Inspection on 18/12/06 for Fairfield Residential Care Home

This inspection was carried out on 18th December 2006.

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

Fairfield Residential Care Home 09/02/09

Fairfield Residential Care Home 21/02/08

Fairfield Residential Care Home 30/08/07

Fairfield Residential Care Home 28/07/06

Fairfield Residential Care Home 15/11/05

Fairfield Residential Care Home 09/06/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Fairfield Residential Care Home 27 Old Warwick Road Olton Solihull West Midlands B92 7JQ Lead Inspector Susan Scully Key Unannounced Inspection 18th December 2006 09:30 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 Fairfield Residential Care Home DS0000063831.V324451.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. Fairfield Residential Care Home DS0000063831.V324451.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fairfield Residential Care Home Address 27 Old Warwick Road Olton Solihull West Midlands B92 7JQ 0121 706 2909 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) Santok Mayariya Mr Dilip Mayariya ** Post Vacant *** Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Fairfield Residential Care Home DS0000063831.V324451.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The current registered double room is to remain as a permanent single room for as long as the existing service user chooses to remain in that room. During this period the effective capacity of the Home will be seventeen service users. Service users in the six upstairs bedrooms located in the original part of the house may continue to live there as long as their needs can be met. Until such time as the difficulty of split level floors is solved to the satisfaction of CSCI all future service users residing in this area must be ambulant. In the event of the Registered Manager leaving, a fulltime care practice consultant must be retained until such time as a replacement manager is actually registered. This arrangement to exist for a period of two years and applies to any reoccurrence of a registered manager leaving within that period. The current minimum staffing levels must be maintained until such time as agreement is reached with CSCI on the basis of service user needs, environmental factors and staff competency that these may be changed . 28th July 2006 2. 3. 4. Date of last inspection Brief Description of the Service: Fairfield is a large extended detached house providing care for up to 18 older service users. The home is located in the Olton area of Solihull and is readily accessible to amenities such as shops, places of worship and public transport. The home comprises of 16 single bedrooms, thirteen of which have en-suite facilities and there is one double bedroom. Accommodation is provided on two floors. There are two lounges separated by glass doors, which when opened creates one large lounge area. A dining room and conservatory are also provided. There is a shaft lift to the upper floor. One small area of the home on the first floor is reached by a further small staircase and therefore is only accessible by those that are ambulant. The gardens to the rear of the property are accessed via a ramp from the conservatory enabling access for service users in wheelchairs or with a Fairfield Residential Care Home DS0000063831.V324451.R01.S.doc Version 5.2 Page 5 disability. Handrails are also provided. Limited parking facilities are available at the front of the building, however onroad parking is readily available outside the home. The fee payable range from £314.00 to £355.00 per week. Fairfield Residential Care Home DS0000063831.V324451.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced fieldwork visit took place over a one-day period. Information was obtained from relatives, service users, and health professionals to establish whether or not the home is providing an effective service. In order to compile this report a number of people using the service, and members of the organisation’s management and staff team were interviewed. Records were sampled during the visit and these included service users’ plans of care, health and safety documentation and records relating to the homes policies and procedures. Information received at the commission over a period of a fivemonth since the last inspection was also used. The inspector would like to thank service users and staff for their contribution during the visit. What the service does well: What has improved since the last inspection? The practise pertaining to recruitment has improved which means all the relevant checks are completed before the commencement of employment. Menus show a nutritional varied meal is provided daily which mean service users needs are met pertaining to a balanced diet. Comments from service users include: “I am happy here, they look after me well, I like the food and we have just started to do more activities such as the Christmas party that was really good’’. The owners always ask if we are all right and do we needs anything. “I am comfortable and staff assist me with what I want to do’’. Fairfield Residential Care Home DS0000063831.V324451.R01.S.doc Version 5.2 Page 7 “ Sometimes I wish I could do more for my self but the staff always encourage me and help me’’. “Well if I have to be somewhere and not at home I would rather be here at least staff treat you as if you are a person not like the last home I was in when I came out of hospital’’. “ The staff are pretty good some you like and some you don’t, like but they treat us well’’. There was good recording of financial records pertaining to service user monies held by the home showing all transactions with receipts numbered for good auditing purposes. The recording of medication has improved. All staff have received training in the safe handling and admission of medication to ensure only competent experienced staff administer medication. