Inspection on 28/07/06 for Fairfield Residential Care Home

This inspection was carried out on 28th July 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 18/12/06

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 Unannounced Inspection 28th July 2006 09:00 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 Fairfield Residential Care Home DS0000063831.V305167.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.V305167.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.V305167.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. 15th November 2005 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 disability. Handrails are also provided. Limited parking facilities are available at the front of the building, however on-road parking is readily available outside the home. The fee payable range from £314.00 to £355.00 per week. Fairfield Residential Care Home DS0000063831.V305167.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors completed the fieldwork over a one-day period. One inspector spent the complete visit with service users and any family members that were present. Information was obtained before the fieldwork and included: A pre-inspection questionnaire, comment cards and information that had been received at the Commission such as history of regulatory activities. During the visit, records pertaining to resident’s healthcare, infection control, food stocks, recruitment were looked at, and a brief tour of the building including resident’s bedrooms was undertaken. The inspectors interviewed a number of staff and residents. Since the last inspection, the Providers have appointed a manager. There have been two complaints and an Adult Protection since the last key inspection. What the service does well: What has improved since the last inspection? Clear efforts have been made to meet requirements set at the time of the last inspection. Residents’ assessments and statements of need have also been updated, and this should now inform future care planning more appropriately. Work has been done to develop care plans and risk assessments, and this should be expanded and developed further. Efforts have also been made to increase the range of activity opportunities available, and this should be further encouraged and continued. Fairfield Residential Care Home DS0000063831.V305167.R01.S.doc Version 5.2 Page 6 The Placing Authority has completed care reviews for all the service users currently accommodated. This will enhance the development of updating all information pertaining to service user needs, goals and aspirations. 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. Fairfield Residential Care Home DS0000063831.V305167.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fairfield Residential Care Home DS0000063831.V305167.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available in the form of service user guide and statement of purpose. A trial visit is recommended. An assessment is completed before admission with full details of the needs of the service users. The service is offered only after a full assessment has been completed to ensure service users’ needs can be met. EVIDENCE: The manager advised that before a placement is offered a comprehensive preadmission procedure will be carried out to ensure that the home is able to meet the individual’s needs. The assessment paperwork of the home has been changed recently. Although these changes have not had time to fully become established, they represent an improvement on previous paperwork and should make it easier for information to be transferred into individual plans of care. Fairfield Residential Care Home DS0000063831.V305167.R01.S.doc Version 5.2 Page 9 Previously the home did ensure that potential residents were assessed before admission. Prospective service users had the opportunity to visit the home where they could mingle with other service users and have lunch. This is an area where the manager said he was up dating records to ensure staff knew the needs of prospective service users could be met. As part of the assessments, a trial visit would be offered with an overnight stay if required. The manager identified it was important to ensure the staff team had the skills necessary to meet the individual needs. Intermediate care is not provided within this service. The Statement of Purpose contains information about the service, aims, objectives and what the service users can expect. The Statement of Purpose and Service User Guide are given to all service users before admission to enable them to make a judgement to use the service. Fairfield Residential Care Home DS0000063831.V305167.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Placing Authority has completed reviews on all service users living in the home, and includes risk assessment, health care and care plans. Therefore, it would not be accurate to assess the input they have had against previous records at the home. The home must demonstrate how they will use this information. This will be assessed at the next inspection. Medication records are not robust to ensure errors are identified and dealt with in accordance with the homes polices and procedures. Service users confirmed they were treated with respect and are frequently asked by the owners if they are ok. EVIDENCE: As part of the complaint received before the inspection and the subsequent Adult Protection Investigation, all care plans have been reviewed by the Placing Authority; these include risk assessments and healthcare records. Fairfield Residential Care Home DS0000063831.V305167.R01.S.doc Version 5.2 Page 11 The manager has now to record the current needs of service users in a care plan that must be monitored and reviewed. Health care records now contain updated information that the manager must ensure is kept under review. Previously, information contained in care plans did not demonstrate the health and welfare of service users were being maintained. The lack of information contained in healthcare records, risk assessments and care plans placed service users at risk. Records such as accident records, medication records and risk assessments were not reviewed. Records contained information from a number of years ago and were not relevant to the current needs of service user. This information was confusing and conflicting with the current needs of service users. Further progress will be assessed at the next inspection. Current records do not demonstrate the Provider’s input into the assessments completed or records updated. To assess these records would