Inspection on 04/07/05 for Fairhaven

This inspection was carried out on 4th July 2005.

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

Other inspections for this house

Fairhaven 24/10/06

Fairhaven 10/02/06

Fairhaven 08/02/05

Fairhaven 08/10/04

Fairhaven 30/09/02

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Fairhaven 19 Park Avenue Watford Hertfordshire WD18 7HR Lead Inspector Julia Bradshaw Unannounced 04.07.05 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 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. Fairhaven I52_s19346 Fairhaven v233695 040705 stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Fairhaven Address 19 Park Avenue Watford Hertfordshire WD18 7HR 01923 220811 01923 490585 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs C Fletcher Mrs C Fletcher Care Home 15 Category(ies) of OP Old Age - 15 registration, with number of places PD(E) Physical Disability - 15 Fairhaven I52_s19346 Fairhaven v233695 040705 stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: There are none. Date of last inspection 08.02.05 Brief Description of the Service: Fairhaven is a large double fronted house with a purpose built extension to the side and to the rear of the home. There are eleven bedrooms for single occupancy and two rooms that are shared. Bedrooms are situated on both the ground floor and the first floor, which is serviced by a small two-person lift. The home is situated in a tree-lined road on the outskirts of Watford Town centre. The home has a homely and welcoming atmosphere and is in good decorative order throughout. There is a large garden to the rear of the home, in which there is a small patio area for free standing furniture. The home is situated in close proximity to Watford Town centre with all its community service, shopping centres, local and national bus and train services. Fairhaven I52_s19346 Fairhaven v233695 040705 stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced inspection of the inspection year and took place over one day. The majority of time was spent talking to service uses, visitors and staff. Some time was spent in the office looking at service user plans and staff files. The main focus of this inspection was the new development of number 17 Park Avenue to increase the occupancy of the home from 15 service users to 19. Discussions were held with the Joint proprietors Mr and Mrs Fletcher and a tour of the new provision was carried out with Mr Fletcher and the Architect and building manager. This was a positive inspection, feedback received from service users spoken to was favourable and the standard of most aspects of ther service observed was good. What the service does well: What has improved since the last inspection? The manager has worked hard to improve and develop the supervision process and now offers supervision on a monthly to six-week basis. The manager has worked hard to ensure the building work being carried out next door has not impinged on the day-to-day running of the home. The manager has been vigilant in updating the current risk assessments in relation to the building work being carried out and has updated these to relect the changing risks to the service users. Fairhaven I52_s19346 Fairhaven v233695 040705 stage4.doc Version 1.40 Page 6 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. Fairhaven I52_s19346 Fairhaven v233695 040705 stage4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Fairhaven I52_s19346 Fairhaven v233695 040705 stage4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not inspected on this occasion. EVIDENCE: These standards were not inspected on this occasion. The manager will update and amed the current Statement of Purpose and Service User Guide once the new service has been registered. Fairhaven I52_s19346 Fairhaven v233695 040705 stage4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9, & 10 Personal care and assistance offered to service users is of a very high standard, thus meeting the individual needs of the residents, whilst maintaining dignity and respect. Care staff are unobtrusive and sensitive in their approach. Care plans are detailed and are reviewed on a monthly basis ensuring changes to health and social care needs are recognised and met. The health and safety of one service user is currently being compromised. EVIDENCE: Care plans were detailed and had been reviewed since the last inspection. Some service users spoken to during the inspection confirmed that they had been consulted in devising their care plans. However, the manager must carry out a risk assessment on the serive user who has difficulty with eating and swallowing in order to ensure their health and safety is not compomised and the risk of choking is identified and managed effectively. This must be included in the current service user plan. Manual handling risk assessments were available on file and the manager has worked hard to implement individual risk assessments for service users living within the home. The manager stated the home has good working relationships with outside health professionals and support services. Individual care practice observed was both Fairhaven I52_s19346 Fairhaven v233695 040705 stage4.doc Version 1.40 Page 10 professional and caring. Service users requiring assistance with meals are seated in the smalled lounge/dining area where dignity was promoted and protected. The medication system was being well managed. No gaps were found in the administration records and