Inspection on 23/05/05 for Fairburn Vale

This inspection was carried out on 23rd 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fairburn Vale 21/11/06

Fairburn Vale 03/11/05

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

CARE HOME ADULTS 18-65 Fairburn Vale Wheldon Complex Wheldon Road Castleford WF10 2PY Lead Inspector Gillian Walsh Unannounced 23 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 Vale J51J01_s62963_Fairburn Vale_v228778_230505.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Fairburn Vale Address Wheldon Complex Wheldon Road Castleford WF10 2PY 01977 521786 01977 521787 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 Mentally Disabled - 10 registration, with number Physically Disabled - 10 of places Terminally Ill - 5 Fairburn Vale J51J01_s62963_Fairburn Vale_v228778_230505.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 Vale is a new purpose built facility offering nursing and social care within dedicated units to 10 people between the ages of 18 - 65 with physical disability which may include some mental disorder, due to trauma or illness, who require permanent residential care and 10 people between the ages of 18 - 65 with physical disability which may include some mental disorder, due to trauma or illness, who have a potential to return to the community. 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 and well equipped. Communal areas are spacious and comfortable. The home benefits from the services of a physiotherapist based at the home. Fairburn Vale J51J01_s62963_Fairburn Vale_v228778_230505.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and lasted six and a half hours. This was the first inspection of Fairburn Vale since registration in February 2005. The home manager, who has applied to be the registered manager, is referred to in the report as the acting manager. There has been a change of responsible individual for the home, which initially appeared to result in a lack of support for the acting manager although steps are now being taken to address this. Currently only the downstairs unit is being used, and there are 8 residents. 3 residents spoke with the inspector on this occasion. Other residents were either unable, or chose not to speak with the inspector. Discussion also occurred with the acting manager, the responsible individual and several members of nursing, care and support staff, all of whom appeared relaxed and friendly in their approach to residents. The home provides a high standard of accommodation for residents, with all required aids and adaptations in place to meet individual needs. Signs are needed to indicate which building is Fairburn Vale and where the entrance is, which the responsible individual said is being arranged. Problems were identified in relation to medication systems and good practice recommendations have been made in relation to some issues about care planning and staff approach to residents. The inspector would like to thank residents and staff for their time and assistance during this inspection. What the service does well: What has improved since the last inspection? This is the first inspection since the home was registered. Fairburn Vale J51J01_s62963_Fairburn Vale_v228778_230505.doc Version 1.30 Page 6 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 Vale J51J01_s62963_Fairburn Vale_v228778_230505.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 Vale J51J01_s62963_Fairburn Vale_v228778_230505.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) 2, 3, 4, and 5 Good procedures are in place to ensure that the home can meet residents individual needs and that residents are given opportunity to make choices about where they would like to live. EVIDENCE: The acting manager said that before she makes an assessment of potential residents, she gathers as much information as possible from professionals and family to make an initial assessment of the suitability of the home for meeting the needs of the individual. She then goes out to make a thorough assessment of the potential residents’ needs and to invite them to visit the home or to have a trial overnight stay. The potential resident or their next of kin is then written to, to confirm that staff at the home are able to meet their assessed needs. On admission all residents are provided with a copy of their statement of terms and conditions. Documents were seen that confirmed that this happens. Fairburn Vale J51J01_s62963_Fairburn Vale_v228778_230505.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) 6,7 and 9 Residents have input into their care plans and are encouraged to make decisions about their lifestyles. Personal goals are incorporated into the care plan and risks are agreed and managed as part of the promotion of an independent lifestyle. EVIDENCE: The care plans seen reflected the needs of the resident and their individual preferences and choices were included in the plan. The three residents spoken with all said that they were aware of their care plan and an effort is being made by staff to encourage residents or their next of kin to read and sign their care plans. All of the residents spoken with said that they were able to make choices about their care and one person told the inspector about how they were supported by staff to manage personal risks as part of a long term plan to live independently. The care plan file for this person did include a risk assessment but risk management strategies and details of agreed boundaries were not detailed within the care plan. The acting manager said that care reviews are held regularly and residents are encouraged to make the decision about who they would like to be present at these review meetings. Fairburn Vale J51J01_s62963_Fairburn Vale_v228778_230505.