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Fairfield Residential Care Home DS0000063831.V324451.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 Fairfield Residential Care Home DS0000063831.V324451.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): 3 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The service does not ensure the needs of service users can be met by completing an adequate assessment before admission. This results in service users life being disturbed unduly by inappropriate placements of service users without the correct information being obtained. EVIDENCE: A pre assessment is normally completed before admission, however the pre admission assessments completed for three new service users were poor. There was a lack of documentation of the service user needs. For example “require 24-hour care’’. The pre assessments contained no information about the person health, past medical condition, or history. The assessor would not be able to confirm the service could meet the person’s needs with the information contained in the pre assessments sampled. Fairfield Residential Care Home DS0000063831.V324451.R01.S.doc Version 5.2 Page 10 One pre assessment was very poor. This has resulted in one service users needs not being met and the breakdown of the placement causing undue distress to the service user and staff. Fairfield Residential Care Home DS0000063831.V324451.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): 7,8,9,10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The needs, preference, and personal wishes of service users are not respected and the changing needs of service user are not monitored and regular reviewed to ensure service users are not placed at risk. Service users do not receive a consistent service this may lead to the needs of service users not being met and a potential risk to their health and welfare. EVIDENCE: The care plans and assessments of the three service users who had recently been admitted were very poor. They did not demonstrate how the needs of the service users have been met. Daily records are poor describing entries such as “ all care given and ate and drank well’’. The information in daily records does not mention what the person has done each day or if their needs were met, as per care plan, and the assessment completed by the social worker. The home did not transfer the information Fairfield Residential Care Home DS0000063831.V324451.R01.S.doc Version 5.2 Page 12 from the social worker assessment into a plan of care for staff to ensure they maintain the service users identified needs. There was very limited information of the service users wishes or how service users are encouraged to make decision for themselves. There was limited information of how service users are given support when they have increasing infirmity. For example when a service users requires assistance with bathing or personal care there is no information for staff to follow to ensure preservation of dignity and respect. There was no information to enable service users to have a sense of ownership of personal autonomy and choice. This may cause service users to feel that their independence is being taken away from them. One service user admitted recently demonstrated challenging behaviour and suffered with Bi polar which is a mental illness. The full details of the service users history was not provided to the home and the assessment completed before admission was not adequate to ensure the home could meet the person needs. The staff team had no experience in managing challenging behaviour or what the meaning of Bi Polar. This resulted in distress to the service user, staff and other service users. The staff found this difficult to manage, however ensured no other service users were placed at risk by providing one to one care. Staff and management did all they could to ensure an alternative placement was found to ensure the needs of the service user could be met and contacted the relevant professionals for assistance. The lack of information and the inexperience of the assessor resulted in the breakdown of the placement and the service user being moved to alternative accommodation . This clearly demonstrates the need to ensure an experienced person completes the pre assessment for service users before they are admitted to the home. Care plans did not demonstrate how service users emotional needs especially those service users that have a diagnosis of dementia or other medical condition is managed. This could lead to service users and staff becoming frustrated and leading to bad practise. The care plans being used were generic with a space for additional comments. These were not individualised and did not include enough detail of the service users needs or how these needs were to be met by staff. Comments on the care plans included such statements as, under diet, “note any dislikes/allergies and offer an alternative’’, where as any dislikes or allergies