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Inspection on 24/07/07 for Fairfields House

Also see our care home review for Fairfields House for more information

This inspection was carried out on 24th July 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The service offers individual support in a pleasant homely environment to residents. The staff have a good knowledge of the needs of residents and encourage as much independence as possible. Residents are consulted about their wishes and complaints are taken seriously and actioned. Meals are a social event in an attractive dining room with new tablecloths and napkins. There is a wide choice of options available at each meal and food is well presented. The activities offered are suitable for the client group and include outings to the community as well as more sedentary pastimes such as bingo.

What has improved since the last inspection?

What the care home could do better:

Some assessments for emotional or psychological needs that indicated the resident may need some specific support did not have interventions on their care plan. The policy folder did not contain any written guidance on managing soiled linen or caring for a resident with Methicillin Resistant Staphylococcus Aureus (MRSA). The policy for protecting residents from abuse needs to be expanded to give staff fuller guidance. The manager needs to make application to CSCI for registration. Regulation 37 notices of incidents, accidents, deaths and any adverse occurrence that could impact on the residents should be sent to CSCI as they happen. Further training in food hygiene and the correct serving of meals would benefit some carers and give the residents better service. To ensure a full audit trail of medication the number or amount given to a resident when the prescription says, `one tablet or two` or `5mls or 10mls` should be recorded. Medication that required refrigeration was kept in a domestic refrigerator but not in a lockable container. The carpet to one resident`s room was identified to the manager as a possible trip hazard and needs to be attended to. Not all complaints brought to the notice of staff were recorded in the complaints log together with the evidence of the action taken to resolve the issue.

CARE HOMES FOR OLDER PEOPLE Fairfields House 21 Tuddenham Road Ipswich Suffolk IP4 2SN Lead Inspector Jane Offord Key Unannounced Inspection 24th July 2007 09:50 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 Fairfields House DS0000058630.V346962.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. Fairfields House DS0000058630.V346962.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fairfields House Address 21 Tuddenham Road Ipswich Suffolk IP4 2SN 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) 01473 213988 01473 785062 ffch@talktalk.net Fairfields House Ltd Post Vacant Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Fairfields House DS0000058630.V346962.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th May 2006 Brief Description of the Service: Fairfield House is a care home providing personal care and accommodation to up to 23 older people. It is a privately run home and is situated in a quiet area of Ipswich, not far from the town centre. The home is a two-storey building with bedrooms on the ground and first floor. The home has a shaft lift and stair lift. Twenty-one bedrooms are single and twelve provide en-suite toilet and wash hand basin. There is also one double en-suite bedroom. There are car-parking facilities at the front of the building and the rear provides an enclosed garden, which is well maintained and sheltered. The fees for accommodation range between £349.00 and £415.00. They do not cover the cost of hairdressing, toiletries, chiropody and newspapers. Fairfields House DS0000058630.V346962.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection looking at the core standards for care of older people took place on a weekday between 9.00 and 16.00. The manager had a day off but chose to come to the home to assist with the inspection. This report has been compiled using information available prior to the inspection and evidence found on the day. A tour of the home was undertaken with a member of staff but all areas were visited again during the course of the day. A selection of files and documents were seen including some new residents’ care plans, some staff files, maintenance and service certificates, the policy folder, the complaints log and medication administration records (MAR sheets). A number of residents and staff were spoken with and care practice was observed. On the day of inspection the home was clean and tidy with no unpleasant odours noted. Residents were using all areas of the home and looked comfortable and relaxed in their surroundings. Interactions between staff and residents were friendly and independence was encouraged. The lunchtime meal looked appetising and those residents spoken with said they had enjoyed it. What the service does well: What has improved since the last inspection? Some redecoration is taking place to change the dull brown décor of the upstairs paintwork for a fresh white making the area much lighter. Some individual rooms have been redecorated and had new carpet laid. A wheelchair ramp offering level access to the garden has been installed from the dining room. Fairfields House DS0000058630.V346962.R01.S.doc Version 5.2 Page 6 Plans are going ahead for an extension to the main lounge and kitchen to offer more communal space. This will allow the laundry to be moved to a more suitable room. Evidence of recruitment checks on new members of staff has been kept in their files and available for inspection. Residents’ care plans and risk assessments have been improved to help staff support them as they wish. There is evidence that residents are included in the process. 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. Fairfields House DS0000058630.V346962.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 Fairfields House DS0000058630.V346962.