Inspection on 19/12/05 for Fairdene Lodge

This inspection was carried out on 19th December 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 but made no statutory requirements on the home.

Other inspections for this house

Fairdene Lodge 26/09/07

Fairdene Lodge 02/05/06

Fairdene Lodge 28/06/05

Fairdene Lodge 01/02/05

Fairdene Lodge 21/06/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Fairdene Lodge 14 & 16 Walsingham Road Hove East Sussex BN3 4FF Lead Inspector Jane Jewell Unannounced Inspection 19th December 2005 10:00 X10015.doc Version 1.40 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 Fairdene Lodge DS0000014199.V284245.R01.S.doc Version 5.1 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 Older People. 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. Fairdene Lodge DS0000014199.V284245.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Fairdene Lodge Address 14 & 16 Walsingham Road Hove East Sussex BN3 4FF 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) 01273 735221 Mrs Maria Holliday-Welch Vacant Care Home 32 Category(ies) of Dementia - over 65 years of age (32), Old age, registration, with number not falling within any other category (32) of places Fairdene Lodge DS0000014199.V284245.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is thirtytwo (32). Service users must be older people aged sixty-five (65) years or over on admission. Service users with a dementia type illness only to be accommodated. Date of last inspection 28th June 2005 Brief Description of the Service: Fairdene Lodge is a privately owned residential home for up to thirty-two older people who have dementia. Prior to September 2005 the homes registration category was for older people only, following a successful application to the CSCI this was changed to now cater for dementia care. The home’s provider also own a further four registered homes for older people within the Sussex area. The home is located within level walking distance of Hove seafront, close to local amenities and bus routes into Brighton and Worthing. The home consists of two detached Victorian houses organised into House 14 & 16, which are interlinked by a ground floor corridor. All residents have access to both houses. It is presented on two levels, ground and first floor with access to the first floor via stairs or a stair lift. The second floor is a selfcontained flat, which is currently not in use. Resident’s accommodation consists of twenty-two single and five shared bedrooms, with eleven rooms having their own ensuite facilities. Shared facilities include a large lounge, combined lounge dining room and a conservatory overlooking the rear garden. The homes literature states that their aims are to provide residents with a secure, relaxed and homely environment in which their care, well-being and comfort are of prime importance. Fairdene Lodge DS0000014199.V284245.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced routine inspection, which was undertaken between 10am to 3pm. The inspection was undertake with Julie Killen (care manager) and there were thirty residents living at the home. The inspection involved a tour of the premises, examination of the homes records, consultation with staff, residents and visitors. As not all residents are able to tell the inspector their experiences of life at the home therefore much of the inspection was spent observing residents in their daily routines and interactions with staff. This was the homes first inspection since the change of registration to care for residents who have dementia. In order that a balanced and thorough view of the home is obtained, this inspection report should to be read in conjunction with the previous inspection reports. The Inspector would like to thank the residents, staff and management for their assistance and hospitality during the inspection. What the service does well: What has improved since the last inspection? Resident’s have been further safeguarded by improved practices in infection control and recruitment. The environment continues to undergo redecoration to ensure that residents live in a homely environment. Staffing levels have been increased in accordance with the change in residents needs to dementia care. Fairdene Lodge DS0000014199.V284245.R01.S.doc Version 5.1 Page 6 What they could do better: Consistent standards in assessing, care planning and in the management of personal risk is needed to ensure that residents assessed needs are being identified and the risks faced and posed by residents can be effectively managed. Medication practices did not safeguard residents and closer monitoring of staff practices is needed to ensure that the homes policy is being followed and residents protected. The laundry procedures need to be reviewed to prevent resident’s bedrooms being used to store other resident’s laundry. Following the draft inspection report the provider responded with an action plan, which detailed how the shortfalls in practices noted in this report were to be addressed. 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. Fairdene Lodge DS0000014199.V284245.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fairdene Lodge DS0000014199.V284245.