should be detailed on the care plan to ensure staff are aware of them. Fairfield Residential Care Home DS0000063831.V324451.R01.S.doc Version 5.2 Page 13 Another statement included was, “use pads if prone to incontinence’’, this should be known and detailed on care plans as to how continence is managed including what pad size is to be used. Information contained in daily records stated such things as, “needs a little help and supervision with washing and dressing’’, and “enjoy her food’’. In daily records the information was very vague and did not give sufficient information to the reader. There was no information as to what the service users were able to do for themselves or preferences. The acting manager must ensure there is a balance with what information is recorded in care plans and all care plans must be reviewed monthly or before if a new need is identified. Care plans must also demonstrate what influence the n new needs will have on their existing care. Care plans must be evaluated, monitored, reviewed and re- evaluated to ensure consistence with the care provided. Medication records were sampled, of the four service users whose care plans were sampled Medication was recorded and administration record showed all medication sampled and audited correct. A controlled drugs book was not being used for controlled drugs so an adequate audit could not be completed. The provider said she had been told by the visiting pharmacy the medication that was held in the home were not controlled drugs. This must be clarified and if necessary the controlled drug book must be used. Information was seen that showed all medication is recorded that comes into the home and returned to the pharmacy. All staff have received training in the safe handling of medication to ensure service users are not placed at risk by ensuring only staff that are competent and experienced administer medication safely. There was no evidence of any manual handling risk assessments on any of the files sampled. It was evident from other records that one of the residents was not weight bearing but without a risk assessment staff would have been unclear about the handling methods to be used. The acting manager said these had been completed for all service users. During the last inspection three care plans were sampled that contained these documents. However the provider and the acting manager could not find the risk assessments for any service users. This places all service users at risk. Fairfield Residential Care Home DS0000063831.V324451.R01.S.doc Version 5.2 Page 14 The acting manager must either complete new risk assessment for all service users or confirm in writing the existing ones have been found. The risk assessments for the four care plans that were sampled were not available. The manager must ensure the relevant information is available at all times to staff to ensure the safety of service users. There were falls and nutritional risk assessments on the one file but the action plans for these were generic and did not apply to the individuals concerned. No tissue viability assessments had been undertaken and there was evidence that some service users spent long periods of time sitting down and would be vulnerable to pressure sores. This will place service users at risk if not monitored appropriately. Fairfield Residential Care Home DS0000063831.V324451.R01.S.doc Version 5.2 Page 15 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): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are offered and participate in social and recreational activities to ensure they lead a fulfilled life. EVIDENCE: The service users spoken with were content and did not feel there were any rigid rules or routines in the home. Service users did state they could get up when they wanted to. It is strongly recommended that service users are consulted about their preferred waking times and when they would like their breakfast as recent concerns had been identified that service user were got up at a time that was more convenient to the routine of the home. On the day of the inspection service users were observed spending time in their rooms, reading the newspaper, chatting to each other and taking part in an exercise session. There were board games and books available in the home but there was no documented evidence of any activities facilitated by staff. This issue was discussed with the acting manager who stated there was not much going on in the home of late but plan were in progress to consult with service users and a service users meeting was being arranged. Fairfield Residential Care Home DS0000063831.V324451.R01.S.doc Version 5.2 Page 16 It was recorded in one care plan that the service users religion was church of England, however daily records showed she attended holy communion each fortnight, the daily records or care plan did not identify if this was the service user choice, or if it was because it was the only religious activity available in the home. Service users stated they were satisfied with the catering arrangements at the home. They confirmed that if they did not like what was on the menu they could have an alternative. Staff went and asked service users prior to teatime what they wanted and a record of this was seen. A record of record of foods being served to the service was seen. The record also needs to demonstrate that service users have eaten what has been presented. There was a list of special