Inspection on 06/06/06 for Fairhaven

This inspection was carried out on 6th June 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 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 16/01/06

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 Mrs A Taggart Unannounced Inspection 6th June 2006 08:30 Fairhaven DS0000048418.V298068.R01.S.doc Version 5.2 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.V298068.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 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.V298068.R01.S.doc Version 5.2 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.V298068.R01.S.doc Version 5.2 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. 16th January 2006 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.V298068.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced visit was carried out at 9am and lasted for 4.5 hours. During the visit the inspector spent time talking to service users and staff, saw lunch being prepared and observed interactions between the staff on duty and service users. Four care plans were tracked with any identified issues being discussed with service users, staff and the deputy manager. Three staff files were also seen. A tour of the building was undertaken during which the communal areas and all but three bedrooms were seen. The service users occupying these rooms had gone out for the day and locked their doors. Records including complaints, incident and accidents, food provided and risk assessments were seen and all were current and good order. Health and safety and maintenance records were also viewed as were staff supervision, training and development files. Prior to the visit, the inspector completed a planning document using information gained form the last inspection and any other relevant documentation or correspondence concerning the home. The registered manager was not present but the deputy manager Sean Foord assisted with information during the visit. Fees at the home range from £275 to £2,040 per week. What the service does well: The home offers a comfortable, friendly and supportive environment for the people who live there. Service users say they are happy in the home and that they have access to friends and the community, they like living near the sea and enjoy the meals provided. There is sufficient information available to inform the staff team of the needs of the people they a support and service users say that the staff team are kind and caring. Fairhaven DS0000048418.V298068.R01.S.doc Version 5.2 Page 6 There are good support systems in place for both service users and the staff team and the home is well managed. What has improved since the last inspection? 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 DS0000048418.V298068.R01.S.doc Version 5.2 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.V298068.R01.S.doc Version 5.2 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): 234 Quality in this outcome is Good. This judgement has been made using available evidence including a visit to the service. Service users and their families can be confident that their needs will be assessed and that a structured introduction to the home will be carried out in order to ensure the service meets their needs. EVIDENCE: The pre-admission assessment for one new service user was seen. The document contained comprehensive information detailing the physical and emotional needs of the person and had been agreed and signed. There is a structured approach to introducing new service to the home and day and overnight visits are carried out. In order to assess the compatibility of service users, the home ensures that trial periods are agreed. Service users confirmed that they had visited the home before moving in. Fairhaven DS0000048418.V298068.R01.S.doc Version 5.2 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): 6789 Quality in this outcome is Good. This judgement has been made using available evidence including a visit to the service. The home ensures that the staff team are aware of the needs of the people they support by producing clear and concise care plans and risk assessments, which are regularly reviewed and updated EVIDENCE: The care plans for four service users were tracked with any relevant issues being discussed with the service users and staff team. Care plans contained detailed information regarding the personal and emotional needs of each person and had been agreed and signed with service users. The plans are regularly reviewed and updated and an annual full review is carried out with the sponsoring authority. Risk assessments are also in place, which cover both personal and environmental issues and these were also current and reviewed. Fairhaven DS0000048418.V298068.R01.S.doc Version 5.2 Page 10 It was clear from speaking to service users that they were encouraged to be as independent as possible and they are involved in decision-making and in the running of the home. Although there is comprehensive information available to inform the staff team of the needs of the people they support, documents are currently stores in several different files, which can make information difficult to track, especially for new staff members. The deputy manager Mr. Foord said that the home was currently changing to a new system of recording, which will pull all of the information together. Fairhaven DS0000048418.V298068.R01.S.doc Version 5.2 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): 11 12 13 14 15 16 17 Quality in this outcome is Good. This judgement has been made using available evidence including a visit to the service. Service users have access to educational and leisure facilities and are included in the local community. People are supported to maintain relationships and are provided with good food