Inspection on 25/09/07 for Fairhaven [Gloucester]

This inspection was carried out on 25th September 2007.

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 [Gloucester] 12/04/06

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Fairhaven Wolesley Road Elmbridge Gloucester Gloucestershire GL2 0PJ Lead Inspector Mr Richard Leech Key Unannounced Inspection 15:30 – 25 & 26 September 2007 19:15 & th th X10029.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 Fairhaven DS0000066990.V349502.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 and 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 DS0000066990.V349502.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fairhaven Address Wolesley Road Elmbridge Gloucester Gloucestershire GL2 0PJ 01452 530112 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) www.brandontrust.org The Brandon Trust Miss Abigail Clare Rees Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (3), Physical disability (2) of places Fairhaven DS0000066990.V349502.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home providing personal care only- Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories: Learning disability- Code LD Physical disability- Code PD 2. Learning disability, over 65 years of age- Code LD(E) The maximum number of service users who can be accommodated is 5. Date of last inspection 12th April 2006 Brief Description of the Service: Fairhaven provides care for five adults with learning and physical disabilities. There are two bedrooms on the ground floor and three on the first floor. A stair lift is provided to make the upstairs more accessible. There is a lounge, kitchen and dining area as well as enclosed garden with a patio. The home is close to a range of facilities and is near to the city centre. Transport is provided to enable people living in the home to access the local community. The home is run by the Brandon Trust, who took over as service provider in April 2006. Up to date information about fees was not obtained during this visit. Prospective service users and their supporters would be provided with information about the home including copies of the Statement of Purpose and Service Users Guide. Fairhaven DS0000066990.V349502.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection began on a Tuesday afternoon continuing into early evening. A return visit was made on the following day from mid morning to late afternoon. During the visits all of the people living in the home were met, along with many of the staff team. The manager was not present during the inspection. All of the communal areas were checked along with some of the bedrooms. Various records were looked at including examples of care plans, medication charts, training certificates, policies and procedures and healthcare notes. Before the inspection the manager completed an Annual Quality Assurance Questionnaire (AQAA). This is a self-assessment of how the service is performing and also includes plans for further improvement as well as statistical information. Surveys were distributed to people with an interest in the home as well as to the people living there, resulting in a good response rate. Some key findings and comments from the surveys are included in the report. What the service does well: A good care planning system is in place, helping to ensure that people’s needs are clearly documented and that appropriate support is provided. This includes helping service users to access healthcare services (although there is potential to improve some areas of healthcare planning and support). Medication is well handled in the home. There was evidence that the people living in the home are settled and happy, and that staff are knowledgeable about their support needs, personalities and preferences. People living in the home are treated with respect and as individuals. Their privacy and dignity are maintained. They are offered choices in everyday life, helping them to feel more in control of their lives. The people living in the home are supported to have a balanced diet appropriate to their needs. There are plans to further extend choice and variety around eating and drinking. People take part in activities which reflect their needs and interests, and are supported to stay in contact with family and friends. There are good systems for helping the people living at Fairhaven and others involved in their care to raise issues and concerns. Appropriate steps are also taken to protect the people living in the home from harm and abuse. Fairhaven DS0000066990.V349502.R01.S.doc Version 5.2 Page 6 Whilst there have been changes in the team, staffing levels are being maintained. Although it has been necessary to use temporary staff efforts are made to ensure that the same care workers return so that they know the people living in the home. Staff are supported to access appropriate training and to gain relevant qualifications. There was positive feedback about the manager and evidence throughout the inspection that service is well run. There is a robust approach to handling service users’ money, helping to protect the financial interests of the people living in the home. Health and safety is well managed. Positive feedback was obtained from people’s relatives and from health & social care professionals. What has improved since the last inspection? What they could do better: Fairhaven DS0000066990.V349502.R01.S.doc Version 5.2 Page 7 The Statement of Purpose and Service Users Guide would benefit from further review and update. Whilst staff do their best to maintain a pleasant environment, some substantial work is needed to make the home a safer and more comfortable place to live. Some recommendations are made for consideration by the team. These are described in the main body of the report. 