all creams and liquid medication had opening dates recorded. All staff can admisiter medication, but only after an induction carried out by the manager. The local pharmacist also assesses those staff members. The storage and ordering arrangements were well organised. The disposal book was checked and up to date and the pharmacist visits every six months and checks all medication cupboards and stocks of medication. Risk assessments were in place to support this practice. The home has a contract with a local pharmacist who provides all the medication for the home, on a weekly basis. The manager must ensure staff sign the MAR sheet for the “Jevity” feed which is administered to one service user via a peg feed. The home receives a positive and effective service from the local GP’s and health care professionals. Service users are able to maintain their own GP wherever possible. There are regular visits from other professionals, which include opticians and chiropodist. Service users are all offered the opportunity of having a telephone installed in their room and have access to the “house” telephone. All laundry is either identified by nametages or with marker pen and laundry baskets are individually marked. Care staff take responsibility for putting individual laundry away. Service users must be offered a key to their room as part of the admission procedure. All visiting health professionals see service users in their own bedrooms and this is stated in individual care plans. The staff induction includes a section on how to treat and address service users with both dignity and respect. Staff members are aware of how to comfort service users and support their families and friends, this was confirmed during the inspection. Pain relief when required, is prescibed via the G.P. The manager has included on the service user plan the last wishes and funeral arrangements of each service user. Some service users have refused to provide this information and therefore a record has been made on the care plan to reflect this. Fairhaven I52_s19346 Fairhaven v233695 040705 stage4.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, & 15. Where possible the home tries to accommodate everyone’s individual preferences and feedback and suggestions are sought in all aspects. This promotes autonomy and choice. Visitors are welcome and the home promotes integration with the local community in accordance with service users preferences. Service users should be consulted so that the activity programme relects their choices and expands on the current opportunities for trips outside of the home. EVIDENCE: The home does not employ staff specifically to provide activities within the home therefore the care staff provide this service and are responsible for providing the activities programme. The manager should review the current programme in order to ensure that the service users have the opportunity to experience a range of activities within the home. The manager should also consider providing the opportunity for service users to be involved in trips and activities outside of the home. The inspector had the opportunity to speak to a visitor during the inspection who was very positive about the care that their relative receives at the home. Fairhaven I52_s19346 Fairhaven v233695 040705 stage4.doc Version 1.40 Page 12 The manager stated that residents are given the opportunity to live their life as they would in their own home. The menus showed a good selection of traditional meals offered. There was a choice of two main courses with an alternative available. Service users stated that they were very happy with the food provided. The lunchtime main meal was observed being served in the main dining room and on trays. The meal was manged at a leisurely pace and service users were assisted where needed. Fairhaven I52_s19346 Fairhaven v233695 040705 stage4.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17, & 18 The home has a robust complaints procedure of which all sercice users spoken to were fully aware of ensuring that all issues can be dealth with effectively. EVIDENCE: A copy of the complaints procedure is available to prospective and current service users. Reference is made to the Commission for Social Care Inspection. Those spoken to said that they have never had to make a complaint and felt that they would be able to speak to a member of staff or the manager if they had any concerns. No complaints have been received since the last inspection. Staff confirmed they had received training on adult abuse and there is acopy of the Hertfordshire County Council Adult Protection procedure kept within the home. The manager stated that staff have received training on POVA (Last training was in 2004). This training should be repeated on an annual basis. Staff spoken to were aware of the homes Whistle Blowing procedure and a copy should be displayed in the main office of the home. Fairhaven I52_s19346 Fairhaven v233695 040705 stage4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25, & 26. The home and its surroundings offer a pleasant and comfortable environment to its service users. The home is clean and well maintained and bedrooms are personalised offering a homely, lived in feel. The standards of health and safety within the home are adequate. EVIDENCE: The home is currently in the middle of substantial building works which will incorporate number 17 Park Avenue and increase the occupancy from 15 service users to 19. This will provide