dietary needs in the kitchen but no evidence to support these had been adhered to. Comments from service users include: “I am happy here, they look after me well, I like the food and we have just started to do more activities such as the Christmas party that was really good’’. The owners always ask if we are all right and do we needs anything. “I am comfortable and staff assist me with what I want to do’’. “ Sometimes I wish I could do more for my self but the staff always encourage me and help me’’. “Well if I have to be somewhere and not at home I would rather be here at least staff treat you as if you are a person not like the last home I was in when I came out of hospital’’. “ The staff are pretty good some you like and some you don’t, like but they treat us well, I can not say I have ever found or seen any one not treated with respect’’. Staff were seen talking to service users and service users appeared comfortable and relaxed. Fairfield Residential Care Home DS0000063831.V324451.R01.S.doc Version 5.2 Page 17 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): 16,18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users are not protected by policies, practices and procedure of the service. EVIDENCE: Since the last inspection there has been an allegation made pertaining to two members of staff. Both staff have been suspended pending investigation and this will be reported once concluded. Records pertaining to complaints were seen. There have been no complaints since the last inspection. There is no structure for complaints, so staff would be unsure of what to record and may miss information that is important. The home has a complaints procedure but no format to record complaints and action to take in the event of a complaint being made. Lots of bits of paper are used to record information this has no structure and one complaint received at the last inspection was confusing as to the outcome and whether it had been investigated. The provider said she and the acting manager were developing a format that can be used in the event of any concerns or complaints. This will be assessed at the next inspection. Not all staff has received training in adult protection and this remains out standing from the last inspection. Fairfield Residential Care Home DS0000063831.V324451.R01.S.doc Version 5.2 Page 18 There were no risk assessments available for inspection, although the inspector did see three risk assessments during the last visit that required updating. The acting manager and provider must ensure risk assessments are available for staff to ensure safe working practices. Recruitment records for the 3 new starters were adequate. The gaps in employment history need to be completed to ensure the employee has the relevant experience. A full induction must be completed for all staff and be in line with skills for care. At present a three-day induction is completed that shows very little information of what the staff have covered. The staff competence is not assessed at the end of the induction period to establish competence. This is particularly important if the staff member has not worked in the care profession before. Fairfield Residential Care Home DS0000063831.V324451.R01.S.doc Version 5.2 Page 19 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): 19,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a homely, comfortable environment. There were appropriate aids and adaptation available for service users use and this ensures that their comfort and independence are maintained. EVIDENCE: The home was clean and service users said they were comfortable in their rooms. There are a number of aids and adaptation for service user to use if they need them such as toilet seat raiser, wheel chairs, and knife and forks, dishes, and suitable equipment for assisting service users who have a disability when eating. Assisted bathing facilities are available for service users if they need support from staff. Fairfield Residential Care Home DS0000063831.V324451.R01.S.doc Version 5.2 Page 20 Bedrooms are of single occupancy, are individual and natural ventilated. All windows are fitted with restrictors for extra protection. All bedrooms seen were very personalised and accommodated furniture of service users choice. Bedroom doors were wedged open. If there were a fire this would offer service users no protection. This was discussed with the acting manager and provider during the visit. No bedroom doors have handles and are accessible by pushing the door open this could mean privacy is not assured. Discussions must be held with service users to ensure they are able to use this facility or would prefer a handle on their bedroom doors. It must be identified in their care plans that this is suitable to their needs. The maintenance records were seen that gave details of the repairs completed and repairs that had been identified. Repairs identified during the visit must be completed and include: A fly screen must be purchased to ensure infection control when kitchen windows are open. The kitchen work surface that was burnt must be replaced. Removal of mattress and chairs in corridors must be appropriately stored to ensure service users are not placed at risk from trips and falls. The rusty shower chair must be replaced to prevent cross infection. The extractor over the cooker must be cleaned. The lock on the toilet door needs repair to ensure service users dignity All communal