mean assessing the Placing Authority’s input which would not give an accurate picture of the Provider’s ability to maintain service users’ health and welfare. All care plans must be kept under review and regularly updated. Care plans do not contain information relating to individual needs, cultural needs and preferences. Service users were well presented. Information in daily records showed regular visit to the dentist and chiropodist. The hairdresser visits once a fortnight which service users said they enjoy. The management of medication administration within the home was determined to be unsatisfactory. When the inspector completed an audit of PRN (as required) medication a number of tablets were missing. The Provider said she had checked the medication records the day before, however she had not recorded this audit. It is recommended as good practise all audits are recorded. Hand written entries on the MAR charts (medication administration record) did not have two signatures; this had been a requirement of the Pharmacy Inspector on a previous visit. Medication had not been carried forward on the MAR at the end of the month; this caused discrepancy in the amount of medication held in the home. All unused medications are returned to the pharmacy after 28 days or it is recommended appropriately documented on the MAR. One inspector spent the day with service users; positive comments were received about the care provided and the support given by staff. One service user said, “Staff always ask you if you are ok and is there any thing you want. They are always respectful to you and if you have any problem you can speak with Mr Mayariya the owner who asks on a daily basis if you’re ok. If you ask for anything staff normally get it for you, if not at least they tell you why not which is good, you’re not just left wondering’’. Fairfield Residential Care Home DS0000063831.V305167.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Preference and expectation of service users are not recorded in sufficient detail to establish that the cultural needs and religion needs of service user are maintained. Residents are supported to keep in touch with their families and friends. Activities that meet the service users’ needs and wishes are not delivered to ensure their recreational needs are met. Staff respect residents’ rights and encourage them to do things for themselves. Menus showed a wholesome meal is provided each day with a choice. Food stocks were adequate and meals well presented. EVIDENCE: Activities are not part of every day life and service users spoken to said there was not much going on. The manager agreed this is an area that requires attention. One service user said, “Sometimes you just sit here all day and do nothing. Staff are generally very good they sit and talk to you’’. One service user said, “I used to go to church every Sunday but I don’t go now, but to be fair I have Fairfield Residential Care Home DS0000063831.V305167.R01.S.doc Version 5.2 Page 13 not asked about going’’. The manager must ensure all cultures and religious beliefs are taken into account and action taken to ensure this information is recorded on individual plans of care, and service users supported to undertake activities they have chosen and like. Staff said the routine in the home is flexible. However, the inspectors did not find evidence to support this. There were set times for meals. Records showed bath and showers were completed in the morning. There were no entries in those files sampled to show if service users were given the option or choice of having a bath or shower before going to bed. Several service users get up as early as 6am, information was not seen to indicate this was their preference. The manager must ensure all religious and cultural needs are met along with any previous activities the service users participated in before moving into the home that they wish to continue. Regular meetings must take place to ensure the views of service users are taken into consideration. There are no restrictions on visiting and relatives regularly take residents out. One relative said, “Staff are helpful and I have no concerns about the care provided’’. “In fact her relative had come along way since moving into the home’’. There are no records to show how residents exercise choice and control over their lives. Daily records consist of entries such, as slept well, eaten well, no concerns, appears fine. While the menus were not sampled in detail, the inspectors went into the main kitchen to view the preparation areas where food was prepared and served Service users satisfaction surveys and suggestions were not found to be part of the menu planning. At the previous inspection, food stock was limited and contained many home brands. The cook told the inspectors shopping was being done that day and normally there is an adequate stock available. Staff confirmed residents were able to have second helpings if they chose. Residents spoke too confirmed there was always plenty for them to eat. Service users said the food was well presented and always hot. One service user said she was a very funny eater, however the food presented satisfied her. Conversation with residents established they were generally happy, the food was good and they could have as much as they liked. There was also a choice of what they had each day. There were instructions displayed in the kitchen for residents who were diabetic, or had a special diet. The kitchen was clean and a new fridge and freezer had been purchased since the last inspection. This was to assist in the area of maintaining infection control as the freezer was originally situated in the laundry. Sealing around the sink had been completed. During the last inspection, water had leaked under the work surface leaving a distilled water odour in the kitchen. Fairfield Residential Care Home DS0000063831.V305167.R01.S.doc Version 5.2 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 the following standard(s): 16, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Concerns, complaints are not fully investigated this place service users at risk from abuse. EVIDENCE: The Commission For Social Care Inspection had received a complaint. The complaint has been referred to the Adult Protection Team who will complete an investigation into the allegation made. A strategy meeting was held on 11 July 2006 with CSCI, the Adult Protection Team, Contracts, and Police. A further meeting is scheduled for 25 August 2006 with a view to conclusion. When the investigation has been completed, a