Inspection on 26/09/07 for Fairdene Lodge

This inspection was carried out on 26th September 2007.

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 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 02/05/06

Fairdene Lodge 19/12/05

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 Key Unannounced Inspection 26th September 2007 12:00 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.V339529.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V339529.R01.S.doc Version 5.2 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 Fairdenelodge@ntlworld.com 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.V339529.R01.S.doc Version 5.2 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 2nd May 2006 Brief Description of the Service: Fairdene Lodge is a privately owned residential home for up to thirty-two older people who have dementia. The home changed its registration to accommodation people who have dementia in September 2005. The home’s provider also owns further registered homes for older people within the East 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 en-suite 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. The fees vary from £440 for a shared room to £540 depending on the services and facilities provided. Extra such as: newspapers, hairdressing, chiropody, transport , toiletries are additional costs. Fairdene Lodge DS0000014199.V339529.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The information contained in this report has been comprised from an unannounced inspection undertaken over six hours and information gathered about the home. This includes: residents survey questionnaires, discussion with relatives, stakeholders involved in resident’s care and health care professionals. The manager had completed an Annual Quality Assurance Assessment form prior to the inspection and the information contained in this document has been used to inform the inspection of the home. The inspection was facilitated in the main by a supervisor and in part by Mrs M Holliday-Welch (Registered Provider). The inspection involved a tour of the premises, observation of the daily running of the home, examination of records and discussion with residents and staff. There were thirty-two residents living at the home at the home at the time of the inspection. The focus of the inspection was to look at the experiences of life at the home for people living there. Signs of residents well-being/ill-being (terminology used for observing behaviour for people with dementia) were observed. In order that a balanced and thorough view of the home is obtained, this inspection report should 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 visit. What the service does well: Residents continue to live in a pleasant environment that is accessible and homely, which meets their individual and collective needs in a comfortable and informal style. Comments about the environment included “nicely decorated, always looks nice and clean” and “very comfortable”. The home provides both prospective and existing residents, with a good level of information about what services are provided and what to expect when living at the home. A sample of comments made by residents regarding their experiences include: “it’s a very very good home” and “contented”. Comments made by stakeholders involved in residents lives include: “residents looked cared for”; “seems very happy and settled”; “mum seems quite happy all going very well”; “Generally caring home most of the residents seem quite happy” and “mum looks so much healthier. The inspector observed many wellbeing indicators of residents who were not able to verbally share their experiences about the home. Fairdene Lodge DS0000014199.V339529.R01.S.doc Version 5.2 Page 6 There is regular input from a variety of health care professionals to ensure that residents receive a range of medical support and assistance. Flexibility in the daily routines, helps to promote resident’s choices with evidence that residents are treated as individuals. The meals are good offering both choice and variety. Links with families continued to be valued and supported by the home. Residents’ benefit from a stable, well-trained staff team that know them and who are employed in sufficient numbers as is necessary to meet their needs. Comments made about staff include: “do anything they can to help”; “kind above and beyond their duty” and “some and some depends what sort of day they are having as to how they come across to you”; “always positive things going on with staff engaging with residents” and “smartly turned out very welcoming and nice to residents”. What has improved since the last inspection? What they could do better: In order for residents who self medicate to remain safe it is necessary that this processed is risk-assessed to highlight any measures that need to be put into place so they are abele to continue to self medicate safely. In order to ensure residents safety the homes medication policies need to be consistently carried out by all staff. Further work is needed to ensure a consistent approach to preserving resident’s privacy and dignity. The home has been without a registered manager since 2002. The person appointed by the provider to oversee the running of the home is currently on Fairdene Lodge DS0000014199.V339529.R01.S.doc Version 5.2 Page 7 leave and the provider stated that they will be applying to the commission for registration in the near future. 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. The summary of this inspection report can be made available in other formats on request. Fairdene Lodge DS0000014199.V339529.R01.S.doc Version 5.2 Page 8 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.V339529.