towels must be removed from communal bathroom and showers rooms to prevent cross infection. Pedal bins must be used in the kitchen to prevent cross infection. Paper towels and liquid soap must be made available in communal areas and the sluice room to prevent cross infection. Fairfield Residential Care Home DS0000063831.V324451.R01.S.doc Version 5.2 Page 21 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): 28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Recruitment practise are robust to ensure the safety of service users. Training records do not demonstrate staff have the relevant skills and competence to ensure the safety of service users EVIDENCE: Rotas showed adequate staffing levels were maintained and is reflective of the needs of the service users. Staff files sampled showed improvements in recruitment however there were gaps in history of employment for those files sampled. This is not a robust recruitment procedure, as staff records do not demonstrate previous experience that would enable the provider to ensure the right personnel were recruited. To ensure robust recruitment practices the provider must ensure all the necessary precautions to protect service user are completed. Training records sampled showed not all staff have received training in adult protection and manual handling and this may place service users at risk. The acting manager said all staff has completed training in manual handing and she was waiting for the certificates to be forwarded on to her from the training organisation she had used. Fairfield Residential Care Home DS0000063831.V324451.R01.S.doc Version 5.2 Page 22 The majority of staff has completed NVQ level 2 in care to ensure they have the relevant experience to meet service users needs. There are 21 staff employed and nineteen have completed this qualification. Records showed not all staff have completed all mandatory training such as first aid, health and safety, control of substance hazards to health, adult protection, infection control and food hygiene. The home has 5 service users with a recent diagnosis of dementia that have lived at the home for a number of years. Based on this information the provider must ensure staff receive training in dementia, as in not doing so this may result may result in staff being inexperienced to meet service users needs. Care plan must show how the current service needs are being met. The provider must ensure that no service users are admitted to the home who has this prognosis as the service is not registered to admit service users who has a diagnosis of dementia Supervision is not completed regular this may lead to bad practise, performance and staff feeling devalued. The acting manager said staff are completing distance learning for health and safety and infection control but have not yet completed all the Modules. The acting manager said she was looking at all staff training at supervision, as of yet she had completed two or three supervision sessions with staff and was working towards completing all by the end of February 2007. Fairfield Residential Care Home DS0000063831.V324451.R01.S.doc Version 5.2 Page 23 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): 33 35 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is a lack of clear management and leadership with unclear roles and responsibilities. The change in management of the service has resulted in service users not receiving a consistent service. EVIDENCE: The acting manager was most recently working as a trainer in a residential home for the elderly. She has not worked for the last two years. The acting manger is keen to make improvements for the benefit of service users. She displayed a transparent approach to residents, visitors and staff. A number of acting managers have been employed but have not remained. This has been an unsettling time for both staff and service users. The provider Fairfield Residential Care Home DS0000063831.V324451.R01.S.doc Version 5.2 Page 24 must ensure a suitability-qualified manager is appointed who can demonstrate leadership and is able to discharge his/her responsibility. The manager must, having regards to the size of the home, the statement of purpose and the number and needs of service users, have the qualifications, skills and experiences necessary for managing the home. The acting manger does not have at least two years experience at a senior management capacity in managing of a relevant care setting within the past five years as required by the National Minimum Standards as she has not worked for the past two years. The acting manager does not hold NVQ level 4 in management and care and has not identified she hold the equivalent as required by the National Minimum standards. The acting manger is seeking guidance from a college as to what qualifications she will need to complete as she holds a number of other qualifications that may be relevant to her application to apply for registration. The financial records were sampled pertaining to service user monies that the home holds on behalf of service users. The acting manger said they do not deal with service users finance. The money held is given to them for safe keeping by relative and is of a small amount just to ensure if service users want anything such as their hair done or toiletries they have the money available. All records seen were good with full details of expenditure and balance transfers. All receipt are kept