Inspection on 16/09/09 for Fairfield Residential Ltd - Springfields

This inspection was carried out on 16th September 2009.

CQC has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CQC judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

Extracts from inspection reports are licensed from CQC, this page was updated on 18/02/2010.

Key inspection report CARE HOME ADULTS 18-65 Fairfield Residential Ltd - Springfields Springfield 57 Warburton Lane Partington Manchester M31 4NL Lead Inspector Adele Berriman Key Unannounced Inspection 16th September 2009 11:30 Fairfield Residential Ltd - Springfields DS0000073258.V377678.R01.S.doc Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Fairfield Residential Ltd - Springfields DS0000073258.V377678.R01.S.doc Version 5.3 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Fairfield Residential Ltd - Springfields DS0000073258.V377678.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service Fairfield Residential Ltd - Springfields Address Springfield 57 Warburton Lane Partington Manchester M31 4NL 0161 776 2827 0161 776 2827 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) Fairfield Residential Limited Mr Josephat Mkwakwami Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Fairfield Residential Ltd - Springfields DS0000073258.V377678.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only- Code PC To people of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning disability- Code LD The maximum number of people who can be accommodated is: 4 Date of last inspection This is the first inspection of this newly registered service. Brief Description of the Service: Springfield is a large house providing accommodation for up to four people with a learning disability. The home is owned by Fairfield Residential Ltd and is set in its own grounds with parking facilities to the side of the building. The home is situated in the area of Partington in Trafford and is close to local shops and a bus route. The cost of the service is calculated for each individual. Fairfield Residential Ltd - Springfields DS0000073258.V377678.R01.S.doc Version 5.3 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The overall quality rating for this service is 1 star. This means that the people who use the service experience adequate quality outcomes. This was the first key inspection of this newly registered service in which all the key standards were assessed. As part of this inspection we carried out an unannounced visit to the service on the 16th September 2009. Our visited lasted between 11.30am and 6.15pm. During our visit we spent time talking to a person living at Springfield who also showed us around the home and its garden area. We also spoke to current registered manager and the newly recruited manager. We looked at a selection of records, policies and procedures during our visit, these included care plans, medication records and staff files. At the time of our visit two people were in residence at the home and two staff members were on duty. Prior to our visit, the registered manager had completed an Annual Quality Assurance Assessment (AQAA). This document gave them the opportunity to tell us what they felt they did well, what they thought they could improve on and their plans for improvement over the next 12 months. The AQAA told us some of the information that we asked for and also contained some numerical information. What the service does well: They ensure that people’s needs are fully assessed prior to them moving into the home. This helps ensure that the home has the facilities to meet all of the person’s needs and wishes. The management demonstrated a good awareness of the local area arrangements for safeguarding procedures. Individual care plans contained detailed information about the person. A complaints procedure was available in both pictorial and large print for people. The home provided a domestic, homely environment for people to live. Fairfield Residential Ltd - Springfields DS0000073258.V377678.R01.S.doc Version 5.3 Page 6 A speech and language therapist and a lifestyles personal tutor were employed to support people with their communication and daily living skills. Policies and procedures were in place to protect the health, safety and wellbeing of people. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Fairfield Residential Ltd - Springfields DS0000073258.V377678.R01.S.doc Version 5.3 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fairfield Residential Ltd - Springfields DS0000073258.V377678.R01.S.doc Version 5.3 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 2 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have their needs assessed before they move into the home Springfield so that they know that their needs can be met. EVIDENCE: The manager told us that once a person is referred to the Springfield they are invited to visit the home to see the services offered. Prior to a person moving into the home a full assessment of the individuals’ needs and wishes is undertaken. The purpose of this assessment was to ensure that the home has the facilities and knowledge to meet the person’s needs. We saw that a set format was available to record the outcomes of people’s needs assessments. The format gave the opportunity to record people’s needs and wishes in their day to day life. They told us that information from the person’s social worker and any other healthcare professionals involved in the person’s care and treatment was also included in the assessment process. Fairfield Residential Ltd - Springfields DS0000073258.V377678.R01.S.doc Version 5.3 Page 9 We looked at the pre admission assessments of the two people who were resident at the home. We saw that the assessments were informative and contained detailed information. Following the pre admission assessment process the service develops a transition plan with the person and other healthcare professionals involved in their care and support of the individual. We saw a transition plan on one person’s personal file. The plan was informative and showed that the