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 2 3 4 and 5 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. The home provides both prospective and existing residents, with a good level of information about what services are provided and what to expect when living at the home. The way in which prospective residents are assessed ensures that the home admits only those residents who’s needs can be met by living at the home. EVIDENCE: There continues to be a range of well-documented information about the home and the services it provides. This includes a statement of purpose and service user guide, which are made available to prospective residents and other interested parties. Copies of these documents are also available in the home for existing residents. A relative said that the information, provided guidance Fairdene Lodge DS0000014199.V339529.R01.S.doc Version 5.2 Page 10 on what the charges for the home were and included details of what they didn’t include which they found useful. 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. The home ensures that prospective residents are accommodated only following an assessment of their needs by a member of the management team and Social Services. Advice is sought during the assessment process from health care professionals and others who know and understand the needs of the prospective resident in order to build up a picture of the residents needs. There continues to be a wide range of needs being accommodated at the home. This includes a resident who lives an independent lifestyle and residents who have complex physical and dementia needs. There was evidence that the home is able to meet most needs of residents. Staff were able to demonstrate a knowledge and understanding of most needs of residents and also how those needs are to be consistently met. All residents consulted with spoke positively about their experiences at the home. A sample of their comments includes: “it’s a very very good home” and “contented”. Comments made by stakeholders involved in residents lives include: “residents looked cared for”; “seems very happy and settled”; “mum seems quite happy all going very well”; “Generally caring home most of the residents seem quite happy” and “mum looks so much healthier. For some residents not able to verbalise their experiences of the home the inspector observed many wellbeing indicators in their behaviour throughout the course of the inspection. Residents and their representatives consulted with spoke of being provided with the opportunity to visit the home in advance to assess the quality, facilities and suitability of the home. Most residents consulted said that it was their families that looked around the home on their behalf. A Relative said that they were particularly impressed with the warm welcome their relative received when they were moving into the home and how helpful staff were to ensure that their anxieties were minimised. Intermediate care is not offered at the home therefore this standard is not assessed. Fairdene Lodge DS0000014199.V339529.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 and 10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There is a good care planning system in place, which provides staff with the information they need to be able to meet resident’s needs. The health needs of residents are being met with evidence of regular input from health care professionals. In order to ensure residents safety the homes medication policies need to be consistently carried out by all staff. Further work is needed to ensure a consistent approach to preserving resident’s privacy and dignity. EVIDENCE: Four Individual plans of care were inspected and were found to be sufficiently detailed, up to date, and contained information to support staff to meet most needs of residents. Care plans showed evidence of being reviewed on a regular basis. The standard of daily recording was noted to be good with a clear account of actions and events that had occurred. Fairdene Lodge DS0000014199.V339529.R01.S.doc Version 5.2 Page 12 Action had been taken to address the shortfalls in care planning noted at the last inspection, however it is recommended that care plans include personal histories, which enable staff to be aware of significant events and individual lifestyles prior to the onset of dementia. Most risks faced and posed by residents are assessed and any actions needed to reduce or manager risks are recorded in the care plans. All residents consulted expressed little or no interest in the development and review of their care plans, but felt that they could ask to see what is recorded about them. Some care plans had been signed by the residents when it had been first written. Staff consulted with showed a good understanding of the individual needs of residents and how they should be met. Records of medical intervention showed that the home works closely with health care professionals including GP’s, District and specialist nurses and chiropodists to ensure residents receive a range of health care intervention. Residents and relatives consulted said that when they have requested medical advice or intervention then this has been sought promptly. However a health care practitioner recalled an incident where they felt that the home did not seek medical support promptly and they addressed this with the manager at the time who took appropriate action. The medicine administration records demonstrated that systems have been established to ensure staff are appropriately trained and records provide a history