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. Fairhaven DS0000066990.V349502.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Fairhaven DS0000066990.V349502.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Good information is available to help prospective service users and their supporters to make a choice about the home, although some further amendments are needed to bring this fully up to date. A reasonable framework for assessments and admissions is in place, although further support for the manager in handling admissions should promote greater confidence in this area. Fairhaven DS0000066990.V349502.R01.S.doc Version 5.2 Page 10 EVIDENCE: An updated Statement of Purpose (dated July 2006) was seen, though not checked in detail. The Service Users Guide had also been updated and included photographs of the home to make it more accessible. Further updates are needed since the documents referred to the NCSC (rather than CSCI) and to the former rather than current Responsible Individual. It is good practice to review and update the documents at least annually in any case. The Trust’s admissions procedure dated 2000 was seen, along with an in-house assessment format and procedure. These provide a sound framework for handling referrals and admissions. It is understood that an updated admissions procedure from the Trust is imminent, given that the existing one predates the National Minimum Standards. There had been no new admissions since the previous inspection. In the AQAA the manager reported having had no experience of overseeing an admission and that her knowledge of this area was not high. The standard is assessed as met on the basis of the framework and tools available. However, as with all services, actual practice will be considered during future visits. Clearly the manager would benefit from support when handling an admission. Greater confidence may be gained in the meantime from input such as training, peer support, discussions in supervision meetings or through being involved in an admission to another service run by the Trust. Fairhaven DS0000066990.V349502.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A good care planning system is in place, helping to ensure that people’s assessed and changing needs are clearly documented and that appropriate and consistent support is provided. People are assisted to access the healthcare services that they need, promoting their wellbeing, although there is potential to improve some areas of Fairhaven DS0000066990.V349502.R01.S.doc Version 5.2 Page 12 healthcare planning and support. Medication is appropriately handled, helping to ensure that people remain safe and well. People living in the home can be confident that they will be treated with respect, promoting their dignity and self-esteem. EVIDENCE: Care plans for two of the people living in the home were looked at. Each plan had a clear aim and rationale. This was accompanied by a description of the person’s needs, routines and behaviours and what support staff needed to offer. The care plans covered significant areas such as personal care, activities, communication, health, behaviours, eating & drinking, daily routines and safety. They provided clear guidance for staff. There was a system of monthly reviews. Amendments were seen to be made regularly. The plans made reference to people’s needs, choices, preferences and to issues such as respecting privacy and dignity and promoting independence. Further background information was contained in files such as a personality profile and basic details. These appeared to be fully up to date. Essential lifestyle plans (a tool for person-centred planning) were in place, providing further valuable information about people’s preferences, interests and lifestyle choices. There was documentary evidence of regular reviews taking place involving people with an interest in the person’s care. The AQAA referred to further developments in person centred planning taking place. This included for each resident to have a person-centred plan overseen by one of the Trust’s trained facilitators. Discussion with staff provided evidence that this process was underway. Staff described how they involved residents in care planning, for example by day to day observation, monitoring and recording of whether they appeared happy with how they were being supported. Risk assessments for the same two people were checked. Individual assessments covered areas such as environmental considerations, mobility, transport, bathing and safety when eating & drinking. Monthly evaluation sheets provided evidence of regular review of risk assessments. Some original risk assessments had been written many years before, such as in 2002, 2000 and 1997. Although there was evidence of review and update, in such cases it would be better to completely revisit and rewrite the risk assessment, Fairhaven DS0000066990.V349502.R01.S.doc Version 5.2 Page 13 particularly where there have been many handwritten changes which may compromise clarity. As noted, health information was included in care plans. Files also contained assessments and guidance from specialist