Inspection on 28/06/05 for Fairdene Lodge

This inspection was carried out on 28th June 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 19/12/05

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 28 June 2005 9:45am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 H59-H10-S14199 Fairdene Lodge V226806 280605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Fairdene Lodge Address 14 & 16 Walsingham Road Hove East Sussex BN3 4FF 01273 735221 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Maria Holliday-Welch Vacant Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (OP), 32 of places Fairdene Lodge H59-H10-S14199 Fairdene Lodge V226806 280605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users to be accommodated is thirty-two (32). 2. The Service users must be older people aged sixty-five (65) years or over on admission. Date of last inspection 1 February 2005 Brief Description of the Service: Fairdene Lodge is a privately owned residential home for up to thirty-two older people. 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 H59-H10-S14199 Fairdene Lodge V226806 280605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced routine inspection, which took place between 9.45am and 3.20pm. The inspection was undertaken with Mrs Brown (Regional manger) and in part Mrs Holliday-Welch (provider) and on the day of the inspection there were twenty-nine residents living at the home. The inspection involved a tour of the premises, examination of the homes records and discussion with eight staff, fifteen residents and a visiting health care professional regarding their experiences at the home. The focus of the inspection was to look at the quality of live for residents living at the home. 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 hospitality and assistance during the inspection. What the service does well: What has improved since the last inspection? Significant progress has been made in addressing previous shortfalls in practices this has resulted in: • Greater choices being offered to residents in respect of food and the care they receive. Fairdene Lodge H59-H10-S14199 Fairdene Lodge V226806 280605 Stage 4.doc Version 1.30 Page 6 • • • Improved safety of residents through more effective hot water management and fire safety Increased staffing enabling the staff to spend more time socialising with residents. More opportunities for occupation and stimulation. What they could do better: It is of particular concern that recruitment practices still do not safeguard residents and this must be addressed as a matter of priority. Some minor redecoration and maintenance issues need to be addressed in order to provide consistent standards throughout the home. The home practices must ensure that all essential information regarding residents health care needs are passed onto staff to ensure that resident’s health needs can be addressed. Some elements of infection control practices must be addressed in order to protect from cross infection. In response to the draft inspection report, the provided returned to the CSCI an action plan of how they intend to meet the requirements and recommendations made from this inspection. 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 H59-H10-S14199 Fairdene Lodge V226806 280605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Fairdene Lodge H59-H10-S14199 Fairdene Lodge V226806 280605 Stage 4.doc Version 1.30 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 standard(s) 1,2,3 and 4 Prospective residents and their representatives have the information they need to make an informed choice about whether to live at the home. Residents are admitted to the home following an assessment of their needs. Residents looked cared for and relaxed in their environment and all appeared settled and content with the lifestyle of the home. 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, which 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 can be 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. The vast majority of referrals are from social services. Documentation was examined for a recent admission to the home and this showed that the Fairdene Lodge H59-H10-S14199 Fairdene Lodge V226806 280605 Stage 4.doc Version 1.30 Page 9 residents needs had been assessed by the regional manager and that their 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 needs is established. As part of the assessment process the home also speaks to health care professionals and others who know and understand the perspective resident to help inform their assessment. Concern was noted over the poor transfer of information from the assessment documents to the care plans. This is further discussed under standard 7. There is a range of residents needs at the home including some who have developed dementia and others who have complex needs to others who are largely independent. In order to address this range of needs specialist training has been undertaken and there are plans to vary the registration of the home. It was clear that where there are concerns regarding meeting the changing and emerging needs of resident’s additional support or advice from health care professionals has been sought promptly. This has included obtaining moving and handling equipment