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5 Prospective residents and their representatives are provided with information about the home in order to make an informed choice about whether to live at the home. Residents are admitted following an assessment of their needs, further work is needed to ensure that staff are fully informed of the needs of new residents. Residents are offered a trial stay at the home to see if it is the right home for them. EVIDENCE: There is a range of well-documented information about the home and the services it provides. This includes a statement of purpose and service user guide. These are displayed and given to prospective residents, representatives and other interested parties. Residents are provided with a written contract of terms and conditions of residency with the home. This is used with residents and their families to make explicit the placement arrangements and clarify mutual expectations around rights and responsibilities. A signed copy of the contract is retained in resident’s files. Fairdene Lodge DS0000014199.V284245.R01.S.doc Version 5.1 Page 9 The vast majority of referrals are from social services. Documentation was examined for a recent admission and this showed that the residents needs had been assessed by a member of the management team and that these needs could be met at the home. Copies of social care needs assessments were also obtained from the placement authority to ensure that a comprehensive picture of the prospective resident had been obtained. However not all essential information had been transferred to the residents care plan to ensure that staff were fully aware of the new resident’s challenging behaviour. This is further discussed under standard 7. Concern over the poor transfer of information from assessment documents to care plans was previously noted and highlighted the issues of staff skills to undertake assessment and requires to be further addressed. Residents all looked relaxed and comfortable in their surroundings and in their interactions with staff, and described their experiences at the home as: “treated like royalty” “free to come and go as I please” “I like it here as my daughter can visit me all the time” and “You couldn’t wish for better”. The home has experience in meeting the needs of residents who have medium to high needs and in dementia care. During the change of the homes registration to dementia care, residents and their representatives where given the option to move and all decided to stay. Some residents who have been assessed as not requiring dementia care told the inspector that although they have noticed a big change in the needs of residents being admitted, that they would not consider moving. These residents said that they are regularly consulted by management as to whether they wished to remain a the home. The home is able to meet most needs of current residents, however further work is needed to the care planning process in order to evidence that assessed needs are being identified. It was clear that where there have been concerns regarding meeting the changing needs of residents prompt action has been taken to gain additional support. The first six weeks of occupancy is looked upon as trial occupancy. Where social services are the placement authority, it is usual practice that within this period a review be undertaken to determine whether the residents wishes to stay permanently at the home or not. In the case of privately funded residents it was reported that residents and their representatives are contacted to determine the outcome of the trial period. Fairdene Lodge DS0000014199.V284245.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Generally care plans provide a good framework for the delivery of care, however variable standards were noted in the recoding of risks and daily notes. The health care needs of residents are being met with evidence of regular input from health care professionals. Medication was not administered in line with the homes policies placing residents at potential risk. Not all of the homes practices promoted privacy. The home is to be commended on the way that it cared for a resident who was terminally ill. EVIDENCE: Five individual plans of care were examined, and these generally provided a good standard of information to guide staff on the assessed needs of residents. Care plans include a plan of care, nutrition assessment, personal histories and risk assessments. Staff said that they are more actively involved in the care planning process and showed a good understanding of residents assessed needs. Each resident had an assessment of risk, which provided guidance on how best to manage any identified risk, however standards of recording were variable. The risk assessment for a recent admission had not included an assessment of the residents challenging behaviour, despite this issue being highlighted in the Fairdene Lodge DS0000014199.V284245.R01.S.doc Version 5.1 Page 11 needs assessment prior to their admission. This left the resident and staff vulnerable as there was no recognised strategy for managing their behaviour. The risks faced and posed by one resident who regularly went out by themselves had not been undertaken to identify whether any strategies were needed to maintain their safety whilst outside. Two risk assessments had not been reviewed in over a year despite an apparent deterioration in the resident’s mobility and manual handling needs. The standard of daily notes was also variable with an example noted where there had been no notes recorded for a month on a resident. Therefore it could not be established what events and actions had occurred for this individual. Care plans had been recorded as having been reviewed monthly. In addition the care manager checked them weekly in order to identify any changes in needs promptly. Due to the variable standards in daily notes and in the recording of risks it was discussed that the weekly checks should also encompass monitoring of the daily notes and risk assessments. This would ensure that poor standards were able to be