person’s transition into their new home was regularly reviewed. They told us in their AQAA that prior to a person being admitted to Springfield, staff from the home and staff from the person’s current address would work together to help ensure a smooth transition for the individual into their new home. Fairfield Residential Ltd - Springfields DS0000073258.V377678.R01.S.doc Version 5.3 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s care needs were identified in their care plans and were being met by the staff team. EVIDENCE: We saw that each person had their own individual file that contained personal information and their care plan. We looked at the care plans of two people during our visit. We saw that the files included specific information to people’s day to day needs in relation to their health and emotional wellbeing, freedom from discrimination and harassment, choice and control, cultural and religious needs, dignity and respect, sensory and communication needs. We saw that the information contained in the care plans was detailed and informative about how to meet the individual’s needs and wishes. For example Fairfield Residential Ltd - Springfields DS0000073258.V377678.R01.S.doc Version 5.3 Page 11 where areas of needs were identified information was available for what action was needed to meet the need. The two care plans that we looked at were written in different formats. We saw that care plans considered people achieving ‘economic wellbeing’ and ‘making a positive contribution’, these terms could confuse people. To help ensure that people understand the contents of the care plans plain English should be used where possible. We saw that people’s choices and decision making had been considered in the care plans. For example we saw information on one care plan about the individuals’ preferences when getting up in a morning and on going to bed. Another care plan clearly stated people’s choices regarding the situation in which they wished to have their meals. Daily records formed part of people’s care plans. We looked at a selection of these records and saw that they were brief and task orientated. We saw records that stated “watching DVD in his room” and “had his bath.” The entries did not record whether the person had enjoyed the activity or interaction. To help ensure that people receive the support they require, a detailed account of the person’s day should be recorded. During our visit we observed staff respecting people’s decisions about choice of activity, for example we observed staff asking people whether they wished to go to the local shops for grocery shopping. They told us that they had a key worker system in place to support people with their care planning. We saw that individual risk assessments formed part of people’s care plans. A set format was available to record identified risks that considered the source of the risk, the level of risk, who may be harmed, the person responsible and actions needed in prevention of the risk. We saw several risk assessments that had been completed, these included, for when a person challenged the service, inappropriate behaviour and when a person was being transported in a vehicle. Fairfield Residential Ltd - Springfields DS0000073258.V377678.R01.S.doc Version 5.3 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 12,13,15,16 & 17 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A planned activities programme provided people with a structure to their day. EVIDENCE: A resident of Springfield showed us the homes weekly activities planner. The activities included going grocery shopping, cookery, gardening, swimming class, visiting the library, visiting the park, going for a walk and watching movies. They told us that they liked making gingerbread biscuits and chocolate cake. A tutor for Independent Life Skills visited for two afternoons a week. In addition, a speech and language therapist was employed on a part time basis to assist people with their communication, this included the use of a non verbal communication system. Fairfield Residential Ltd - Springfields DS0000073258.V377678.R01.S.doc Version 5.3 Page 13 They told us that they planned to increase the hours that both the speech and language therapist and the tutor over the next 12 months so that they were available to offer specialist support. They told us that they had initiated an integrated art club where people from Springfield can benefit through joint activities with other people from within the local community. One of the people who lived at the home showed us around the dining room. People had the option to eat their meals in a dining room which was furnished with a large table and chairs or in their own room. They showed us the kitchen and where their food was stored in the fridge, freezer and cupboards. He told us that he liked the food at Springfield. They told us that regular trips were made to purchase groceries. One person followed a Halal diet. They told us that in order to meet the person’s dietary needs and wishes meat was purchased from a Halal butcher. Fairfield Residential Ltd - Springfields DS0000073258.V377678.R01.S.doc Version 5.3 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Medication practices and procedures were not clearly defined and therefore did not demonstrate people’s medication was well managed. EVIDENCE: Each person was registered with their own GP. In addition, they told us in their AQAA that they have a contract with a team of private doctors that provide 24 hour advice, training and guidance for staff. We saw that health plans had been developed for people. One care plan contained information about how a person’s medication had been altered over the past few months to meet their needs. We saw no evidence in people’s care plan records of when medical appointments or GP visits had taken place. To ensure that information is available at all times a record of all GP, hospital visits should be maintained in the person’s care plan. Fairfield Residential Ltd - Springfields DS0000073258.V377678.R01.S.doc Version 5.3 Page 15 We