Inspection on 16/01/06 for Fairhaven

This inspection was carried out on 16th January 2006.

CSCI 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 CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fairhaven 06/06/06

Fairhaven 13/07/05

Fairhaven 07/12/04

Fairhaven 30/06/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

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

CARE HOME ADULTS 18-65 Fairhaven 5 Alexandra Terrace Clarence Road Bognor Regis West Sussex PO21 1LA Lead Inspector Ms J Hartley Unannounced Inspection 16th January 2006 16:45 Fairhaven DS0000048418.V274876.R01.S.doc Version 5.1 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 Fairhaven DS0000048418.V274876.R01.S.doc Version 5.1 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 Adults 18-65. 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. Fairhaven DS0000048418.V274876.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Fairhaven Address 5 Alexandra Terrace Clarence Road Bognor Regis West Sussex PO21 1LA 01243 829956 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) Allied Care (Mental Health) Ltd Mrs Zoe Rutter Care Home 13 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (13) of places Fairhaven DS0000048418.V274876.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named service user in the category of mental disorder (MD/E) over the age of 65 years may be accommodated. 13th July 2005 Date of last inspection Brief Description of the Service: Fairhaven is a three-storey terraced house situated in the centre of Bognor Regis. It is a short walk from the sea front and main shopping area. Fairhaven offers accommodation to thirteen service users from eighteen to sixty-five years of age with a mental disorder. There are seven single bedrooms and three double bedrooms, two lounges, (one of which is designated for nonsmokers), and a separate dining room. There are two bathrooms and two separate toilets, all with washbasins. The responsible individual is Mr Aslam Dahya, (who represents Allied Care (Mental Health) Ltd.), has other established care homes. The Registered Manager is Mrs Zoe Rutter who is responsible for the day-to-day running of the home. Fairhaven DS0000048418.V274876.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was carried out over a period of two and a half hours. The inspector examined information held on the service file since the last inspection in July 2005, and read the previous two inspection reports, the Service User Guide and the Statement of Purpose During the inspection the inspector spoke to five the service users, and two members of staff. The inspector undertook a tour of the premises and looked at three care plans and three staff files. Various record books, policies and procedures were also examined. This report should be read in conjunction with the report of the announced inspection held on 13th July 2005. All the key standards, which should be inspected in a twelve-month period, are covered in these two reports. What the service does well: What has improved since the last inspection? What they could do better: Some redecoration is needed in the corridors on the top floor of the home. The home has good recruitment policies and procedures in place, however application forms do not currently require a full employment history from applicants. A requirement has been made that a full employment history is obtained for prospective employees, and that any gaps in the employment record are explored prior to employment commencing. Fairhaven DS0000048418.V274876.R01.S.doc Version 5.1 Page 6 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. Fairhaven DS0000048418.V274876.R01.S.doc Version 5.1 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 Fairhaven DS0000048418.V274876.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 The home has an up to date Service User Guide and Statement of Purpose that enable service users to make an informed decision about where to live. Standards Two and Five were inspected during the last inspection and were found to have been met. EVIDENCE: The registered manager has just updated the Statement of Purpose and Service User Guide. Copies were available at the inspection. The registered manager will send copies to the Commission as soon as they are available. Both documents contain the required information to enable service users to make an informed decision about where to live. Fairhaven DS0000048418.V274876.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8 Service users are offered the opportunity to participate in aspects of life in the home. Standards Six, Seven and Nine were inspected during the last inspection and were found to have exceeded the minimum standard. EVIDENCE: Service users are encouraged to take part in the running of the home through doing jobs such as washing the floor, preparing tables before meals etc. One service user said that they are able to contribute ideas for activities and menus. During the inspection one service user was washing the kitchen floor, he said that he enjoyed doing this job. The company is in the process of changing its service user record keeping system to the “Cared For” system. One of the service users was involved in making suggestions to make it suitable for people with mental health problems. Fairhaven DS0000048418.V274876.R01.S.doc Version 5.1 Page 10 Evidence was seen that house meetings are held approximately every two months. During house meetings service users are able to make suggestions about the running of the home. At present service users are not involved in interviewing prospective staff. Fairhaven DS0000048418.V274876.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 15 Service users have plenty of opportunity to take part in age, peer and culturally appropriate activities. Service users have appropriate personal, family and sexual relationships. Standards Thirteen and Sixteen were inspected during the last inspection and found to have been met. Standard Seventeen was exceeded. EVIDENCE: Fairhaven provides a wide range of activities for service users to take part in if they wish. Activities include trips out, bowling, going out for meals, iceskating and shopping. Some service users attend courses at college including daily living skills, maths, English, German and photography. One service user has an allotment to attend as he enjoys gardening. Service users are supported in maintaining links with their family and friends. One service user told the inspector that staff take him to see his parents regularly as they are unable to visit him in the home. Others are enabled to Fairhaven DS0000048418.V274876.R01.S.doc Version 5.1 Page 12 visit family and partners, and visitors are welcomed in the home. Telephone contact is also encouraged. Service users are able to develop and maintain intimate personal relationships. Specialist guidance and support is available through a counsellor who visits the home on a weekly basis, contraception advice and access to relationship counsellors if required. Fairhaven DS0000048418.V274876.