healthcare services, providing evidence of appropriate referrals and clear links with community teams. Staff reported that a district nurse visited the home regularly to help meet one person’s specialist needs, but also providing advice and guidance in respect of other people living in the home. Files contained some health profiles and hospital assessments, though in some cases these were not complete. There were also some partially completed Health Action Planning formats. The information requested in these formats should be filled in as they are potentially useful summaries of people’s health and related support needs for the home, and for hospital staff in the event of an admission. Healthcare records were well organised and included clear write-ups of appointments and outcomes. However, these records indicated that some routine checks (oral and eye health) may be overdue for some people. This should be looked into and appointments made if necessary. Staff spoken with demonstrated awareness of people’s healthcare needs and how these were met. Positive feedback was obtained from healthcare professionals completing surveys. Comments included about staff being quick to pick up on health issues, the residents being well cared for and that they led active lives. Staff were referred to as helpful, respectful and knowledgeable, and the residents as happy and settled. One comment was made about ensuring that staff supporting service users at medical appointments needed to make sure that they were fully aware of the issues that would be discussed. Medication storage and records appeared to be fully in order. Documentary evidence was seen of staff being trained in-house and externally in the handling of medication. There was also evidence of a recent reassessment of competency in the light of some medication errors, although this exercise had not yet been completed for all staff. Notifications to CSCI provided evidence of appropriate action being taken at the time when the errors were realised. Examples of protocols for medication to be administered when required were seen, though these were not signed and dated. Local and national guidance about handling medication in care homes was seen to be available. The Trust has a policy about handling medication dating from 2000, although it was reported that has been updated and that the new version would be rolled out soon. Fairhaven DS0000066990.V349502.R01.S.doc Version 5.2 Page 14 A copy of a British National Formulary (a reference book about medication) dating from 2004 was in the home. A more up to date copy should be obtained. The Statement of Purpose and individual care plans provided information and practical guidance about how people’s privacy and dignity was respected. Care plans also provided information about people’s preferences, needs and routines in personal care. Interaction by staff was observed to be courteous and respectful. The people living in the home were seen to be dressed individually and to exercise choice about their appearance. The AQAA gave examples of how equality and diversity issues were considered by the team, including through recognising people as individuals with their own needs, interests, cultures and beliefs. Discussion with staff provided clear evidence of awareness of care plans (including recent changes), people’s needs and conditions and of the importance of respecting people’s privacy and dignity. This was further supported by observations throughout the inspection. Fairhaven DS0000066990.V349502.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home are enabled to access activities appropriate to their needs and interests, and to stay in contact with family and friends, enhancing their quality of life. They are offered choices in everyday life, helping them to feel valued and in control of their lives. People are supported to have a balanced diet appropriate to their needs, promoting their wellbeing. Plans to extend choice and variety around eating and drinking should further enhance people’s enjoyment of their food. Fairhaven DS0000066990.V349502.R01.S.doc Version 5.2 Page 16 EVIDENCE: Care plans described people’s activities and had guidelines for the support required for each one. A photographic activity board in the lounge was in use as part of the home’s total communication approach. Staff were aware of the importance of people knowing what was planned for the day in respect of particular needs and conditions. Daily records were checked for two weeks of September 2007 to establish how people had spent their time. These provided evidence of people being supported to access a range of activities in the home and community appropriate to their needs, ages and interests. This included evening and weekend activities. Staff were seen to offer more spontaneous activities such as taking one person to the local shop. They also described helping people to access local services such as hairdressing salons, pubs, shops and leisure facilities. Discussion with staff provided evidence of holidays being provided for people. The team had begun preparing a ‘community map’ – a folder with leaflets and information about local facilities and services, along with ideas for new activities to try. The Statement of Purpose noted an ‘open door’ policy for visitors and relatives and the support that was offered people to stay in contact. Discussion with staff along with daily records and care plans provided clear evidence that