EVIDENCE: Service users access a variety of community activities and have opportunity for personal development. Most people are very independent and go out and about as they wish. One person said they really liked living by the sea and went for a walk every day and another said they liked gardening both at the home and in an allotment that had been rented. Most people said they liked living right by the sea. Some service users choose to go to college and a variety of community activities are undertaken, including the gym, pubs and clubs, cafes and restaurants and one person said they really liked playing pool. Fairhaven DS0000048418.V298068.R01.S.doc Version 5.2 Page 12 Several service users are currently planning holidays both abroad and in other parts of the country and the staff team are supporting them in saving for this. During the day some people went out for a drive and a drink and others helped with cooking and cleaning. Personal and sexual relationships are addressed in the care planning process and the staff team support people to keep in touch with families and friends. If necessary, personal relationship counselling can be accessed through the local community team. Rights and responsibilities are addressed and discussed during resident’s meetings and also in one to one key working sessions, which are recorded. Any infringements of rights are agreed with the service users and documented and signed. Menu’s show that a variety of home–cooked fresh food is available and service users were seen planning the next week’s menus and shopping list with a member of staff. Nutritional needs are recorded in the care plans and special diets can be catered for. Service users said they really enjoyed the food provided and were included in shopping and preparation. People also said they liked going out for meals and snacks. Fairhaven DS0000048418.V298068.R01.S.doc Version 5.2 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 19 20 Quality in this outcome is Good. This judgement has been made using available evidence including a visit to the service. Service users receive personal care in the way they choose and emotional needs are assessed and supported. Medication is in good order. EVIDENCE: Care plans include information on how each service user chooses to be supported with personal care. Many of the service users in the home are very independent and choose to carry out their own personal care but staff say they are vigilant in observing how people care for themselves to ensure that they are kept well and healthy. Staff members were heard to offer personal care to people in a sensitive and quiet manner and they carried out the care in the service user’s own timescales. The home is involved with a variety of healthcare professionals including, psychiatrists, psychologists, community learning disability and mental health teams and regular reviews are recorded. There have recently been a number of incidents of challenging behaviour in the home, which have included people being physically attacked. This has caused Fairhaven DS0000048418.V298068.R01.S.doc Version 5.2 Page 14 emotional stress to some service users and they have been able to discuss this with the manager and deputy. All records are in place and incidents have been reported to the Commission as required. There is a plan underway, which involves other professionals to resolve the issues. Behaviour management plans are in place and the staff team receive training in conflict management. The home has an agreement with a local pharmacy and uses a NOMAD system for administering medication. Staff members receive training as part of the induction process and also have in-house training in the home’s procedures. Mr Foord said that the home was currently accessing accredited training for all staff. Medication is safely stored and recording sheets were current and in good order Fairhaven DS0000048418.V298068.R01.S.doc Version 5.2 Page 15 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): 22 23 Quality in this outcome is Good. This judgement has been made using available evidence including a visit to the service. Complaints are recorded and acted upon and people are protected from risk of abuse. EVIDENCE: The home has a complaints procedure in place, which is also available in an accessible form for service users. Three complaints from service users and one from a neighbour had been recorded. The complaints had been dealt with in a satisfactory way and outcomes had been recorded. Service users said that they felt confident about making a complaint and said that they were always listened to. Incidents of aggressive behaviour have been recorded and appropriate action is being carried out to ensure that service users are compatible and are not at risk from attack or abuse. Mr Foord said that all staff had received training on the protection of vulnerable adults from abuse, but as yet the certificates of attendance had not been received. Mr. Foord said he would ensure that they were accessed and placed on file. Fairhaven DS0000048418.V298068.R01.S.doc Version 5.2 Page 16 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): 24 25 28 30 Quality in this outcome is Adequate. This judgement has been made using available evidence including a visit to the service. Although the service provides a homely and comfortable environment, the standard of décor needs updating and improving. EVIDENCE: The service provides a homely and comfortable environment for the people who live there. There are two lounges and a dining room with access to courtyard gardens. A tour of the home was undertaken during which all-communal areas and all but three bedrooms were seen. The occupants of these bedrooms had gone out for the day and locked their doors. The front smoking lounge has recently been