further letter will be sent to the Providers detailing the findings of the investigation and the action they must take. A subsequent complaint was made before the inspection. The complaint alleged: • The Providers not taking the views of service users into consideration. Service users are moved from room to room without the consent of the service user, family or a representative. When sampling records pertaining to the service users concerned evidence was seen to show full, consultation had taken place with the service users family Fairfield Residential Care Home DS0000063831.V305167.R01.S.doc Version 5.2 Page 15 and a letter confirming the outcome of the review and the consultation from the service user relative. • Appropriate washing cycle not being used for infection control. The manager said, “I instruct staff to use the appropriate washing cycle when necessary’’. “There are no restrictions on what cycle to use I am at a loss as to where this information has come from’’. Through observation, the home did not have all the equipment for ensuring infection control such as red bags for soiled items during the last visit on the 7 July 2006. Since that time a supply has been purchased and infection control is now maintained adequately. • Service users choice of food. During the visit, one inspector spent the whole visit with the service users. He spoke with service users and family members. Positive feedback was given about the food, and the quality and quantity. Service users said they could have what they wanted, when they wanted. The presentation of food was good and they could have seconds if they so wished. • • The poor attitude of manager. The poor attitude of Provider. Service users paid compliments to the Providers and the manager and said they were supportive and listened. One service user said, “ Staff are friendly we all get on, there is the odd disagreement but what do you expect, we are not all the same, so there will be disagreement it’s nature’’. • Service users risk of being hit by other service users. There was no documented evidence to suggest service users hit other service users. • A service user falling out of bed at night. It is known that one service user falls out of bed at night. This service users’ file and daily records showed there had been ongoing consultations with the GP, falls clinic and family. The appropriate measures had been taken, such as close monitoring and regular checks being made, as previously advised by the falls clinic had also been made in the service user bedroom. Records showed monitoring takes place and preventive measures are taken. Records sampled pertaining to concerns /complaints showed they are not fully investigated. A complaint had been received by Social Services on 12 May 2006, raising concerns about a member of staffs conduct in the home towards a service Fairfield Residential Care Home DS0000063831.V305167.R01.S.doc Version 5.2 Page 16 user. Social Services referred the complaint back to the Provider to investigate. Written evidence pertaining to the investigation was poor, no formal investigation was completed. General discussion with staff had taken place with no written evidence to show how the Provider had come to the conclusion as inconclusive. As part of the follow up to the complaint, the Provider was to monitor and observe more closely the member of staff and use supervision constructively with appropriate reference to those concerns identified if required. Fairfield Residential Care Home DS0000063831.V305167.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of décor within the home is good. Current maintenance programmes ensure there is a provision for improvement. The environment at present responds to the needs of the current service users and therefore provide a safe, homely and comfortable place to live. The home is clean and comprises of pleasant surroundings. EVIDENCE: In general, Fairfield is well maintained and has been decorated to a good standard. Service users were comfortable and had the benefit of two lounge areas. Attached to the rear of the property is a conservatory that service users can use if they wish. Fairfield Residential Care Home DS0000063831.V305167.R01.S.doc Version 5.2 Page 18 Adaptations included hoists, assisted bathing, a call system in all bedrooms, bathrooms and toilets as well as the small lounge. Staff were observed entering the main lounge regularly to respond to any requests and ensure that residents comfort was being maintained. Bedrooms were decorated and furnished to an adequate standard in line with the service user wishes. Service users spoken to said they had been consulted about what furniture they wanted in their rooms. Bedrooms were personalised to the degree preferred by the service user and included many personal possessions. Those service users who preferred had their own telephones. Fairfield Residential Care Home DS0000063831.V305167.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are adequate and meet the service users’ needs. The Provider cannot demonstrate service users are in safe hands at all times. Recruitment practice places service users at risk. Adequate information is not obtained before employment commences. The Provider does not demonstrate staff have received adequate training in mandatory areas that place residents at risk. EVIDENCE: Records sampled pertaining to recruitment showed there was inconsistency in practise relating to employment. Three files were sampled. One contained all relevant information. A further two files contained very little information. One had no references, no proof of identification, no medical clearance, no induction and no evidence to show they were qualified to undertake the work they were to perform. The other file sampled, showed no induction, no Criminal Records Bureau check, no identification, no application form and again no evidence to show what training they had completed. Gaps in employment history did not have an explanation. There were no risk assessments in place where a member of staff was found to have had a criminal conviction previously. Fairfield Residential Care Home DS0000063831.V305167.R01.S.doc Version 5.2 Page 20 The Provider must ensure all relevant checks are completed before the commencement of employment for all staff. At the time of the visit, rotas showed adequate staffing levels were maintained. Depending of the needs of the service users, the manager said he would assess when required. As good practise, he is advised to maintain records of his assessment. Records pertaining to training were sampled. Training certificates were not available to show the person was adequately qualified for the work they were to perform. Staff spoken to said there were certain areas of training that was required, such as Adult Protection, Fire Safety, Manual Handling, Food Hygiene, and NVQ Level 2 or above. Out of the three staff files sampled, only one had copies of certificates to demonstrate the training they had received. The Provider must ensure all those employed receive relevant training to the work they perform. The action plan received said CRB and training records are kept separately, these however were not shown to the inspector on the day of the visit and will be assessed at the next visit. Fairfield Residential Care Home DS0000063831.V305167.