people were assisted to stay in touch with family and friends. There was also information about birthdays and contact details. Surveys forms from family members provided very positive feedback about the service. There was praise for activity provision, residents’ privacy being respected, the quality of personal care and for treating people as individuals. There was also reference to their relatives being happy living in the home. Staff spoken with gave examples of how the people living in the home were offered choice, such as about activities, routines, food & drink, clothing and personal appearance. They also described how people with different communication needs made their views known. Care plans included information about how each person communicated and also made reference to promoting choice as much as possible. Daily records and observations provided evidence of people being offered choices in everyday life such as about how they spent their time and when they went to bed. Fairhaven DS0000066990.V349502.R01.S.doc Version 5.2 Page 17 A mealtime was observed. People appeared to be enjoying their food, which was freshly prepared and attractively presented. Some of the people living in the home were asked if they had enjoyed the meal and confirmed that they had. They were also asked about the food in general, and indicated that they were happy with it. People’s activities include a regular lunch club and other opportunities to have meals out. As noted, care plans referred to eating and drinking issues, including special dietary and support needs. These were underpinned by specialist assessments and advice from speech and language therapy and dietician services. Staff spoken with demonstrated awareness of the care plans and guidance. A five-week menu was in operation. Staff said that they hoped to extend this to an eight-week menu to introduce more variety, and said that alternatives were available if people did not want what was being prepared. The AQAA described plans to offer a more varied menu and more choice. Fairhaven DS0000066990.V349502.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home and others involved in their care are confident that they can raise issues and concerns, helping them to feel listened to and reassured. Arrangements are in place which help to protect the people living in the home from harm and abuse. EVIDENCE: It was reported in the AQAA that there had been no formal complaints in the last 12 months. The manager referred to the total communication approach and the team’s culture as helping the people living in the home to express their thoughts and views. It was also stated that the local complaints procedure had been updated and that ‘I want to complain’ forms were included with clients’ contracts. The Trust and in-house complaints procedures were seen. Fairhaven DS0000066990.V349502.R01.S.doc Version 5.2 Page 19 As noted, care plans included information about how each person communicated. Staff spoken with were able to describe how they would know if different people were unhappy or upset and how they would respond. Most relatives completing surveys forms indicated that they knew how to make a complaint if necessary and had received a good response to any issues they had raised. One respondent did not know how to complain. Some of the people living in the home were asked if they felt able to speak up if they were unhappy about something. They indicated that they did. The AQAA stated that the service could be better at reminding people of their right to complain, and described plans for creating an in-house pictorial complaints procedure to help with this. This would be a positive development. Health and social care professionals completing surveys indicated that they would be confident about raising any concerns/issues with the team and felt that they would get a positive response. The Trust has policies covering safeguarding adults and whistle blowing, although the latter dated from 2000 and should be reviewed. A copy of the local Adults at Risk procedures were seen in the home. Records provided evidence that staff had received recent training covering adult protection and abuse. Discussion with staff demonstrated a good understanding of issues and responsibilities in this area. People expressed confidence about being able to report concerns if they needed to. Some of the people living in the home were asked if they felt safe and secure there, and indicated that they did. Fairhaven DS0000066990.V349502.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Some improvements are needed to the environment in order to make the home a safer and more pleasant place to live. Fairhaven DS0000066990.V349502.R01.S.doc Version 5.2 Page 21 EVIDENCE: Bedrooms were seen to be spacious and personalised. Some of the people living in the home were asked if they were happy with their rooms, replying that they were. Specialist equipment was seen to be provided as necessary. Staff pointed out some new multi-sensory equipment in one person’s room. The lounge and dining room appeared comfortable and pleasantly decorated. The team had redecorated the dining room since the previous inspection. Staff pointed out some issues in the laundry room, located in an annexe. The floor was ridged and grooved, making it very difficult to clean. Staff also reported that they would like a proper hand basin and sluice facility, and that the ceiling should be made flat. In the adjoining garage