looked at their medication policy. We saw that the policy did not include information about the appropriate management of controlled drugs or medication prescribed on an as and when required basis (PRN). The medication policies must contain information about the safe management, storage and administration of controlled drugs. In addition, detailed guidance must be available for staff when administering as and when required medication (PRN). This will help ensure that medication is managed and recorded appropriately. We saw that a record sheet was in use to record medication administered at the home. We looked at several medication records and saw that they did not give sufficient information for a clear audit trail of medication received, dispensed and returned to the pharmacist to take place. To help ensure that medication is managed appropriately clear records must be maintained in the home of all medication received, administered and leaving the premises. We saw that a medication record was available for the administration of pain relief medication on an as and when required basis. The record contained information about two people, one of which was a previous resident and one person who had lived at the home prior to it being registered as a care home for adults. To ensure that medication is managed appropriately, clear individual records of all medication administered must be maintained in the home at all times. A cupboard was available for the storage of medication. We saw that the cupboard was small in size and the manager told us that they were unable to store medication dispensed in a monitored dosage system. A monitored dosage system is when tablets are dispensed in a packet which contains people’s daily doses of medication. To ensure that safe storage of medication advice must be sought from the Royal Pharmaceutical Society of Great Britain about the safe handling and storage of medication. Fairfield Residential Ltd - Springfields DS0000073258.V377678.R01.S.doc Version 5.3 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. To help protect people more detailed records are required when physical interventions take place. EVIDENCE: We saw that the service had a complaints procedure. It was available in large written text and in pictorial form. We saw that the procedure informed people of who they needed to contact if they had a concern or a complaint. We spoke to a person who lived at the home. He told us that if he was not happy he would tell a member of staff. He told us that he felt safe at the home. They told us that they had not received any complaints about the service since the home was registered. We saw that policies and procedures were in place to protect people. We saw that they had copies of Trafford and Stockport Social Services Safeguarding procedures. The manager demonstrated a good awareness of local safeguarding procedures during our visit. We saw that they had a policy on the use of physical intervention/restraint. They told us that they use the Team Teach approach to physical intervention. Fairfield Residential Ltd - Springfields DS0000073258.V377678.R01.S.doc Version 5.3 Page 17 They told us that this was approved by Concept in Education and that it was accredited for the British Institute of Learning Disabilities (BILD). We saw that they had an incident form that was completed by staff when an incident had occurred that resulted in physical intervention. We saw two incident forms that had been completed. The forms contained information about the situations that had occurred, however, the information that we saw did not fully demonstrate the lack of capacity of the person being restrained before the action was taken, a full record of the assessment or the action taken or a full review of the actions as demonstrated in the Mental Capacity Act 2005 framework. Detailed records must be maintained of all incidents involving physical intervention to help to protect people. Fairfield Residential Ltd - Springfields DS0000073258.V377678.R01.S.doc Version 5.3 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A clean and comfortable environment is provided for people. EVIDENCE: We saw that Springfield provided residential accommodation for four people over two floors. There were three bedrooms and a shared bathroom on the first floor. One bedroom was on the ground floor with en-suite facilities. A separate toilet was available on the ground floor. The kitchen, with laundry facilities, a dining room and lounge were situated on the ground floor. We saw that the accommodation provided a domestic style accommodation for people. The person showing us around the home told us that he liked living at Springfield. Fairfield Residential Ltd - Springfields DS0000073258.V377678.R01.S.doc Version 5.3 Page 19 The garden for the property was at the front of the house and car parking was available at the side. The home is situated on a main road with near access to the local bus service and local shops. We saw that people’s comfort and safety had been considered with regard to the living environment. For example, a sound proof window had been fitted to one bedroom to minimise any external noise for the person. They told us that the use of furniture in people’s bedrooms is assessed to help minimise any identified risk to people. We saw that risk assessments had been carried out for if and when an emergency occurred. They told us in their AQAA that their plans for the next 12 months included employing a fulltime handyperson and to involve people in the on-going decoration of the home. Fairfield Residential Ltd - Springfields DS0000073258.V377678.R01.S.doc Version 5.3 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 & 35 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Training arrangements do not ensure that people are cared for and supported safely. EVIDENCE: At the time of our visit there were two carers on duty to meet the needs of the 2 people in residence. The registered manager was also available. The person who showed us around the home told us that they liked the