promptly identified. Records of medical intervention showed that the home works closely with health care professionals including GP’s, District and specialist nurses, chiropodists, opticians and dentists to ensure residents receive the necessary health care intervention. Residents consulted said that when they have asked to see a Doctor then this has been undertaken promptly. There are clear procedures on medication management at the home, however these were not being followed by all staff and placed residents at potential risk. Issues identified were: • A prescribed medication instruction had been changed with no explanation as to why or who had authorised the change. It was immediately required that the correct instructions be clarified with the GP. • Hand written medication records had not been checked and countersigned for accuracy by a second member of staff. This is needed to reduce any risk of errors in copying the prescribed instructions. This issue had been previously discussed with the home. • Several examples were noted whereby there were no individual instructions for when “as required medication” should be administered. A clear system has been developed to ensure that staff have this information but it had not been followed in these instances. • An example was noted whereby staff were signing to say that they had been administering a medication which had run out several weeks before. This raised issues regarding staff not following the correct administering procedures. The inspector received written confirmation from the regional manager subsequent to the inspection that these issues have been addressed immediately following the inspection. Fairdene Lodge DS0000014199.V284245.R01.S.doc Version 5.1 Page 12 Resident’s appearance was presented in a manner that preserved their dignity, namely appropriately clothing for weather conditions, which were laundered to a good standard and regular hairdressing input. However not all resident’s privacy was being respected by the home’s practices. This relates to the laundry practices of laundered clothes and spare continence aids being stored in a shared room prior to them being distributed back to residents. This meant that the room stored several baskets of other resident’s laundry with staff frequently entering the room to collect the laundry. On one occasion a staff member entered the room without knocking. It was discussed that this practice did not promote privacy for the occupants of this room and must be reviewed immediately. Staff spoke sensitively regarding a recent death at the home and the support they had received from health care professionals to care for the resident. Staff said that they were enabled to sit with the resident for as long as they wanted so the resident was not alone and they were given the time to undertake personal care in a timely manner. The resident’s family spoke positively about the palliative care that they’re relative had received in their final days saying, “She died with dignity and peacefully we could not have wished for better care”. Fairdene Lodge DS0000014199.V284245.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above 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, 14 and 15 Social activities and meals continue to be creative and provide daily variation and interest for people living in the home. Staff try to make life in the home as flexible as possible for example getting up or going to bed. Residents are encouraged and supported to keep in regular contact with family and friends. EVIDENCE: Staff said that there was no set routine to the day other than meal times and residents confirmed that they went to bed and arose when they wanted. Residents were observed moving around the home freely choosing what room to be in and the level of company they wanted to enjoy. Opportunities for occupation and stimulation are well managed and appropriate for people with dementia. Some residents spoke of playing bingo, singing, gentle exercising and board games. Many residents said that they preferred just talking and spending time with staff individually. Many activities had been arranged for over the Christmas period, which included a musical entertainer on the day of the inspection. As in previous visits, the home was busy with many visitors noted throughout the course of the inspection. All visitors consulted said that they are always made to feel welcomed and are free to visit at any time. One visitor said that Fairdene Lodge DS0000014199.V284245.R01.S.doc Version 5.1 Page 14 the home has such a friendly atmosphere and it was always a pleasure coming to see their relative. Much work has been done to improve practices around autonomy and choice for residents as noted in previous inspections. Almost an hour prior to lunch being served drinks had been placed on the tables. The choice of drink was predetermined and dependent on whether the resident was a diabetic or not. The care manager said that a resident likes to set the tables. It was discussed that a sensitive approach is needed to ensure that residents are provided with choice while enabling residents to be involved in the daily running of the home. The kitchen was well-equipped and provided suitable facilities for catering. A few maintenance issues highlighted at the previous inspection have not yet been addressed these were: • Cracked flooring which could harbour bacteria and needs to be repaired and made impermeable to water. • Loose wall sheeting to be re-attached to prevent accidental injury. Residents described the food as: “lovely”, “plenty to eat” “you get far too much” “always to a good standard”. The meals served