the light switch was located such that it was necessary to cross the room before it could be switched on. Staff said that the light was usually left on at night as a result. The light switch should be moved, or another fitted, so that the light can be turned on when people enter the room from the laundry area. Staff said that some problems with the shower room had been reported to the Housing Association on several occasions. It was stated that the stainless steel tray had sharp edges as well as being slippery at times. It was also reported that the doors kept breaking, that the shower holder was broken and in an inconvenient location forcing staff to lean, and that the grab rails needed to be re-sited. In addition one of the side panels was missing at the time having been broken. The manager had written a risk assessment about the missing panel on the shower surround. Staff felt that an ordinary shower tray would be suitable, and said that an Occupational Therapist had concurred with this view. Staff were also concerned about the kitchen. Some of the metal strips around work-surface joins had sharp edges. The work surface itself was damaged in places, presenting hygiene issues. Some units were in a poor state of repair with missing handles and ill-fitting doors or drawers with gaps. Staff also said that the oven tower was in a location which could be a hazard when service users accessed the room, and that the hinge and seal had kept breaking and were unreliable. It was also stated that it was quite high, meaning that staff had to reach up and over to open it. The home has a well-maintained back garden. Records indicated that this was regularly used by the people living in the home. Staff reported that the dining room doors were likely to be replaced as they had been assessed as a fire and security hazard. Fairhaven DS0000066990.V349502.R01.S.doc Version 5.2 Page 22 It was reported that the Housing Association was going to be replacing the flooring/carpets throughout the house in the near future. This will be a positive step as some areas were becoming worn and stained. The ground floor bathroom radiator should be replaced as it was rusting and had peeling paint. Some of the light shades in the home were becoming dirty and filling with dead insects. These should be cleaned. Staff said that the Housing Association had to be called for this job and for changing bulbs due to the nature of the lights. They had requested that new ones be fitted that could be maintained by the staff on site. The letterbox on the front door had gaps. This should be draught proofed, particularly with colder weather coming. There was some damaged paintwork around the home such as on skirting boards and doorframes. This would benefit from being freshened up. A letter was seen from the manager to the Housing Association with a list of requested improvements, including to the shower room, providing evidence of issues being chased up. A maintenance book provided further evidence of this. A night file was seen which included some general cleaning duties and a ticklist to indicate completion. The home was seen to be clean throughout during both visits. Service users completing surveys indicated that the home was always fresh and clean. Protective equipment was seen to be available for staff to use when necessary. There was discussion with staff about mobility and other issues in relation to the environment. The team is aware of, and planning for, probable changes in people’s conditions which may result in it no longer being possible to meet their needs at Fairhaven. Fairhaven DS0000066990.V349502.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Whilst there have been changes in the team, staffing levels are being maintained and steps taken to ensure that temporary staff know the service users, promoting the consistency of care. Staff are supported to access appropriate training and to gain relevant qualifications, helping to ensure that the quality of care is high. Updating the recruitment and selection policy would help to make the framework for employing new staff more robust. EVIDENCE: Fairhaven DS0000066990.V349502.R01.S.doc Version 5.2 Page 24 Staff reported that there had been some turnover of staff since the last inspection. In addition one person was on secondment and there were some issues around sick leave. This was resulting in the team feeling stretched. However, it was also reported that bank staff were being used and that it was generally possible to have the same people each time to promote continuity and consistency. Staff spoken with felt that there had been no negative impacts on the people living in the home and that they were continuing to take part in their usual activities in the home and community. Service users completing surveys indicated that staff treated them well. According to the AQAA of the 10 permanent staff five had achieved National Vocational qualification (NVQ) level 2 or above in health and social care, with a further three people working towards an NVQ. It was also reported that there was a qualified assessor in-house and that the manager was working towards becoming an assessor. The senior social care worker was due to begin the NVQ level 4 in health and social care in September 2007. Training records and accompanying certificates were looked at for three staff. These provided evidence of mandatory training being up to date or booked for the near future. Staff had also accessed