to support residents declining mobility and requesting reviews of residents needs by the placement authority. A visiting health care professional said how well residents with higher needs are cared for at the home and that residents that they visit have always said how happy they are to live there. All residents consulted said that they were happy living at the home and felt that their needs were being catered for. Residents described the experiences of the home as “homely” “everything is taken care of” “I don’t have to worry about anything” “Can’t fault it” “it’s the little extras that make all the difference” and “I didn’t want to live in a home but now I am glad I came”. Fairdene Lodge H59-H10-S14199 Fairdene Lodge V226806 280605 Stage 4.doc Version 1.30 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 standard(s) 7,8 and 10 Generally care plans provide a good framework for the delivery of care, however further work is needed to ensure that all health care information is passed onto staff and is clearly recorded. The home works closely with health care professionals including GP’s, District nurses, Specialist nurses, chiropodists, opticians and dentists to ensure residents receive the necessary health care intervention. EVIDENCE: Comprehensive information is gathered and recorded in an individual care plan for each resident. This includes a plan of care, nutrition assessment and personal histories. Four care plans were examined and these provided staff with a good guide to the assessed needs of residents. However, despite the comprehensive information gathered regarding the needs of a new admission, critical health care information had not been passed onto staff, recorded in the care plan or appropriate measures put into place to ensure their medical condition was monitored. The regional manager started to rectify this immediately. It has been required that care plans detail the actions needed to ensure that all aspects of the health needs of residents are identified and the actions needed to meet these needs. This will provide a basis for continuity of care and ensure that the home can account for its actions in meeting resident’s needs. Fairdene Lodge H59-H10-S14199 Fairdene Lodge V226806 280605 Stage 4.doc Version 1.30 Page 11 Care plans are reviewed weekly to ensure that any changes in needs are identified promptly. All residents consulted said that they were not interested in being involved in their care plan but felt able to ask to see it. Residents do sign their care plan to indicate that they are aware of it. The standard of daily recording was noted to be good with a clear account of actions and events that had occurred. Individual highlights needed to guidelines resident. risk assessments have been undertaken for each resident, which any risk, faced or posed by the resident and includes the actions manage or reduce them. In line with previous requirements greater are provided for staff on the safe moving and handling of each Residents consulted said that when they have asked to see a Doctor then this has been sought promptly. Records showed that regular support is provided by GP’s, District nurses, dentists, opticians and community psychiatric nurses. 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. All residents consulted felt that personal support is offered in such a way as to promote and protect their privacy, dignity and independence. Medication systems were not inspected on this occasion as a medication audit was being undertaken the following day by the supplying pharmacist. Therefore medication will be fully assessed during future inspections. Fairdene Lodge H59-H10-S14199 Fairdene Lodge V226806 280605 Stage 4.doc Version 1.30 Page 12 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 standard(s) 12,13,14 and 15 Social activities and meals are both well managed, creative and provide daily variation and interest for people living in the home. There are no set times for getting up or going to bed. Residents are encouraged and supported to keep in regular contact with family and friends. EVIDENCE: Residents said that there is flexibility in daily routines regarding meal times, going to bed, rising and bathing. Residents were observed moving around the home freely and choosing what room to be in and the level of company they wanted to enjoy. In line with previous requirements the use of lap tables has been reviewed to prevent them being a restriction on residents movement. Lap tables are now used for meals only, with the exception of one resident who has requested to use one throughout the day. Many improvements have been made to increase the opportunities for occupation and stimulation. This includes additional staff during the afternoon to enable them to spend more time focusing on the social needs of residents. In addition equipment has been purchased such as a portable darts game, board games and a white board in order to play word games. Staff spoke of the afternoon now being a more focused time to spend with residents on social activities. Residents spoke of particularly enjoying individual time with staff. Some residents preferred to make their own arrangements for occupation and Fairdene Lodge H59-H10-S14199 Fairdene Lodge V226806 280605 Stage 4.doc Version 