an additional four bedrooms with ensuite facilities, a lounge/dining room, a larger kitchen and utility room, a main office area and two assisted bathrooms. The original home will also have a new treatment room. The manager has implemented serveral risk assessments to ensure service users are safegaurded whilst the building work is being carried out. Service users are encouraged to bring personal items such as furniture and pictures into their room when they move in. Service users spoken to were happy with their rooms and did not appear to be too disadvantaged by the disruption of the building work. The home was clean and Fairhaven I52_s19346 Fairhaven v233695 040705 stage4.doc Version 1.40 Page 15 attention to detail is given. One care worker stated that hygiene and infection control procedures are good and that gloves and aprons are always readily available. The communal areas of the home are adequate although the new provision will give the service users the opportunity to all eat together in the large dining room which is being created in number 15. The home currently divides the eating areas between the lounge and the dining room, with some service users using trays and some people eating within their own rooms. There is adequate heating and lighting throughout the home and the new provision will double the size of the garden area, to include a large patio area and wheelchair access. Fairhaven I52_s19346 Fairhaven v233695 040705 stage4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30. The staff team are enthusiastic and appear to take great pride in the service. The skills and experience of the staff is varied and the manager is providing adequate training. The current recruitment procedure was not being implemented. EVIDENCE: The manager stated that the home was fully staffed and that the staffing levels are adequate to meet the required needs of the current service user group. There is a total of eight staff employed. Two staff are employed on both the morning and evening shift and one waking night care. The manager has worked hard to improve and develop the supervision programme for all staff and this includes annual appraisals, which are carried out annually. Staff spoken to confirmed that they are receiving a variety of training, which includes, Dementia training, moving and handling, fire training, and food hygiene. All members of staff are currently involved in NVQ training and the manager commenced her NVQ 4 training in May 2005. The manager has recently appointed a new member of staff but unfortunately there was insufficient evidence to confirm that the manager had followed the correct recruitment procedures in relation to protecting the service user from abuse. The manager had employed the member of staff without receiving the POVA or CRB clearaance. This practice must cease immediately and the manager must ensure that all staff receive POVA clearance before commencing employment. Fairhaven I52_s19346 Fairhaven v233695 040705 stage4.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 & 38 Health and safety procedures were being implemented appropriately within the home. However, care must be taken to ensure all service users are protected from abuse by the implementaion of robust recruitment procedures. EVIDENCE: The manager communicates a clear sense of leadership within the home, and promotes a sense of belong to it’s service users. Pride and dedication is taken in every aspect. Service users commented on how the manager has daily contact with each service user and that issues raised are managed efficeintly and effectively. Staff files contained miutes of supervision meetings. Health and safety records are accurate and up to date with recent risk assessments being developed in relation to the building work being carried out in both homes. The fire records were up to date with a fire drill being carried out on the 16.02.05. There is a current fire certificate displayed in the front hallway. The last service on the fire appliances was carried out on the 01.06.05. The emergency lighting was last checked on the 29.06.05. Fairhaven I52_s19346 Fairhaven v233695 040705 stage4.doc Version 1.40 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 x x x x x x 2 Fairhaven I52_s19346 Fairhaven v233695 040705 stage4.doc Version 1.40 Page 19 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 7.3 Regulation 13 (4) (c) Requirement The manager must carry out a risk assessment on the service user who has a peg feed with regard to the risk of choking. The manager must ensure that the Jevity feed is recorded on the MAR sheet when administered. The manager must ensure that the correct recruitment procedures are followed with regard to the protection of service users, in line with the current regulations and standards. Timescale for action From 04.07.05 and Henceforth From 04.07.05 and Henceforth From 04.07.05 and Henceforth 2. 9.1 13 (2) 3. 29.3 38 17 (2) Schedule 4 19 (1) (b) Schedule 2 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 12 Good Practice Recommendations Service users should be consulted so that the activity programme reflects their choices and offers opportunities of trips outside of the home. Fairhaven I52_s19346 Fairhaven v233695 040705 stage4.doc Version 1.40 Page 20 Commission for Social Care Inspection Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 I52_s19346 Fairhaven v233695 040705 stage4.doc Version 1.40 Page 21 - 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!