at inspection looked appetising and was presented to a high standard with large portions. The mealtime was observed to be relaxed and unhurried. Residents are asked each morning what choice of main meal they would prefer. There is a list of alternative meals displayed in case a resident doesn’t like the choices on offer. A vegetarian diet is also catered for. The majority of residents eat their meals in the dinning room with others preferring to eat in the privacy of their bedrooms. Several residents were being assisted to eat prior to the main group with the reason given for one resident was that this was due to their antisocial behaviour. One resident was being assisted to eat in the lounge while other residents were seated around them watching the television. No suitable explanation was provided for their exclusion from main group. During the serving of the main meal two carers where assigned washing up duties. The inspector questioned whether these staff would be better deployed in the dining room to enable all residents to eat together. Fairdene Lodge DS0000014199.V284245.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The home has a complaints procedure with residents feeling able to air any concerns. There are procedures and practices in place that supports the protection of vulnerable adults. EVIDENCE: There is an accessible complaints procedure for residents, their representative and staff to follow should they be unhappy with any aspect of the service. No complaints has been received or recorded by the home. Residents and visitors consulted felt confident to approach any member of staff with any concerns and felt that it would be dealt with promptly. There is an adult protection procedure to guide staff on identifying abuse and who to report to if abuse is suspected. Most staff have undergone training in adult protection and knew how to report any suspicions. The management team also had a clear understanding of adult protection guidelines and have initiated this procedure where there have had concerns regarding residents behaviour towards one another. Some male carers are employed, who showed sensitivity towards female residents being able to express any gender preferences they may have when personal care is to be undertaken. Fairdene Lodge DS0000014199.V284245.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 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, 20, 21, 22, 24, 25 and 26 Residents continue to live in a comfortable and homely environment. Residents have the specialist equipment they need to help maximise their independence. Laundry practices need to be reviewed to ensure that other residents laundry is not being stored in service users bedroom. EVIDENCE: The home is located within walking distance of Hove sea front and close to local amenities including shops, pubs and bus routes. There is a door entry system in operation, to enable staff to be aware when people are entering or leaving the building for security reasons. The standard of décor is good with minor redecoration works needed to some communal areas to ensure consistent standards throughout. The area manager stated that these works were planned to commence early 2006. The home was found to be warm and comfortable, with good levels of light and ventilation Fairdene Lodge DS0000014199.V284245.R01.S.doc Version 5.1 Page 17 The home is generally well maintained. A missing floor tile on the front pathway presented a trip hazard and it was immediately required that this be rectified. The area manager subsequently reported that this had been completed. A bath panel had become loose and needed attention, the care manager agreed to address this. Resident’s bedrooms are decorated and furnished to a good standard and all bedrooms seen had been personalised with resident’s belongings. All residents consulted said that they liked their bedroom. Some bedrooms have lino flooring to support odour management. The method for their cleaning has been reviewed to prevent a sticky residue build up, which had previously been noted. A shared room had only one wardrobe and therefore resident’s clothes were being stored together. It is recommended that separate hanging facilities be provided. Shared space consists of a combined lounge dining room, separate lounge and conservatory. The home was festively decorated with many residents commenting on how nice the decorations were. There is well-maintained rear garden, which is accessed via a ramp. Eleven rooms have their own ensuite facilities. There are two assisted baths, one of which has recently been refurbished to a high standard. The inspector was assured that a towel rail installed did not work and therefore did not pose any risk of accidental scolding. The home is not designated to provide a service to people with physical disabilities as the stairs and other access arrangements would make it unsuitable for residents with a permanent restricted mobility. Access to the first floor is via stairs or a chair lift with some additional small flights of stairs both on the ground and first floors. There are a variety of aids and adaptations around the building to promote residents independence. These include walking aids, raised toilet seats and grab bars. The premises have previously been assessed by an Occupational Therapist and recommendations made from this have been actioned. Call points are fitted throughout the home that enable assistance to be summoned and those checked were in working order and promptly answered by staff. This was confirmed by a resident who said that “they have had to use the call bell a lot recently and staff have always answered