1.30 Page 13 wanted to remain in their own bedrooms and this was respected by staff. One resident goes out independently and helps out in a local shop. During the course of the inspection many visitors were seen around the home talking with their relatives/friends along with other residents. Residents said that their visitors are always made to feel welcomed by staff and are offered beverages during their stay. Several residents said that they receive their visitors in the privacy of their own bedroom. In line with previous requirements the home has addressed concerns around residents being able to exercise personal autonomy and choice by introducing a selection of beverages, which residents choose from each time they are offered a drink. In addition closer supervision of staff is being undertaken to ensure that choices in the care residents receive is being offered and respected. The kitchen was well equipped and provided suitable facilities for catering. A few maintenance issues were highlighted which 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. All records required to be kept for food safety were maintained and up to date. Meals are prepared by a cook who develops the menus based on resident’s likes and dislikes. The meal served at inspection was plentiful and appetising with individual preferences being catered for eg vegetarian and diabetic. Residents said that staff ask them each morning what choice of meal they would like. All residents consulted spoke positively about the food provided. The majority of residents eat their meals in the dinning room with others preferring to eat in the privacy of their bedrooms. The mealtime was observed to be relaxed and unhurried with residents offered discrete assistance where needed. In addition to main meals snacks and drinks are provided throughout the day. The cook reported that home made cakes were now served with afternoon tea, which has proved popular with residents. Fairdene Lodge H59-H10-S14199 Fairdene Lodge V226806 280605 Stage 4.doc Version 1.30 Page 14 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 standard(s) 16 and 18 The home has a satisfactory complaints system with residents feeling able to air any concerns. Staff know what to do if abuse is suspected. Rigorous recruitment practices including police checks must be undertaken in order to safeguard residents. 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. All residents 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 what is abuse. Most staff have undergone training in adult protection with those who have not due to undertake this in the near future. Staff demonstrated knowledge of how to report any suspicions of abuse, and following a recent incident at the home several expressed their concern to the inspector regarding their vulnerability as carers to allegations of abuse. The provider plans to address this by further training on vulnerability in the workplace. In order to safeguard resident’s police checks must be undertaken for all existing staff and ensure that rigorous recruitment practices are followed. Fairdene Lodge H59-H10-S14199 Fairdene Lodge V226806 280605 Stage 4.doc Version 1.30 Page 15 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 standard(s) 19,20,21,22,24,25 and 26 Residents live in a comfortable and homely environment with some minor maintenance and redecoration needed. Some improvements need to be made to infection control practices in order to safeguard residents and staff. Aids and adaptations have been obtained in order to help promote independence. EVIDENCE: The home comprises of two detached Victorian properties connected by a ground floor corridor. 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 home has undergone an extensive refurbishment to upgrade the environment over the last two years, this has resulted in a homely and comfortable environment. Further works planned to be undertaken includes replacing most sinks and two bathrooms in the near future. Fairdene Lodge H59-H10-S14199 Fairdene Lodge V226806 280605 Stage 4.doc Version 1.30 Page 16 Resident’s bedrooms are decorated and furnished to a good standard and all bedrooms seen had been personalised with resident’s belongings. Some bedrooms have lino flooring to support odour management and it is recommended that the method of cleaning this type of flooring be reviewed to eliminate the sticky residue noted by the inspector. Shared space consists of a combined lounge dining room, separate lounge and conservatory. These are decorated and furnished to provide a homely feel. Some minor redecorations works is needed to some parts of the lounge, which the regional manager had already identified and was making arrangements to address. There is well-maintained rear garden, which is accessed via a ramp. Several residents said how much they liked to sit out in the garden in nice weather and enjoy the fresh air. The home has sufficient number of toilets and bedrooms including two communal assisted baths and one standard bath. During the inspection one bathroom was out of action due to a leak from the floor above and is due to be refurbished in the near future. The inspection was undertaken during a very hot summers day and residents had been provided with regular cold drinks in order to ensure that they remained cool. Much effort was also made to ensure that the home was well ventilated and maintained at a comfortable level, which included the home obtaining some individual desktop fans for residents. 