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5, 6. Quality in this outcome area is good. People who use this service can expect to have their needs assessed prior to admission and have enough information available to make an informed choice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: This service does not offer intermediate care. Three relatively new residents’ files were seen and showed each of them had had a pre-admission assessment of need carried out by a senior member of staff. The assessment covered physical needs such as personal hygiene, mobility, continence, diet, oral and foot care, sight, hearing and medication. Other information included the resident’s religion if they practised one, family involvement and the resident’s social interactions and interests. In one assessment it was noted that the prospective resident wished to visit the home and did so for lunch two days later. Fairfields House DS0000058630.V346962.R01.S.doc Version 5.2 Page 9 The home has an up to date Statement of Purpose available to any prospective resident or their representative. It can be made available in large print if required. The Statement of Purpose contains all the information required in standard 1 of the national minimum standards (NMS) for care homes. The service is also developing a Web site about the home to give more information to people who may live out of Suffolk or prefer to access information electronically. Fairfields House DS0000058630.V346962.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is good. People who use this service can expect their health needs to be met and a care plan in place to assist staff in meeting their daily living needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three new residents’ files were seen and each had an assessment of need on admission to the home. The documents covered areas of physical need such as personal hygiene, continence, diet, night needs and mobility. There was further information about communication, memory, orientation and the ability to co-operate with staff to help meet their own needs. Each file had an individual care plan to meet the needs of that resident. One had interventions about diet as the resident was diabetic and another about medication as the resident had a diagnosis of Parkinson’s disease and needed medication at specific times to control their symptoms. The care plans were all signed and agreed by the residents or their representative. Fairfields House DS0000058630.V346962.R01.S.doc Version 5.2 Page 11 The assessment for one resident had included information about some ongoing anxieties they had around settling into the home and the changes that would be needed. In addition they were concerned about a member of their family who was seriously ill. Their care plan had no interventions to help staff know how the resident wished to manage these issues. The files contained contact details of any health professionals involved in the care of the resident including GP, community nurse, chiropodist, optician, Parkinson’s disease specialist nurse and diabetes consultant nurse. Risk assessments were completed for moving and handling, nutrition and selfmedicating if the resident chose to do so. Any known allergies were also recorded. The staff communication book recorded health professional visits to residents and their instructions or treatment prescribed. One record was that the continence nurse had visited and completed an assessment on a resident prescribing the specific continence aid the resident required. The medication management policy was seen and contained comprehensive guidance on all aspects of managing medication safely. It included guidance on homely remedies, covert administration of medicines and what to do if an error occurred. Part of a medication administration round was followed. Medicines are stored in a secure trolley. The carer washed their hands prior to commencing the round and ensured the trolley was locked each time they left it to dispense medication to a resident. They said they had done the recognised medication training offered by a pharmacy company. This was confirmed when the training records were inspected. The MAR sheets had identification photographs attached and there were no signature gaps noted. ‘As required’ (PRN) prescriptions that offered a choice of dose such as, ‘one tablet or two’ did not always have the amount administered recorded making an audit trail impossible. However the disposal of unused tablets that had been dispensed was correctly recorded. Some medication requiring refrigeration was stored in the domestic refrigerator but on the shelves not in a lockable container. The controlled drugs (CDs) register was looked at and a sample of the CDs held in the home was checked. The amounts tallied with the records. During the day care practice was observed and staff were seen knocking on doors before entering rooms. Residents were offered choice about where they wished to be and at lunchtime what they wanted to eat and drink. Staff were able to give examples of how they preserved residents’ dignity during any work they did with them such as giving personal care. Fairfields House DS0000058630.V346962.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. People who use this service can expect to have a lifestyle to meet their expectations and be offered a well-balanced diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The residents’ files seen contained information about their interests and hobbies. Each one had some life history work done with either the resident or a member of their family or representative. One care plan had the resident’s choice of daily newspaper recorded and all the files had the resident’s religion if they had any spiritual persuasion. There is a weekly activities programme displayed in the entrance hall and activities records show pastimes such as cards, manicures, armchair football and quizzes take place regularly. The home has a monthly church service that takes place in the lounge. There is a nominated activities co-ordinator who enables residents to take part in cake making and bingo sessions. Several residents recently went to a local pub for lunch and enjoyed it so much that they requested a repeat through the residents’ meeting. Fairfields House DS0000058630.V346962.R01.S.doc Version 5.2 Page 13 The files all contained contact details of the resident’s next of kin and anybody important to the resident. The home encourages visitors and a number were seen to come and go during the day of inspection. Daily records noted when a resident had had visitors or been on an outing. Staff and residents said seaside trips were planned for later in the summer and a visit to a local park had taken place already. The kitchen was visited and found clean and tidy. Food stored in refrigerators was labelled and dated and the records of temperatures of refrigerators and freezers showed they were functioning within safe limits for food storage. The store cupboard of dry goods was well stocked with a wide variety of dry