of what was given by who and when. However in order to safeguard residents who self medicate this practice must be supported by a risk assessment to assess that they are safe to do so. There is a need to ensure that there are individual instructions provided for staff on the administration of “As required” medication. These must make clear the individual requirements for when these medicines should be administered. In accordance with good infection control practices the use of communal creams must stop and only administered to the prescribed individual. In the main the homes practices helped to preserve resident’s privacy and dignity. Observation of such practices included staff using residents preferred names, personal support being carried out in private, knocking on bedroom doors prior to entry and in the respectful tone of language used during interactions with residents. However some practices that did not were highlighted to the Provider who agreed to address them immediately these were: Personal care information being displayed in a shared bedroom, the open storage of continence aids in bedrooms and the storage of equipment not belonging to specific residents in their bedrooms. Fairdene Lodge DS0000014199.V339529.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 and 15 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Flexible in the daily routines, helps to promote resident’s choices. There is evidence that residents are treated as individuals. The meals are good offering both choice and variety. Links with families continued to be valued and supported by the home. EVIDENCE: Observation of the daily routines and discussion with residents and staff continue to confirm that staff accommodate resident’s personal wishes with regard to meal times, going to bed, rising and bathing. During the inspection residents were observed to move around the home choosing which room to be in and what level of company they wanted to enjoy with a resident saying “Can choose what I want to do when I want to do it”. Residents’ views regarding activities varied between those who enjoyed socialising and others who were not so interested. Residents spoke of watching TV, playing bingo, and musical entertainers visiting. At the time of the Fairdene Lodge DS0000014199.V339529.R01.S.doc Version 5.2 Page 14 inspection an art therapist was undertaking their first small group session at the home. Those residents who were participating were observed to be actively engaged and appeared to be enjoying the session. A staff member commented “they do quite a lot of activities” which also included nail painting and massagers. A video picture screen is displayed in the entrance, which displays pictures of events held at the home. A relative said that it was really nice to see their relative enjoying themselves. Visitors commented upon how welcomed they are made to feel during their stay, this included being offered beverages or meals and staff being friendly and approachable. Staff were observed involving residents in as much choice in planning their day to day support and activities as possible. For a few residents exercising their choice was more difficult. The staff were seen to use their acquired knowledge of a resident to help them in these circumstances to make decisions on a residents behalf. Staff spoke knowledgeable about the individual needs and preferences of residents and of any cultural or religious beliefs. The meal served at inspection was presented well with resident’s individual preferences respected and specialist diets begin catered for. The atmosphere was relaxed with residents who needed assistance being supported in a discreet and sensitive manor. Some residents are served their meals on small tables while they remain in lounge chairs. The inspector observed that this did not always promote good posture to aid digestion or aid independence. The supervisor agreed to look into this immediately. The inspector was assured that following lunch these residents were assisted to mobilise to ensure that they did not remain in these seats for significant periods. The chef said that Environmental Health had recently visited the home and awarded the home a three star food safety standard. A sample of comments about food includes: “eatable”; “dam good chef”; “lunch today was risotto and it was bloody good” and “I am Vegetarian and they really consider this”. Hot drinks and snacks are made available throughout the day. A relative said that there are always cold drinks available which residents can help themselves to. Fairdene Lodge DS0000014199.V339529.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. A complaints procedure and appropriate adult protection policies and training for staff in safeguarding adults helps to enable resident’s rights and interests are promoted and protected. EVIDENCE: Details of how to make a formal complaint are displayed within the home. All residents and relatives consulted with felt confident to approach staff with any concerns. Records of formal complaints are maintained which includes the outcome of any investigation. Records showed that complaints had been dealt with in accordance within the timescales of the homes policy. There are written policies covering safeguarding adults and whistle blowing. These make clear the vulnerability of people in residential care, and the duty of staff to report any concerns they may have to a responsible authority for investigation. The staff consulted with said that they had attended safeguarding adults training and showed an understanding of their roles and responsibilities under safeguarding adults guidelines. Fairdene Lodge DS0000014199.V339529.