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. The premises have been assessed by an Occupational Therapist and recommendations made from this have been actioned. Some adaptations and aids are provided including, raised toilet seats, and grab bars to assist in resident’s independence. Fixed call points are fitted throughout the home, those tested were in working order and although promptly answered by staff was cancelled before attending to the call. This is not considered good practice, as it does ensure that all calls for assistance would be answered. The provider addressed this immediately with the member of staff concerned. One resident who was in bed at the time of the inspection had been provided with an extension cord so they could call for assistance easily whilst in bed. The provider assured the inspector that there is a supply of extension cables should other residents also need them. A call point in one bedroom could not be found by the inspector and not all shared bedrooms had two call points fitted. It has been required that all rooms are provided with an accessible alarm facility. Fairdene Lodge H59-H10-S14199 Fairdene Lodge V226806 280605 Stage 4.doc Version 1.30 Page 17 Generally the home was cleaned to a good standard and odours were confined to some bedrooms. It is recommended that a carpet cleaner be obtained in order to assist in the effective elimination of odours. Some poor standards of infection control practices were noted, these were: • Some bedrooms are provided with commodes. The practices for emptying these were not in line with good infection control standards. It has been required that full protective equipment be made available for staff when disposing of human waste. It was subsequently confirmed by the regional manager that staff have been provided with all necessary equipement. It is recommended that a sluice facility be obtained in line with good infection control for the cleaning of commode pans. • Many staff and some visitors were observed entering the kitchen area without any protective clothing on. The kitchen is often used as a quick walk through between the two homes and it was discussed with the provider the importance of reviewing this practice on health and safety grounds. Fairdene Lodge H59-H10-S14199 Fairdene Lodge V226806 280605 Stage 4.doc Version 1.30 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 and 30 Staffing levels enable staff to have time to spend socialising with residents as well as caring for physical needs. The procedures for the recruitment of staff are still not sufficiently robust and do not provide the safeguards necessary to protect residents. There is a commitment to improving staff skills through an ongoing training programme both in practical matters and the broader aspects of caring for older people. EVIDENCE: The staffing level at inspection was for three care assistance, senior carer and care manager, plus the cook and cleaner. In line with previous requirements the deployment of staff has been reviewed to provide additional hours during the afternoon to undertake social activities. During the night there are two staff on duty. The staffing level is sufficient to meet the assessed needs of residents. Both residents and staff confirmed that the current staffing levels enabled individual time to spend talking with one another. Staff confirmed that sickness and leave shifts are now covered to ensure that the staffing structure remains consistent. The inspector observed many sensitive interactions between staff and residents and much good practice was seen in the way that support was provided. Residents described staff as “ Very helpful” “Kind” and “friendly” Recruitment documentation was seen for two members of staff. This showed that although recruitment standards had slightly improved the required documentation was still not being maintained to a satisfactory standard in order to safeguard residents. This includes two written references not being Fairdene Lodge H59-H10-S14199 Fairdene Lodge V226806 280605 Stage 4.doc Version 1.30 Page 19 obtained and Police checks not being undertaking for all existing employees. Recruitment practices must be improved as a matter of priority. Staff confirmed that they have undertaken compulsory training such as manual handling, adult protection, first aid, food hygiene and Fire. With some undertaking additional NVQ and dementia care training. Training reported to be planned in the near future include COSHH and bereavement. New staff confirmed that they received a good induction and demonstrating an understanding of their role and responsibilities. Fairdene Lodge H59-H10-S14199 Fairdene Lodge V226806 280605 Stage 4.doc Version 1.30 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33, 36 37 and 38 The home is openly managed in the best interests of residents. The home now regularly reviews aspects of its performance through a program of self-review and consultations, which include seeking the views of resident’s staff and others involved in their care. The health and safety of residents and staff are generally promoted and protected with the exception being some exposed hot pipe work and infection control practices. EVIDENCE: The home has been without a registered manager for three years. It was clear that much work is still being undertaken to ensure that an appropriate person is recruited. The Inspector has been kept in regular contact regarding the situation. 