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 20 There are no service users living at Fairhaven that need personal care. Other support is provided in the way service users prefer. No-one living at Fairhaven self- administers their medication. Medication policies and procedures protect service users. Standard Nineteen was inspected during the last inspection and was found to have been met. EVIDENCE: Care plans and records show that service users are prompted and given guidance with personal care when needed. Times for getting up and going to bed are flexible. Service users are able to choose their own clothes and hairstyles. Medication policies, procedures and records were inspected and found to be in good order. All medication was seen to be clearly and individually labelled. There was no over-stocking of medication. The recording of medicines administered was seen to be up to date and accurate. There are currently no service users self-medicating. Training records show that staff who administer medication have received appropriate training. Fairhaven DS0000048418.V274876.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The above Standards were inspected during the last inspection and were found to have been met. EVIDENCE: Fairhaven DS0000048418.V274876.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26 Service users bedrooms are personalised and promote their independence. Standards Twenty-Four and Thirty were inspected during the last inspection and were found to have been met. EVIDENCE: The bedrooms seen during the inspection were found to be in reasonable decorative order. One bedroom that was in need of a new carpet has had the carpet replaced and has been redecorated. Furniture and fittings are of a suitable quality. Residents are able to personalise their rooms with their own belongings, pictures etc. Two service users told the inspector that they chose the colour schemes for their rooms. All bedrooms have locks fitted and service users have their own keys. The corridors on the top floor of the house are in need of redecoration. This is in the maintenance schedule for this year. Fairhaven DS0000048418.V274876.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 Staff at Fairhaven are competent and qualified to support the needs of the service users in the home. The home has suitable recruitment policies and procedures in place to protect service users. However, application forms do not currently ask for a full employment history. A requirement has been made that a full employment history is obtained for prospective employees, and that any gaps in the employment record are explored prior to employment commencing. Standard Thirty-Five was found to have been met at the last inspection. EVIDENCE: Records of staff training and qualifications seen during the inspection indicate that service users are supported by competent and qualified staff. Allied Care (Mental Health) Ltd. has a comprehensive training programme available to staff which includes courses specific to the needs of service users within the home. Individual training records seen indicate that staff have attended various courses including Health and Safety, Medication, Alcohol and Substance Misuse, Adult Protection, Mental Health and Conflict Management among others. Evidence was seen that all new staff receive an induction Fairhaven DS0000048418.V274876.R01.S.doc Version 5.1 Page 17 programme within six weeks of employment and foundation training within six months. Application forms do not ask for a full employment history from prospective staff. The manager needs to ensure that a full employment history is obtained for prospective employees, and that any gaps in the employment record are explored prior to employment commencing. Qualifications and training records show that one member of staff, (excluding the manager), has an NVQ level four in care; two have NVQ level three; and two have nursing qualifications from abroad. One further member of staff is currently doing the NVQ level three in care. Recruitment policies and procedures were inspected and found to be thorough. Three staff files were examined and were seen to include all the required information. Evidence was seen that references, CRB and POVA checks are taken up prior to employment commencing. Staff appointments are subject to a three-month probationary period. Fairhaven DS0000048418.V274876.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Fairhaven is a well run home that is managed by a qualified and experienced registered manager. Allied Care (Mental Health) Ltd has recently set up a quality monitoring system for all its homes. The health, safety and welfare of service users are protected by the homes’ working practices and procedures. EVIDENCE: The registered manager at Fairhaven, Mrs. Zoe Rutter, has the experience and qualifications required to manage the home. She has a Level Four NVQ in Care, a Btec. Diploma in Care and a Registered Managers award. Allied Care (Mental Health) Ltd has a Quality Assurance manager in post and has recently set up a new quality monitoring system which it is in the process of rolling out. The home is having its’ first Quality Assurance audit in February. Fairhaven DS0000048418.V274876.R01.S.doc Version 5.1 Page 19 Training records seen show that the company provides compulsory training for staff in safe working practices, including Moving and Handling, First Aid, Fire Safety, Food Hygiene and Infection Control. The home was found to be suitable for its stated purpose, accessible, safe and well maintained throughout. Environmental risk assessments are in place regarding Health and Safety of the home. These were last reviewed in December 2006. During the tour of the home it was noted that all radiators have covers. Accident and incident records were inspected and seen to be up to date and reported to the required authorities when necessary. Fairhaven DS0000048418.V274876.R01.S.doc Version 5.1 Page 20 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 3 2 X 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 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 3 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X 3 X X LIFESTYLES Standard No Score 11 X 12 4 13 X 14 X 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X 3 X 3 X 3 X X 3 X Fairhaven DS0000048418.V274876.R01.S.doc Version 5.1 Page 21 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 YA34 Regulation 19 Requirement Ensure that a full employment history is obtained for prospective employees, and that any gaps in the employment record are explored prior to employment commencing. Timescale for action 16/03/06 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 Fairhaven DS0000048418.V274876.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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 Fairhaven DS0000048418.V274876.R01.S.doc Version 5.1 Page 23 - 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. 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