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 have opportunity to engage in appropriate activities using the home’s own facilities and those available in the community. Residents enjoy a choice of healthy meals and snacks. EVIDENCE: The acting manager said that there is an activities organiser available at the home who works with residents to enable them to engage in useful and appropriate activities of their choice. None of the residents currently wish to, or are able to, undertake any further education or employment. One resident said that they enjoyed spending time with other residents, another had been out shopping with staff on the day of the inspection and another said that they liked to spend their time in their room where they have a selection of electronic games, but did join in with activities when they chose to. Little is available within the local community but residents use the local pub for drinks and meals and enjoy visits to a shopping centre and activities centre in the nearest town. Residents have a good choice of meals and one person said that the food is “too good”. Snacks and drinks are available when residents would Fairburn Vale J51J01_s62963_Fairburn Vale_v228778_230505.doc Version 1.30 Page 11 like them and the inspector observed one person being provided with a bacon sandwich as a snack as they had requested. Fairburn Vale J51J01_s62963_Fairburn Vale_v228778_230505.doc Version 1.30 Page 12 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 Resident’s preferences in the way staff support them are not always followed, particularly with regard to privacy, confidentiality and approach. Resident’s are not protected by the homes procedures for dealing with medicines. EVIDENCE: Resident’s preferences regarding how they would like to receive personal care is detailed within their care plans. Two residents said that staff are considerate of their privacy and dignity but one residents said that staff often come into their room without knocking and sometimes spoke to them like a child. Whilst the inspector was speaking with this resident staff entered the room on two separate occasions without knocking or asking if it was all right to come in and one member of staff started to speak to the resident about their toileting needs whilst the inspector was still in the room. None of the residents choose, or are able to manage their own medications at the moment although this is an option unless a risk assessment shows that this would not be appropriate. Medication systems were checked and problems were found with balancing stock against what had been recorded as given, e.g. according to the MAR (Medication Administration Record) sheets, there should have been 56 Diclofenac tablets left in stock but there were 61 tablets left. Gaps had been left on MAR (Medication Administration Record) sheets where Fairburn Vale J51J01_s62963_Fairburn Vale_v228778_230505.doc Version 1.30 Page 13 nursing staff should have recorded whether or not the medication had been given. Immediately these issues were found, staff took steps to find out why they had arisen and to ensure a safer system. Fairburn Vale J51J01_s62963_Fairburn Vale_v228778_230505.doc Version 1.30 Page 14 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 and 23 Residents feel that their views would be listened to if they had had a complaint. Procedures are in place to protect residents from abuse. EVIDENCE: The acting manager said that no complaints have yet been received at the home. Residents said that they would speak to staff if they had any complaints or concerns. The acting manager said that issues surrounding the protection of vulnerable adults are discussed on induction but staff have not yet received formal training in this subject. Fairburn Vale J51J01_s62963_Fairburn Vale_v228778_230505.doc Version 1.30 Page 15 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 communal areas were clean, comfortable and furnishings were modern and suitable for the needs and lifestyles of the residents. Bedrooms are spacious, nicely furnished and include equipment as needed by the individual resident. All rooms have fittings to enable residents to have their own telephone and computer. Toilet and bathroom areas provide the equipment and privacy required. Fairburn Vale J51J01_s62963_Fairburn Vale_v228778_230505.doc Version 1.30 Page 16 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 Resident’s are supported by an effective staff team with a range of skills appropriate to meeting their needs. Residents are protected by the home’s recruitment practices. EVIDENCE: The acting manager said that staff have overcome some initial problems with a lack of clarity of staff roles and responsibilities and that residents will benefit from this in that they will become familiar with staff and will know what responsibilities they have within the home. 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. A team of ancillary staff ensure that cleaning, laundry and catering services are provided to meet resident’s needs. A physiotherapist is also employed at the home to support resident’s physical needs. Good recruitment procedures are followed to ensure the protection of residents, but the inspector was concerned that some of the staff’s references were character rather than professional references. Fairburn Vale J51J01_s62963_Fairburn Vale_v228778_230505.doc Version 1.30 Page 17 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 38 The acting manager has established a positive atmosphere within the home but clear management strategies have not yet been established. EVIDENCE: The acting manager’s application to the Commission to be registered as the homes manager is currently being processed. For the purposes of the report she is referred to as the acting manager. The acting manager said that her induction has not been thorough but this problem is being addressed and she is now receiving support, which will enable her to provide better leadership to her staff and establish a firm management approach. Fairburn Vale J51J01_s62963_Fairburn Vale_v228778_230505.doc Version 1.30 Page 18 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 x 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 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 3 x 3 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Fairburn Vale Score 2 x 1 x Standard No 37 38 39 40 41 42 43 Score x 2 x x x x x J51J01_s62963_Fairburn Vale_v228778_230505.doc Version 1.30 Page 19 N/A 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 23.5.05 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. Refer to Standard YA6 Good Practice Recommendations Care plans should specify details of any agreements made between residents and staff with regard to limitation of choice. Staff should continue to encourage residents or, where appropriate their representative, to read and sign their care plans Staff should respect residents privacy and dignity at all times, this should include knocking on residents doors and speaking to residents in a respectful manner. Staff should recieve training in the protection of vulnerable adults. Work should continue to develope clear management strategies within the home. 2. 3. 4. YA18 YA23 YA38 Fairburn Vale J51J01_s62963_Fairburn Vale_v228778_230505.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. 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