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 21 22 24 25 and 26 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. The home provides a pleasant environment that is accessible and homely, meeting residents’ individual and collective needs in a comfortable and informal style. 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 safety and security reasons. The standard of décor remains overall good with an ongoing programme of minor redecoration. There was evidence that maintenance issues were promptly attended to, with all reasonable steps taken to maintain a safe home. Fairdene Lodge DS0000014199.V339529.R01.S.doc Version 5.2 Page 17 The organisation employs its own maintenance staff, who is clearly popular amongst residents. A resident said that they had reported a fault directly to the maintenance staff who was always helpful and got things done quickly. The provider spoke of their plans for some major alterations to the ground floor offices and laundry area. This was to improve the laundry facilities and make the office more accessible to residents. Resident’s bedrooms are decorated and furnished to a good standard with appropriate furniture and fixtures. Individual rooms were found to be personalised and clean. A relative said that “mum was encouraged to bring in items into her room” and felt that the room was “well decorated with no odours”. The provider said that residents who share bedrooms have a shared room agreement, which is discussed with the residents their representative and the placement authority. Communal space consists of a two large combined lounge dinning rooms. A relative said that these rooms were “nicely decorated, always looks nice and clean” further comments include: “very comfortable” “the home is always busy therefore residents are not isolated in the two lounges as there is always staff walking around”. There is a small secure rear garden, which is accessible by a ramp, has seating areas and is well maintained creating a pleasant environment for residents to use and view. 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 continues to be a range of individual aids and adaptations to assist resident’s mobility and independence, including raised toilet seats, walking aids, grab rails. Fitted throughout the home are call points, which enable assistance to be summoned when pressed. A resident tested their call bell in the presence of the inspector and staff responded quickly. The supervisor reported that the previous concerns regarding the lack of hand washing facilities in the laundry have been addressed through the use of alcohol gel and wipes. This is a temporary measure pending the relocation of the laundry room. Parts of the home visited were observed to be clean with any melodious odours confined to a few areas. Suitable measures are in place to ensure that standards of cleanliness are able to be maintained. In order to follow good practices in infection control it was discussed that in shared bedrooms each resident should have their own storage container for toothbrushes and personal toiletries. Some new commodes have been purchased in order to address the previous concerns regarding their state of repair. Fairdene Lodge DS0000014199.V339529.R01.S.doc Version 5.2 Page 18 A sluice facility has been installed to ensure the suitable cleaning of commode pans. The provider reported that previous concerns noted relating to the fire safety considerations following its installation have now been addressed. However evidence suggests that the sluice is not currently being used and the provider agreed to investigate this to ensure that suitable infection control methods were being followed. Fairdene Lodge DS0000014199.V339529.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 and 30 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Residents’ benefit from a stable, well-trained staff team that know them and who are employed in sufficient numbers as is necessary to meet their needs. EVIDENCE: Staff, visitors and residents felt that there was sufficient numbers of staff on duty for staff to undertake their roles in a timely manner and for residents to receive the support they needed, when they wanted it. In addition to care staff there is a senior care officer and supervisor on duty during the day along with ancillary staff. Staff confirmed that there is some flexibility in staffing levels should residents needs increase. All staff were found to have a good rapport with residents and visitors which promoted a relaxed atmosphere in the home. A sample of residents comments made about staff include: “do anything they can to help”; “kind above and beyond their duty” and “some and some ”depends what sort of day they are having as to how they come across to you”. Comments made by other people involved in residents lives regarding the staff includes: “smartly turned out very welcoming and nice to residents”; “great”; “Staff all seem very friendly”; “always positive things going on with staff engaging with residents”. A health care practitioner felt that staff did not always show an understanding of people who have dementia and said that Fairdene Lodge DS0000014199.V339529.R01.S.doc Version 5.2 Page 20 they had raised this with the supervisor who said that they would address this with the individuals. There is a core group of staff that have worked at the home for many years and who demonstrated a good understanding of residents individual needs and preferences. In information submitted to the Commission as part of the inspection process, the area manager stated that currently over half of the staff team have completed National Vocational Qualifications to at least NVQ Level 2. Staff have the opportunity to undertake a variety of training courses, which includes core topics such as manual handling, fire safety, safeguarding adults and food safety as well as specialist training in dementia. Staff consulted with highlighted the dementia training as being particularly beneficial in improving their understanding of people who have dementia and in helping them to deal with challenging situations when residents have complex needs. Fairdene Lodge DS0000014199.V339529.