ingredients. The menus offered a choice of two main meals at lunchtime for example beef casserole or lambs liver with roast potatoes and vegetables followed by Eve’s pudding or blancmange and fruit. There were additional options available of fish in a sauce, eggs and/or bacon. Lunch on the day of inspection was ham and eggs with peas, mashed potatoes or chips. A plate of prepared bread and butter was offered to residents but the carer gave out the slices of bread by hand. The dessert was bread and butter pudding and custard or a selection of ice cream or fruit. The tea menus offered a wide choice of hot and cold snacks such as egg or salmon sandwiches, soup, pilchards or spaghetti on toast, fish fingers or baked beans, salad and teacakes. Residents spoken with said the food was ‘lovely’ and that they ‘always enjoy my meals here’. Residents can choose whether they have their meals in the dining room or in their own room. The dining room is a light attractive room with high ceilings and windows overlooking the garden. The manager has recently purchased new tablecloths and place mats, which make the tables look very smart. Residents had commented on the improvement during the residents’ meeting and their comments had been included in the minutes. Fairfields House DS0000058630.V346962.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18. Quality in this outcome area is good. People who use this service can expect to have complaints taken seriously and be protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s complaints policy is on display in the entrance hall and available in large print if required. The minutes of a residents’ meeting held in early July 2007 show that the manager explained the complaints policy and copies were made available to all residents and their representatives. One resident spoken with was clear about how to complain and added, ‘and I would if I felt the need but things are good here’. The complaints log was seen and showed that the home had had two complaints since the beginning of the year. They were both fully investigated with documentary evidence of the investigation undertaken retained. CSCI has not received any complaints about this service since before the last inspection. On checking the staff communication log a further complaint was recorded that had not been transferred to the complaints log. This was brought to the notice of the manager who agreed to rectify the omission. The manager had in the office a list of residents who had requested postal voting papers that they were in the process of obtaining on their behalf. Fairfields House DS0000058630.V346962.R01.S.doc Version 5.2 Page 15 The home’s protection of vulnerable adults (POVA) policy was seen and did not offer full guidance on managing a potentially abusive situation for staff to follow. It did not cross-reference to the Suffolk guidelines or detail the correct way to make a POVA referral. Staff spoken with were able to discuss situations that could be considered abusive and were clear about their duty of care. POVA instruction is given during induction training and this was evidenced in the staff files. The home has a whistle blowing policy to protect staff who report concerns. Fairfields House DS0000058630.V346962.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. Quality in this outcome area is good. People who use this service can expect to live in attractive, homely surroundings that are clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Fairfields House is a large brick built house in a quiet residential area close to the centre of Ipswich. There is an extensive park nearby and public houses within walking distance. Shops, churches and other amenities can be accessed in the town centre. The house offers accommodation over two floors with the communal rooms on the ground floor. There is a large lounge with a quiet alcove attached, which was where the hairdressing service was set up on the day of inspection. The attractive dining room retains a period fireplace and has level access into the secure gardens. Fairfields House DS0000058630.V346962.R01.S.doc Version 5.2 Page 17 The age of the property means the individual bedrooms vary in shape and size but they all benefit from either and en suite or a wash hand basin in the room. There are thirteen single rooms on the ground floor with eight on the first floor and one double room. There is a passenger lift and a stair lift for access between the floors. The home offers a welcoming feel with fresh flowers in the entrance hall and no unpleasant odours apparent. The décor is appropriate for the building and residents’ rooms have redecoration as they become vacant. One room recently done and still vacant was seen and looked fresh and attractive with co-ordinating soft furnishings. The dark brown doors are gradually being repainted white to lift the corridors and give the home a more airy feel. Residents were using all areas of the home and looked relaxed in the environment. One resident spoken with in their room said they enjoyed their own company and passed the time doing crosswords and reading but they could see into the garden and they liked that. The carpet at the entrance to one resident’s room was badly frayed and was a potential trip hazard. The laundry was visited and proved to be an extremely tiny area. It contained washing machines with a sluice programme and automatic product feed and a tumble dryer. Staff were able to explain the management of soiled linen and the use of alginate bags to prevent cross infection but the home does not have a written policy for guidance. The manager said that with the proposed extension plans the room, at present used for kitchen stores, will become vacant due to enlarging the existing kitchen. The manager plans to move the laundry into there, which will offer much more appropriate space. The home has some residents with hospital-acquired infection of MRSA and precautions are in place to prevent any spread to other people. Domestic staff spoken with gave clear explanations of the way they work, the products they use and the protective clothing they wear while doing their job. The policy folder does not contain any guidance about the management of a resident with MRSA. Fairfields House DS0000058630.V346962.