very promptly day and night”. Residents clothes were observed to have been laundered to a good standard, however as previously noted due to restricted laundry space clean items were being stored in residents bedroom prior to them being distributed. It has been required that this practice be reviewed. Hand washing facilities in the laundry had recently been removed, none of the staff consulted knew why. It has been Fairdene Lodge DS0000014199.V284245.R01.S.doc Version 5.1 Page 18 required that hand washing facilities are available in line with good infection control practices. It was previously recommended that a sluice facility be installed to promote good infection control practices in the cleaning of commode pans. It was reported that the provider is seriously considering this. Some parts of the building were in need of cleaning / vacuuming. The inspector was informed that there had been no domestic staff on duty over the weekend due to sickness. By the end of the inspection all areas in need of attention had been addressed. Fairdene Lodge DS0000014199.V284245.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 The staff group includes a stable core group who have worked at the home for a number of years. Their experience, together with training indicates that they have a good level of competence to meet the objectives of the home and the individual needs of residents. Residents are supported and protected by the home’s recruitment policy and practices. EVIDENCE: The staffing level at inspection was for four-care staff and a person in charge to be on duty throughout the waking day. This is in addition to domestic and kitchen staff. This staffing level was sufficient to meet the needs of residents. Rota’s stated that the home had not always been able to meet this staffing level due to sickness. The inspector was assured that when this has occurred the acting manager had undertaken care duties, and every effort had been made to cover shifts at short notice. There is a core group of staff who have worked at the home for a number of years and who have a good understanding of residents needs and preferences. All residents consulted spoke positively about staff saying: “do anything for you” “they wear themselves out for you” “nothing is too much trouble” and “they are all so kind and helpful”. The inspector observed much good practice in the way that staff interacted with residents and the support they provided to residents. With the change of registration to dementia care staff said that they were given the choice to transfer to another of the organisations homes, which none Fairdene Lodge DS0000014199.V284245.R01.S.doc Version 5.1 Page 20 did, and that they were provided with the necessary training in dementia care to be able to meet the needs of residents. All staff said that they felt that the transition went smoothly and moral remained good. Staff have undertaken compulsory training such as manual handling, adult protection, first aid, food hygiene and fire safety. In addition specialist training in dementia care, bereavement, is made available. It was reported that four staff are in the process of completing an NVQ in care. At inspection a care staff member was undertaking domestic duties as overtime. It was not clear what induction/training they had received to undertake domestic duties and had limited knowledge on the safe use of the chemicals they were using. It was discussed that where staff change roles suitable induction/ training must be provided. The inspectors reviewed a sampled batch of recruitment and selection documentation. These revealed that practices have improved with the required recruitment documentation being maintained. This includes CRB checks, application forms and references being obtained prior to employment commencing. Fairdene Lodge DS0000014199.V284245.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 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, 35, 36, 37 and 38 Although the home is without a registered manager the home continues to be openly managed in the best interest of residents by the management team. Resident’s financial interests are being safeguarded. The health and safety of residents and staff are generally promoted and protected with the exception being the smoking practices of staff, accident recording and the suitability of fire exit mechanisms. EVIDENCE: The home has been without a registered manager since 2002. An acting manager had been in post for several months prior to the inspection but subsequently is no longer employed. In the interim the regional manager and care manager undertake the day-to-day management responsibilities of the home with the provider visiting several times a week. The care manager has worked at the home for a significant number of years and provides a stable and consistent leadership in the interim. Staff and residents continue to speak positively about them with particular reference to their relaxed nature. The Fairdene Lodge DS0000014199.V284245.R01.S.doc Version 5.1 Page 22 care manager models good care practices. All staff felt that they receive the necessary support from the management team to undertake their duties, including formal supervision. In addition staff felt that all of the management team were approachable. One staff member said that they had made several suggestions to improve practices and that they had acted upon these. Where shortfalls in practices have been noted the area manager and provider continue to demonstrate a commitment to addressing them promptly in order to ensure that residents quality of life and safety remain the main focus of the home. It was