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 36 and 38 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. In the absence of a registered manager the interim management arrangements are satisfactory to ensure that residents continue to receive good quality consistent care. The systems for resident consultation are good with a variety of evidence that indicates that resident’s views are sought and acted upon. A range of regular health and safety checks helps to ensure the health and safety of residents and staff. EVIDENCE: Fairdene Lodge DS0000014199.V339529.R01.S.doc Version 5.2 Page 22 The home has been without a registered manager since 2002.The provider reported that the area manager will be applying to the commission to become the registered manger following their return from maternity leave. Prior to their leave they were appointed by the provider to manage the home and have done so for the previous twelve months. In the interim a supervisor who has worked at the home for a significant number of years overseas the day to day running of the home. The provider reported that they plan to visit the home most days during the absence of the area manager. A staff member said that the area manager and the provider were easy to talk to and “they encourage a clear management direction” and “Management are excellent they do a really good job”. Without exception all persons consulted about the supervisor who now overseas the home spoke positively about them, comments include: “she’s a doll never flustered or flaps or forgets”; “very caring”; “she is very good at organising the care” and “brilliant”. A health care practitioner said “seems like a nice well run place”. Although it remains outstanding that an application is made to the Commission to register a manager at the home, the interim management arrangements are satisfactory, to ensure suitable direction and leadership of the home. Much work has been undertaken to obtain feedback on the quality of the services and facilities offered from residents, and other stakeholders involved in their care. The outcome of feedback questioners have been compiled into a summary. Evidence showed that service improvements were made following the outcome of feedback questionnaires. Residents are encouraged to retain control of their own finances for as long as they are able to do so and if unable then this responsibility is taken on by a relative or another responsible persons external to the home. Staff are in the main supervised by the supervisor working along side them each shift and all staff consulted with felt well supported. Care staff spoke of receiving formal supervision on a regular basis. There are policies and procedures related to health and safety. Records submitted by the manager prior to the inspection stated that all of the necessary servicing and testing of health and safety equipment has been undertaken. The areas of shortfall relating to health and safety noted at the last inspection have now all been addressed. Systems were in place to support fire safety, which included: regular fire alarms and emergency lighting checks, staff training and maintenance of fire equipment and fire drills were reported to have been undertaken. The provider reported that A fire risk assessment had been undertaken by a fire safety expert, which recorded significant findings and the actions taken to ensure adequate fire safety precautions in the home. Fairdene Lodge DS0000014199.V339529.R01.S.doc Version 5.2 Page 23 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 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 3 Fairdene Lodge DS0000014199.V339529.R01.S.doc Version 5.2 Page 24 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 OP9 Regulation 13(4)(c) & 13(2) Requirement That written risk assessments are completed for those service users wishing to self medicate which records the actions to managed identified risks and is reviewed frequently. That prescribed medical creams are administered to the prescribed service user only That the homes practices and procedures ensure that the privacy and dignity of service users all times. That a registered manager is in post. (First made at inspection of 22/01/03). Timescale for action 30/11/07 2 OP10 12(4)(a) 30/11/07 3 OP31 8 30/01/08 Fairdene Lodge DS0000014199.V339529.R01.S.doc Version 5.2 Page 25 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 OP7 2 OP9 Refer to Standard Good Practice Recommendations That care plans include personal histories of residents where possible in order to inform staff of significant events and individual lifestyles prior to the onset of dementia. That additional instructions are provided for staff on the administration of “As required” medication, which make clear the individual requirements for when this medications was prescribed. Fairdene Lodge DS0000014199.V339529.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Fairdene Lodge DS0000014199.V339529.R01.S.doc Version 5.2 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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