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 to oversee the home. The care manager has worked at the home for a significant number of years and provides a stable and consistent leadership in the interim. Where shortfalls in practices have been Fairdene Lodge H59-H10-S14199 Fairdene Lodge V226806 280605 Stage 4.doc Version 1.30 Page 21 noted the provider had demonstrated a commitment to addressing them promptly in order to ensure that residents quality of life remains the main focus of the home. Staff and residents spoke positively about the management team with particular reference to their approachability and the care manager’s knowledge of residents needs. Staff felt supported by the management team to undertake their roles. New supervision practices have been introduced which include performance appraisals. In addition formal supervisions sessions are about to be introduced to monitor individual practices, philosophy of care, and career development needs. A range of ways was seen of how residents and staff can affect the way the service is run and offer feedback on the services provided by the home. This includes regular reviews with placement agencies, recorded monthly audits by the regional manager, individual discussion with residents and staff meetings. In addition feedback questionnaires are sent out regularly to residents and other stakeholders eg GP’S, district nurses and relatives on their comments on the home. The regional manager then compiles a summary of the feedback provided. Records required by law and to safeguard residents were generally well organised and supportive to the effective and efficient running of the home, with the exception being recruitment and care planning. Practices that were noted which promote the health and safety of resident’s, staff and visitors are: • A clear account of accidents is maintained, with no specific patterns identified. One resident had completed their own accident record. • 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. • Radiators are fitted with guards to prevent accidental scolding. • Hot water is controlled at source to deliver hot water within the required temperature range. • It was previously required that window restrictors be checked regularly to ensure that they remain in place. Their checking now forms part of the recorded monthly visit by the provider. The regional manager also reported that they are also checked weekly. Areas that need to be addressed which do not promote adequate health and safety are: hot pipe work to be boxed in to prevent accidental scolding in a ground floor toilet and as previously noted some infection control practices. Fairdene Lodge H59-H10-S14199 Fairdene Lodge V226806 280605 Stage 4.doc Version 1.30 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 2 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION 2 3 2 2 2 2 3 2 STAFFING Standard No Score 27 3 28 x 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 x 3 x x 3 2 3 Fairdene Lodge H59-H10-S14199 Fairdene Lodge V226806 280605 Stage 4.doc Version 1.30 Page 23 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 15(1) Requirement 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. That maintenance issues noted at inspection are addressed. That a call system with an accessible alarm facility is provided and accessible in all service users bedrooms. That full protective equipment is provided for staff when disposing of human waste. That suitable protective clothing is worn by all persons entering the kitchen area. That Criminal Record Bureau checks are undertaken for all existing employees. That a registered manager is in post. (First made at inspection of 22/01/03). That employment and recruitment documentation is maintained within the home in accordance with the National Minimum Standard. (First made Timescale for action 30-8-05 2. 3. 19 22 23(2)(b) 23(2)(n) 30-9-05 30-9-05 4. 5. 6. 26 26 29 13(3) 13(3) 19(1)(b) (i) Sch2 (7)(b) 10 19(1)(a) (i)& Schedule 2(1-6) Immediate Immediate Immediate 7. 8. 29 31 30-11-05 Immediate Fairdene Lodge H59-H10-S14199 Fairdene Lodge V226806 280605 Stage 4.doc Version 1.30 Page 24 at inspection of 29/8/02). 9. 38 13(4)(c) That hot pipe work is boxed in to prevent accidental scolding. 30-7-05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 24 26 26 Good Practice Recommendations That the method of cleaning lino flooring be reviewed to eliminate the build up of a sticky residue. That a carpet cleaner be obtained. That a sluice is obtained for the safe disposal and cleaning of commode pans. Fairdene Lodge H59-H10-S14199 Fairdene Lodge V226806 280605 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI Fairdene Lodge H59-H10-S14199 Fairdene Lodge V226806 280605 Stage 4.doc Version 1.30 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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