residents. This is particularly relevant to residents with Huntingtons Disease as the home has links with the Huntingtons disease society, who assist in supporting residents and in staff training. The care manager said that none of the current residents choose to, or are able to self medicate although facilities are available should anybody choose to do so. The care manager said that new procedures have recently been introduced at the home to monitor policies and procedures with regard to maintaining a safe system for the storage, administration and returns of medication. Current systems for storage and administration of medication were checked and problems were identified. Stock balances on the MAR (Medication administration record) sheet for one persons’ Lorazepam indicated that a balance of 53 tablets should be available. Only 38 tablets were available and Fairburn Mews DS0000062960.V253799.R01.S.doc Version 5.0 Page 14 no explanation could be given for the 15 missing tablets. Another persons stock balance of Diazepam tablets was incorrect in that there appeared to be one tablet missing. Due to the new procedures in place for monitoring medication systems, the care manager was able to identify the short period of time in which these problems had occurred. Fairburn Mews DS0000062960.V253799.R01.S.doc Version 5.0 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): 23 Systems are in place to protect residents from abuse and neglect. EVIDENCE: Training files showed that some staff have received training in protection of vulnerable adults. The care manager said that she had not yet received this training and was not familiar with Wakefields’ own adult protection policies and procedures. Documentation was available to show that a recent adult protection incident had been dealt with appropriately by the acting manager. The responsible individual said that further training is booked for those who have not yet received it. Fairburn Mews DS0000062960.V253799.R01.S.doc Version 5.0 Page 16 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): 24,25 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 communal areas were clean, comfortable and furnishings were suitable for the needs and lifestyles of the residents. 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. Fairburn Mews DS0000062960.V253799.R01.S.doc Version 5.0 Page 17 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): 31, 32 and 34. 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. EVIDENCE: Since the last inspection there have been a number of changes and improvements within the staff team and in the way their roles are defined. Staff are now settled into their roles and have a good understanding of the home and their responsibilities. Only one resident chose to meet the inspector, but gave a positive response when asked about staff. Evidence within staff training files, the daily rota and from speaking to staff, demonstrates that an 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.V253799.R01.S.doc Version 5.0 Page 18 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. Resident’s benefit from a well run home which has a staffing structure designed to assist and support the registered manager. Quality monitoring is ongoing to ensure that residents’ views underpin the review and development of the home. The health safety and welfare of residents and staff is protected by systems in place at the home. EVIDENCE: The manager is a qualified nurse with many years experience of managing residential care. She is currently studying for the registered managers award and the day following the inspection successfully completed the registration process with the Commission for Social Care Inspection. A system for monitoring all aspects of care provision and quality monitoring has now been established and aspects of this were seen, although due to the Fairburn Mews DS0000062960.V253799.R01.S.doc Version 5.0 Page 19 newness of the home a report has not yet been completed to demonstrate the results of this process. Records relating 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. Fairburn Mews DS0000062960.V253799.R01.S.doc Version 5.0 Page 20 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 X X 3 Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 X 3 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Fairburn Mews Score X 3 1 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 3 X DS0000062960.V253799.R01.S.doc Version 5.0 Page 21 YES 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. Timescale for action 31/10/05 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. 2. 3 Refer to Standard YA1 YA6 YA23 Good Practice Recommendations The Statement of Purpose and the Service User Guide both need updating. Care plans and reviews should be signed by the resident or representative. Where this is not possible an explanatory note should be made. Training should continue to ensure that all staff are familiar with local policies and procedures to protect residents from abuse. Fairburn Mews DS0000062960.V253799.R01.S.doc Version 5.0 Page 22 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.V253799.R01.S.doc Version 5.0 Page 23 - 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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