staff. We observed staff communicating and supporting people in a positive manner. We looked at the staff rota and saw that staff were always available throughout the day and night. We saw that the rotas contained only the first names of the staff team. To ensure accurate record keeping the full names of staff on duty should be recorded on the rotas. Fairfield Residential Ltd - Springfields DS0000073258.V377678.R01.S.doc Version 5.3 Page 21 We looked at the recruitment files of four staff members. We saw that some information on the files was relevant to the previous service that was registered at the premises. The majority of files contained written references, application forms, proof of address and evidence of a Criminal Record Bureau disclosure being completed. However, the files did not contain photographs of the staff members. To help ensure that people are protected by the services recruitment procedures all staff files must contain up to date information as detailed in schedule 2 of the Care Homes Regulations 2001. We saw evidence on two staff files that the members of staff had undertaken an induction into their role. We saw that the information in the induction pack related to children’s services. We saw no evidence of induction information that related to the support of young adults. One staff file demonstrated that the member of staff had undertaken training in medication and that they had made an application to complete the NVQ level 3 in Health and Social Care. Other staff files contained evidence of other training related to supporting children. The manager told us that he and three staff had undertaken training in the Protection of Vulnerable Adults (POVA). We saw no record of staff training related to health and safety awareness, physical intervention training, safe food handling, medication training or other training related to the needs of the people living at Springfield. To help people be cared for in a safe manner and to protect people from unnecessary harm, all staff must receive specific training for their role which is linked to the service’s aims and objectives. The told us in their AQAA that four staff had completed their NVQ level 2 or above award. Fairfield Residential Ltd - Springfields DS0000073258.V377678.R01.S.doc Version 5.3 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The current record management systems do not always ensure the efficient running of the home. EVIDENCE: At the time of our visit the registered manager of the home was in the process of leaving the service. They had employed a new manager who had been in post for a couple of weeks. The newly recruited manager demonstrated a good awareness of what changes needed to take place to improve the service. Fairfield Residential Ltd - Springfields DS0000073258.V377678.R01.S.doc Version 5.3 Page 23 We saw that recruitment practices and training had been managed in line with a children’s service and not always within the aims and objectives of a service for young adults. All policies and procedures at Springfield must consider the rights and opportunities for adults. We saw that they did not always inform us of situations that had occurred. For example, we saw two records of incidents that involved physical intervention taking place. The Commission must be informed at of all incidents related to Regulation 37 of the Care Homes Regulations 2001. They told us that they were in the process of carrying out a quality audit on the service. We saw that they had written to people’s families informing them of a residents meeting and asking them if they had anything to contribute to the meeting. They told us that the meeting was to gain people’s views and to look at ways they could improve the service. We saw that they had policies and procedures were in place to protect the health, safety and wellbeing of people. Fairfield Residential Ltd - Springfields DS0000073258.V377678.R01.S.doc Version 5.3 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 3 x Version 5.3 Page 25 Fairfield Residential Ltd - Springfields DS0000073258.V377678.R01.S.doc no 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 YA20 Regulation 13 Requirement A full record of all medication brought into the home, administered and disposed of must be maintained and demonstrate a clear audit trail in the home. The medication policy must contain information about the management and stage of controlled drugs and medication prescribed on an as and when basis (PRN). 2. YA34 19 Recruitment procedures need to demonstrate that information contained in Schedule 2 of the Care Homes Regulations 2001 has been obtained at the time of employment. A training programme specific to the needs of the home must be developed to ensure that staff are able to carry out their role in a safe manner. The registered person must notify the Commission of all events which adversely affects the wellbeing or safety of people. DS0000073258.V377678.R01.S.doc Timescale for action 20/11/09 20/11/09 3. YA35 13 (6) 20/11/09 4. YA37 37 01/11/09 Fairfield Residential Ltd - Springfields Version 5.3 Page 26 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. Refer to Standard YA6 Good Practice Recommendations A full record of people’s day to day activities should be recorded. Care plans should be written in plain English to make them easy to understand. A record of all GP and medical appointment should be maintained as part of people’s care plans. Records of all physical interventions should contain detailed information of all actions taken prior, during and after the incident as stated in the Mental Capacity Act 2005 framework. The homes policies and procedures should fully demonstrate and consider the rights and opportunities of adults. 2. 3. YA19 YA23 4. YA37 Fairfield Residential Ltd - Springfields DS0000073258.V377678.R01.S.doc Version 5.3 Page 27 Care Quality Commission North West Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Fairfield Residential Ltd - Springfields DS0000073258.V377678.R01.S.doc Version 5.3 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!