and numbered for adequate auditing purposes. Staff supervision has not been completed for all staff, however given the time the acting manager has been in post she cannot be held responsible. Health and safety records were sampled and in general were satisfactory. Bedroom door must not be wedge open, as this would place service users at considerable risk in the event of a fire. The constant changes to the management structure do not ensure the home is run in the best interest of service users. Service user said in general said they were comfortable and felt the staff were kind and respected their wishes, however the provider must ensure that service users views are incorporated into a quality assurance monitoring system and reflect the change made if required. Fire records were satisfactory with regular testing of fire equipment and fire safety awareness training for staff had been completed. Servicing of the fire safety system had been completed and an external servicing contractor had checked all fire equipment. General repairs and replacement of the lock on the toilet door identified during the visit must be repaired. The shower chair that was rusty must be replaced. Fairfield Residential Care Home DS0000063831.V324451.R01.S.doc Version 5.2 Page 25 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 X X 1 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 X X 2 Fairfield Residential Care Home DS0000063831.V324451.R01.S.doc Version 5.2 Page 26 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 The provider must complete an adequate pre assessment for all service users before being admitted to the home. All service users must have their needs regularly assessed and care plans written and implemented each month to reflect their dynamic needs. Outstanding from the last inspection. 3 OP8 14(1a)(2) Sch3(3m) The registered person promotes and maintains service users’ health and ensures access to health care services to meet assessed needs. Outstanding from the last inspection. 4 OP7 15(2,a,b) All care plans must be kept under review and re evaluated when service user needs change. The care plan must include all related health care needs including, bathing, washing, DS0000063831.V324451.R01.S.doc Timescale for action 28/02/07 2 OP7 15(2,b,c) 28/02/07 28/02/07 28/02/07 5 OP10 12(4)(a) 28/02/07 Fairfield Residential Care Home Version 5.2 Page 27 6 OP12 16(2)(m, n) using the toilet or commode, consultation with, and examination by, health and social care professionals, entering bedrooms, toilets and bathrooms, to ensure all staff maintain service users dignity and service users are treated with respect. The routines of daily living and activities made available are flexible and varied to suit service users’ expectations, preferences and capacities. The registered person conducts the home so as to maximise service users’ capacity to exercise personal autonomy and choice. The registered person ensures that there is a simple, clear and accessible complaints procedure that includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. All staff must receive training as to the work they are to perform including any specialist training in dementia. All staff must be trained manual handling and confirmation available for inspection. All staff must complete training in adult protection Outstanding from the last inspection. 28/02/07 7 OP14 16(2)(m, n) 28/02/07 8 OP16 22(3) 28/02/07 9 OP18 13(4) (c) 28/02/07 10 OP18 13(4) (c) 28/02/07 11 OP18 13(4)(c) 28/02/07 12 OP26 23 (a) The maintenance records were seen that gave details of repairs completed. Repairs identified during the inspection must be DS0000063831.V324451.R01.S.doc 28/02/07 Fairfield Residential Care Home Version 5.2 Page 28 13 OP27 18(1)(a) 14 OP29 13(4)(c) 15 OP31 8(1) 16 OP33 24(1a,b) (2)(3) completed and include, • A fly screen must be purchased. • The kitchen work surface that is burnt must be replaced. • The removal of the mattress in the corridor must be stored appropriately • The shower chair that is rusty must be replaced. • The extractor fan in the kitchen must be cleaned. • The lock on the toilet door must be repaired. • All communal towels must be removed in all communal bathroom and shower rooms. • Pedal bins must be purchased to assist with infection control. • Paper towels and liquid soap must be available in the sluice room. Staffing levels and experienced staff must be on duty at all times staff must be suitable qualified and have completed the relevant training pertaining to their work. The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. The manager must be qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. An application form for registration with the CSCI must be submitted to the Commission. Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to DS0000063831.V324451.R01.S.doc 28/02/07 28/02/07 28/02/07 28/02/07 Fairfield Residential Care Home Version 5.2 Page 29 17 OP38 13 (4) (c) measure success in meeting the aims, objectives and the statement of purpose of the home. All wedges must be removed from doors that assist to contain a fire. 28/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Fairfield Residential Care Home DS0000063831.V324451.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Fairfield Residential Care Home DS0000063831.V324451.R01.S.doc Version 5.2 Page 31 - 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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