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Manager is experienced, and has strong leadership skills. Positive comments were made about the management of the home. Service users finances are safeguarded by policies and procedures, and regular audits. Supervision is not carried out on a regular basis. This puts the service users at potential risk. The health and welfare of service user are not protected and significant improvement in maintaining adequate and relevant information is required to safeguard service user from harm. Fairfield Residential Care Home DS0000063831.V305167.R01.S.doc Version 5.2 Page 22 EVIDENCE: The manager had recently commenced employment; the home has been without a manager for a short period of time. The manager demonstrated his commitment to improving this service. There have been two complaints and one Adult Protection referral since his appointment that has no relevance to his performance. The manager said he had concentrated on areas that required improvement. He had so much to sort out that he needed to ensure the needs of resident were being met. It was his intention to bring the home up to the required standard, and this would take a little time. It was evident the manager is an experienced manager and demonstrated his knowledge and experience. The Provider must ensure the manager has adequate support to be able to perform his management responsibilities. Staff files sampled showed no supervision had been completed for some time. The manager had commenced supervision with all staff. Staff spoke with said the manager had made positive changes and supervision was one of the changes the staff appreciated. This would enable the personal development of staff, oversight of staff practice and values, and identified what training was required. At present the home, hold monies for some service users where money is deposited by a relative for things such as hairdressing, and personal items. Records sampled showed all transactions are receipted. When money is handed to the home by a relative a receipt is not always given. All receipts must be included in a regular audit. Monies handed into the home must be supported with a receipt. As good practise, it is advised to complete an audit on a regular basis. Records pertaining to health and safety, such as fire safety records, electrical wiring and servicing of lifting equipment had been completed. Fire records, checks, maintenance and drills were in place. Training in fire prevention and procedures was scheduled. Records pertaining to the health and welfare of service users in respect of care plans, risk assessment and care plan are now in place. These had been completed by the Placing Authority as part of the investigation under Adult Protection. All care plans had been reviewed by the Placing Authority. This information must be transferred into individual plans of care to protect service user health and welfare. All documentation must be reviewed on a regular basis. Fairfield Residential Care Home DS0000063831.V305167.R01.S.doc Version 5.2 Page 23 The manager was at the time of the visit implementing the information from reviews in to the care plans. Fairfield Residential Care Home DS0000063831.V305167.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 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 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 2 X 2 Fairfield Residential Care Home DS0000063831.V305167.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP7 OP7 Regulation 15(2,a,b) 15(2,b,c) Requirement All care plans must be kept under review, monitored and up dated. 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. 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. The registered person must ensure that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. DS0000063831.V305167.R01.S.doc Timescale for action 01/09/06 01/10/06 3 OP8 14(1a)(2) Sch3(3m) 01/10/06 4 OP9 13(2) 01/10/06 Fairfield Residential Care Home Version 5.2 Page 26 5 OP12 16(2) (m, n) 6 OP14 16(2) (m, n) 7 OP16 22(3) 8 OP18 13(4)(c) 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. The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self-harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. Outstanding from the last inspection. A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. Outstanding from the last inspection. The registered person must operate a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. DS0000063831.V305167.R01.S.doc 01/10/06 01/10/06 01/10/06 01/10/06 10 OP28 19(5)(b) 01/10/06 11 OP29 13(4) (c) Sch2 01/10/06 Fairfield Residential Care Home Version 5.2 Page 27 12 OP30 18(1)(i) 13 OP31 8(1) 14 OP33 24(1a,b) (2)(3) The registered person must ensure that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs 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 must be installed and must be based on the views of the service users in the home. Outstanding from the last Inspection. The registered person must ensure that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. People depositing money with the home for service users must be provided with a receipt, these must be maintained as part of the auditing process. The registered person must ensure so far as is reasonably practicable the health, safety and welfare of service users and staff. 01/10/06 01/12/06 01/10/06 15 OP35 16(2)(i) 13(4)(c) 01/10/06 16 OP38 13(4)(c) 01/10/06 Fairfield Residential Care Home DS0000063831.V305167.R01.S.doc Version 5.2 Page 28 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.V305167.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Fairfield Residential Care Home DS0000063831.V305167.R01.S.doc Version 5.2 Page 30 - 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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