clear that where staff have not fulfilled their roles and responsibilities effectively, prompt action has been taken to address this by the management team. Appropriate records were maintained where the home manages resident’s personal allowances. The home does not hold any residents personal monies instead relatives are invoiced for any additional expenditure All records requested by the inspector were made available and were securely stored. Not all records required by law and for the effective running of the home were maintained to a satisfactory standard, as previously noted this includes medication, care planning and risk assessment records. Practices that were noted which promote the health and safety of resident’s, staff and visitors were: • Hot water is controlled at source to deliver hot water within the required temperature range. • Radiators are fitted with guards to prevent accidental scolding. • Regular servicing and testing of fire safety equipment is undertaken, along with fire drills and training. A comprehensive fire risk assessment is in place which records the actions being undertaken to ensure adequate fire safety precautions. Staff were noted using the boiler room as a smoking area. It was required that this practice stop immediately for fire safety reasons. It was subsequently reported that this had been stopped. In light of the change of registration to dementia care there is a need to assess the risk of residents being able to leave the building unsupervised through fire exit on the first floor. It has been required that this door be risk assessed to determine whether an alternative opening mechanisms needs to be fitted. The Second floor contains an unused flat that is currently used to store spare equipment etc. At the time of inspection this was unlocked and posed a potential hazard for resident if they gained entry. It was discussed that access to this area needs to be restricted. Fairdene Lodge DS0000014199.V284245.R01.S.doc Version 5.1 Page 23 Accident records are maintained with each accident being reviewed by the acting manager who checks for standards of recording and for any patterns of accidents. Reference to an injury was noted in the daily notes but no record of the accident could be located. The care manager was asked to investigate this. Fairdene Lodge DS0000014199.V284245.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 2 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 x 3 3 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 x x 3 3 2 2 Fairdene Lodge DS0000014199.V284245.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? YES 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 OP3 Regulation 14(1)(a) Requirement That the needs of services users have been assessed by suitably qualified persons prior to admission. That care plans detail the actions needed to ensure that all aspects of the health and social care needs of service users are identified and which make explicit the actions needed to meet these needs. (Made at inspection of 28/6/05 with timescales of 30/08/05 not met). That comprehensive personal risk assessments are completed for all service users which are reviewed regularly and records the actions to manage identified risks. That suitable arrangements are in place for the recording, handling, safekeeping ,safe administration and disposal of medicines received into the home. That there are suitable arrangements to ensure that the care home is conducted in a DS0000014199.V284245.R01.S.doc Timescale for action 19/12/05 2 OP7 15(1) 28/02/06 3 OP7 13(4)(c) 28/02/06 4 OP9 13(2) 19/12/05 5 OP10& OP26 12(4)(a) 19/12/05 Fairdene Lodge Version 5.1 Page 26 6 OP19 23(2)(b) 7 OP26 13(3) 8 9 OP29 OP30 10 18(1)(c) (i) 23(4)(a) 17(1)(a) Sc3 (3)(j) 10 11 OP38 OP38 12 OP38 13(4)(a) manner, which respects the privacy of service users. That maintenance issues noted at inspection are addressed. (Made at inspection of 28/6/05 with timescales of 30/09/05 not met). That hand washing facilities are prominently sited in areas where infected material is being handled. That a registered manager is in post. (First made at inspection of 22/01/03). That staff received the necessary training and induction to undertake domestic duties safely. That smoking is not permitted in the boiler room. That a record of any accident affecting the service user and of any other incident which is detrimental to the health or welfare of service users, which records the nature, date, time, whether medical treatment was required and the name of the persons who were respectively in charge of the home. That the risk of service users leaving the building unsupervised from a first floor fire exit be risk assessed. 28/02/06 28/02/06 30/04/06 28/02/06 19/12/05 19/12/05 19/12/05 Fairdene Lodge DS0000014199.V284245.R01.S.doc Version 5.1 Page 27 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 4 5 Refer to Standard OP9 OP15 OP24 OP26 OP26 Good Practice Recommendations That hand written Medication Administration Records (MAR) are checked and countersigned by a second member of staff for accuracy. To review the deployment of staff during meal times to enable all residents who want to eat together to do so. That the occupants of shared rooms are provided with separate clothes hanging facilities. That a carpet cleaner be obtained. (Made at inspection of 28/6/05) That a sluice is obtained for the safe disposal and cleaning of commode pans. (Made at inspection of 28/6/05) Fairdene Lodge DS0000014199.V284245.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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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