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is good. People who use this service can expect to be supported by adequate numbers of correctly recruited and trained staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The duty rotas were seen and showed that there were three care staff on duty during the day and two at night time. The manager is supernumerary but is on call at all times and will cover shifts if they cannot be covered by bank or other staff at short notice. The care team is supported by a cook and a domestic daily, and a maintenance person three times a week. Staff spoken with felt there were enough staff to meet residents’ needs at present. Residents said they did not often wait for their bells to be answered and on the day it was noted that buzzers did not ring for long periods. Three new staff files were seen and each contained two references and a full work history. There was evidence of a POVA 1st check being undertaken before the person commenced in post and the manager was able to provide evidence that criminal records bureau (CRBs) had been done and received within the first couple of weeks of employment. In two files there was documentary evidence that the persons’ identity had been verified. Fairfields House DS0000058630.V346962.R01.S.doc Version 5.2 Page 19 There was evidence of each member of staff undergoing an induction programme that covered fire awareness, health and safety, the principles of care, moving and handling, food hygiene, privacy and dignity, control of substances hazardous to health (COSHH) regulations and POVA. This was confirmed by discussions held with staff on duty on the day. The home employs nineteen care staff of whom seven hold an NVQ level 2 award or above and a further seven are undertaking the programme at present. On completion the percentage of carers with a relevant qualification will exceed the required 50 per cent in Standard 27 of the national minimum standards (NMS) for care homes. Fairfields House DS0000058630.V346962.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38. Quality in this outcome area is good. People who use this service can expect to live in a well managed home and have their interests and welfare protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The present manager has been in post since April 2007 and has a history of working in residential care. They hold and NVQ level 4 award and the Residential Managers Award (RMA). They have not yet made application to CSCI for registration and should process that at the earliest opportunity. Residents spoken with were able to identify the manager and said they were approachable and always around the home. Staff said they had felt supported and valued since the manager had been in post. Fairfields House DS0000058630.V346962.R01.S.doc Version 5.2 Page 21 The home holds regular residents and relatives meetings and the minutes were available in the entrance hall, in large print if required. They recorded that the manager had explained the complaints policy to the meeting and made copies available, there had been a discussion about menus and approval of the new tablecloths and place mats, a request was made for more bingo and another visit for a pub lunch also arrangements for a trip to the seaside. Also available in the entrance hall were quality assurance questionnaires for visitors to complete. The home holds the personal monies for some residents in a safe in the office that the manager has the key to. The system used to manage the monies was explained and gave a clear audit trail. Two randomly selected amounts were checked and they tallied with the records. The certificate of registration was displayed in the entrance hall showing the manager’s post as vacant as application to CSCI has not yet been made, as noted earlier. A discussion was held with the manager about the use of Regulation 37 notices. They had been told that they no longer needed to submit them following the death or injury of a resident. It was explained that the regulation 26 visit reports did not have to come to CSCI but must be available for inspection but there was no change in the regulation 37 reports. A number of maintenance and service certificates were seen and showed that the gas safety check had been completed in March 2007, the passenger lift had been serviced in November 2006 and fire alarms and emergency lighting had been tested in February 2007. Fairfields House DS0000058630.V346962.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME 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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Fairfields House DS0000058630.V346962.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No. 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 OP16 Regulation 22 Requirement All complaints brought to the notice of staff must be entered into the complaints log and investigated to ensure residents’ concerns are taken seriously. Timescale for action 24/07/07 2. OP18 13 (6) The POVA policy must be 31/08/07 expanded to include full guidance in line with the county guidelines for managing concerns around potential abuse to ensure residents are protected from harm. The infection control policy must be expanded to include guidance on the management of soiled linen and MRSA infection precautions to protect residents from cross infection. 31/08/07 3. OP26 13 (3) 4. OP38 37 Regulation 37 notices of death, 24/07/07 injury or any occurrence that may affect the well being of residents must be completed and sent to CSCI to ensure the correct agencies can monitor the well being of residents. Fairfields House DS0000058630.V346962.R01.S.doc Version 5.2 Page 24 5. OP38 13 (a) (c) The worn carpet that poses a trip 17/08/07 hazard that was identified to the manager must be made safe to prevent injury to residents and staff. 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 OP7 Good Practice Recommendations Emotional and psychological needs identified during assessment should generate interventions on the care plans to ensure that residents receive the support they require in the way they would wish. The accurate recording of medication and the correct storage of medicines should be addressed to ensure residents’ property is protected. Updated food handling training should be given to some staff to ensure they understand the risks of handling food inappropriately and thereby putting residents at risk. The manager should process their application for registration as soon as possible to ensure stable management of the home is in place for the benefit of the residents living there. 2. OP9 3. OP30 4. OP31 Fairfields House DS0000058630.V346962.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Fairfields House DS0000058630.V346962.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!