Inspection on 03/11/05 for Fairburn Vale

This inspection was carried out on 3rd November 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Fairburn Vale 21/11/06

Fairburn Vale 23/05/05

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 Inspection 3rd November 2005 2 pm Fairburn Vale DS0000062963.V253808.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 Vale DS0000062963.V253808.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 Vale DS0000062963.V253808.R01.S.doc Version 5.0 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 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 Ms Julie Ann Wrigglesworth Care Home 20 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10), Physical disability (10), of places Terminally ill (5) Fairburn Vale DS0000062963.V253808.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 RGN, Level 1, on duty at all times. The homes full-time manager will be supernumerary to the care and nursing rota. 23rd May 2005 2. 3. Date of last inspection 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 DS0000062963.V253808.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 3rd November. Time was spent speaking with residents, two visitors, staff and management. A sample of care plans, and other documentation relating to the running of the home were checked. The inspector would like to thank residents and staff for their time and hospitality during the visit. What the service does well: What has improved since the last inspection? What they could do better: A more thorough audit of the recording, handling and administration of medications would be beneficial in ensuring a safe system. Fairburn Vale DS0000062963.V253808.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 Vale DS0000062963.V253808.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 Vale DS0000062963.V253808.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 Prospective residents have the information they need to make an informed choice about the home and all have their individual needs assessed prior to being offered a place. On admission, residents are provided with a written statement of terms and conditions. EVIDENCE: The home provides a Statement of Purpose and a Service User Guide to assist potential residents and their families in making an informed choice about the home prior to moving in. At the time of the visit the manager was reviewing both of these documents to ensure that they were up to date and to make them a little more user friendly. The manager said that she would forward copies of both of these reviewed documents to the commission when they are completed. Care plan files included details of pre-admission assessments completed both by the home and, where relevant, by the placing authority and any other professionals involved. These assessments were thorough and considered all areas of the potential residents’ needs. On admission, all residents are given a statement of terms and conditions of residence at the home, signed copies of these are retained within each resident’s file. Fairburn Vale DS0000062963.V253808.R01.S.doc Version 5.0 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 and 7. Residents know that their care plans reflect their needs and aspirations. Residents make decisions about their care and lives within the home. EVIDENCE: All of the care plans contained detailed information about residents’ assessed needs and how the resident would like these needs to be met. Care plans also included detail of individual choice and any limitations to choices. Wherever possible, the resident had signed to say that they had read and agreed their plan, others had been signed by the residents’ representative or, where applicable, note had been made that the care plan had been read to the resident but that they were unable to sign it. All of the care plans had been reviewed with the resident to reflect changing needs. Care plans indicated that residents make decisions about their lives and all of the residents spoken to agreed that they were able to make decisions about their care and their lifestyle within the home. Fairburn Vale DS0000062963.V253808.R01.S.doc Version 5.0 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 the following standard(s): 15 and 16. Residents are supported to maintain appropriate relationships. Residents’ rights are respected. EVIDENCE: Residents said that their families and friends are welcome to visit them at the home when they wish and that staff assist and support them, where appropriate, to make their own social visits. In some circumstances, arrangements can and have been made to enable spouses of residents, who would appreciate this, to stay overnight with them. Relatives of one resident said how pleased they were with the support they receive from staff at the home and the care given to their relative. Residents confirmed the information from staff and documentation within care plans, that staff respect their individuality, need for independence and right to privacy within the home. Fairburn Vale DS0000062963.V253808.R01.S.doc Version 5.0 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 the following standard(s): 19 and 20. Resident’s physical and emotional needs are met. Some minor improvements to procedures for dealing with medications would ensure a safer system. EVIDENCE: Care plans had been developed which considered and detailed residents’ physical and emotional needs and how these needs should be met including, where appropriate, professional intervention from outside the home. Residents confirmed that staff gave support and assistance in accordance with their personal choice. The inspector was delighted to see the improvements in the health and abilities of some residents since the last inspection. 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, although there were some discrepancies with balances of medication, these were minor and easily resolved. Fairburn Vale DS0000062963.V253808.R01.S.doc Version 5.0 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 the following standard(s): 23 Residents are protected from abuse and neglect. EVIDENCE: Twelve staff have recently received training from Wakefield Metropolitan Borough Council in relation to protection of vulnerable adults. This training is ongoing. Fairburn Vale DS0000062963.V253808.R01.S.doc Version 5.0 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 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. EVIDENCE: The communal areas were clean, comfortable and furnishings are modern and suitable for the needs and lifestyles of the residents. Bedrooms are spacious, nicely furnished, personalised and include equipment as needed by the individual resident. All rooms have fittings to enable residents to have their own telephone and computer. All areas of the home appeared clean and hygienic. Fairburn Vale DS0000062963.V253808.R01.S.doc Version 5.0 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 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): 35 Residents’ needs are met by appropriately trained staff. EVIDENCE: Staffing rotas showed that residents are supported by a team of staff with a range of skills appropriate to the needs of the residents. This includes an on site physiotherapist who develops individual programmes for residents who require this intervention. Staff training needs are identified within supervision and the manager has developed a training plan which includes individual staff needs as well as mandatory training. Fairburn Vale DS0000062963.V253808.R01.S.doc Version 5.0 Page 15 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 and 42. Residents benefit from a well run home. Policies and procedures in relation to health and safety are in place and followed to protect residents and staff. EVIDENCE: Since the last inspection the manager has completed the registration process with the Commission for Social Care Inspection. The manager is an RGN with many years of experience of neurological and neurosurgical nursing and is currently studying for the registered managers award. 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 Vale DS0000062963.V253808.R01.S.doc Version 5.0 Page 16 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 3 3 X X 3 Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X X X 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Fairburn Vale Score 3 X 2 X Standard No 37 38 39 40 41 42 43 Score 3 X X X X 3 X DS0000062963.V253808.R01.S.doc Version 5.0 Page 17 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA20 Good Practice Recommendations The manager should ensure that MAR (Medication Administration Record) sheets, are appropriately completed. 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