redecorated as have some of the corridors but the overall impression is that the décor especially in corridors and bathrooms needs to be improved and updated. Mr. Foord showed an improvement plan, which was to be presented to senior management and this included new carpet and redecoration throughout the home. Fairhaven DS0000048418.V298068.R01.S.doc Version 5.2 Page 17 Service users bedrooms had been personalised and were generally clean but some carpets needed cleaning or replacing. Mr. Foord said that some of the identified carpets had only recently been renewed but the regime of deep cleaning needs reviewing and increasing. There is a cleaning rota in place and service users like to take responsibility for some areas, but to ensure the risk of infection is minimised this should be risk assessed. As there is a programme of redecoration and improvement underway, a requirement has not been made, but this area will be considered at the next visit. Fairhaven DS0000048418.V298068.R01.S.doc Version 5.2 Page 18 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): 33 34 35 36 Quality in this outcome is Good. This judgement has been made using available evidence including a visit to the service. Service users are supported by a committed and caring staff team who are supervised, supported and trained. EVIDENCE: Rotas showed that five care staff are available on each shift and the staff on duty on the day of the visit matched with the rota. As staff members came on duty they were seen to refer to a shift plan telling them which duties they would be performing and which service users they would be supporting. Service users spoke very highly of the staff team and said they were kind and very friendly. Staff members were seen to be very respectful and friendly in their dealings with service users and de-escalated anxieties in a gentle manner. One person said, “They are great, and help you to do what you want”. Another service user said, “ they really help me and let me choose where I want to go”. Three staff records were seen and all contained all of the required documentation including Criminal Bureau Checks and two references. A Fairhaven DS0000048418.V298068.R01.S.doc Version 5.2 Page 19 requirement regarding the addition of the inclusion of a previous employment record on the application form has been met. There are good training opportunities available and a matrix of future courses is posted in the home. Training records are still awaiting a number of certificates to be included but Mr. Foord said he would chase them up and put them on file. Regular staff supervision is carried out and recorded and staff members said they found the sessions supportive and informative. Staff meetings are also held on a regular basis and records show that both service user and work issues are discussed. The agenda for the next staff meeting was seen on the staff notice board. Fairhaven DS0000048418.V298068.R01.S.doc Version 5.2 Page 20 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 38 39 41 42 Quality in this outcome is Good. This judgement has been made using available evidence including a visit to the service. The home is well managed, service users views are acted upon and records are in good order. EVIDENCE: A capable and competent manager who has the required skills and qualifications currently manages the home. Allied Care have informed the Commission that the manager will be seconded to another home at the end of June and Sean Foord the deputy manager will then be in day-to-day charge of the home. Mr Foord has many years experience of working with the client group, has completed NVQ4 and is currently waiting to begin the Registered Manager’s Award. Mr. Foord was present during the visit and was conversant with all of the issues in the home. Both service users and staff spoke highly of the current manager Mrs. Rutter and also Mr. Foord. Fairhaven DS0000048418.V298068.R01.S.doc Version 5.2 Page 21 Records for the running of the home were seen and these included incident and accident forms, maintenance records, gas and electrical checks and fire training records. All were current and in good order. The current registration document and insurance policy were also displayed. There is a quality assurance process in place that seeks the views of service users and others by way of satisfaction surveys, the results are then collated and posted on the communication board. There is also a monthly newsletter, which service users are involved in producing and the agenda for the next resident’s meeting had issues added by service users. Service user’s monies are safely kept in a locked safe in the office. When people came to collect their money they signed for it and were asked by the staff to bring back receipts if possible. One service user’s money was checked against the recorded amounts and was found to be correct. Fairhaven DS0000048418.V298068.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 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 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 3 29 x 30 2 STAFFING Standard No Score 31 X 32 X 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 3 X 3 3 x Fairhaven DS0000048418.V298068.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. Standard Regulation Requirement Timescale for action 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 YA30 Good Practice Recommendations To ensure that the home is clean and hygienic at all times the programme of redecoration and refurbishment should be carried out as planned. Fairhaven DS0000048418.V298068.R01.S.doc Version 5.2 Page 24 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.V298068.R01.S.doc Version 5.2 Page 25 - 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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