additional training such as about dementia, adult protection, signing, diabetes and the handling of medication. The manager had attended training about the Mental Capacity Act. One person was attending training about autism in the week following the visit. Some training that people had done was not recorded on their training files. These should form a complete record of people’s training. Staff spoken with were satisfied with the training provided. People particularly commented on how valuable the training about people’s specialist conditions had been. There was discussion about whether it may be helpful to have training in other areas such as about obsessive-compulsive disorder and pressure care. Staff said that having access to the Internet and E-mail was allowing them to do more research and to obtain answers to questions more quickly. Some information from the Internet about health conditions was seen on files. The Trust’s recruitment and selection policy was dated April 2004. This predates PoVA and associated changes to the Care Homes Regulations (although other more up to date policies and procedures did refer to staff being checked against the PoVA list). It should therefore be reviewed and updated. A policy about probation periods was seen dated July 2007. No new staff had been recruited since the previous inspection. Staffing files were therefore not checked in detail. The AQAA noted that the manager and senior care worker had attended training about recruitment. Fairhaven DS0000066990.V349502.R01.S.doc Version 5.2 Page 25 The handover file was seen, containing key events and information for the next shift. The communication book provided evidence of a good flow of information within the team, such as about changes to care plans, maintenance issues and people’s healthcare. A file provided evidence of team meetings taking place about every two months. An agenda was on display for a meeting on September 28th 2007. Files provided evidence of further meetings taking place for managers, senior care workers and support workers across the Trust. An in-house policy and procedure file provided information on how to go about certain tasks in the home. There were also documents such as the aims of the team and an in-house induction pack to supplement the Trust’s induction. The AQAA described plans for developing a ‘how to do’ file to ensure that all team members were clear about how certain things were done in the home. Fairhaven DS0000066990.V349502.R01.S.doc Version 5.2 Page 26 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Fairhaven DS0000066990.V349502.R01.S.doc Version 5.2 Page 27 The home is well run, helping to promote the wellbeing of the people living there as well as the cohesiveness and morale of the staff team. A framework for quality assurance is in place, helping to monitor, maintain and improve the quality of care provided. There is a robust approach to handling service users’ money, helping to protect the financial interests of the people living in the home. Health and safety is well managed, helping to safeguard the people living and working in the home. EVIDENCE: Documentary evidence was seen that the manager had obtained the NVQ 4 in health and social care and the Registered Manager’s Award. Training records also indicated that she had attended a range of appropriate courses such as about performance management, diversity and supervisory development. Staff were very positive about the manager, describing her approach as very fair, client-centred, approachable and receptive to ideas. In the last report a requirement had been made to establish and maintain a system for reviewing and improving the quality of care. The AQAA stated that this had been done. Staff described what had been introduced. This included creating a series of survey forms for staff, service users, relatives and professionals. Some had been sent to family members. Staff had also completed forms for discussion in supervision meetings. Other survey forms were due to be distributed in the future. The results will then be compiled into a report with any actions arising. It was stated that one outcome so far had been a recycling initiative. The manager had completed a self-audit against the Trust’s own quality standards, resulting in an action plan for 2007/2008. Good progress has been made with implementing requirements and recommendations from previous reports. Reports from visits made under Regulation 26 are being regularly forwarded to CSCI. One person living in the home confirmed that they were a member of a Brandon Trust group which meets periodically to discuss issues and give feedback about the service. Fairhaven DS0000066990.V349502.R01.S.doc Version 5.2 Page 28 As noted, there is a focus in the home on developing and improving the total communication strategy in order to enable people’s thoughts and views to be more easily expressed and understood. Arrangements for handling service users’ money were checked. Records and receipts were sampled and appeared to be in order. Staff described a recent tightening up of procedures. Balances are now checked at every shift handover and all entries for checks and transactions are double signed. Records were seen evidencing this. The Trust has a health and safety policy dated July 2007. There was also a range of specific policies and procedures related to different areas such as moving & handling, fire safety and management of chemicals in the home. Staff who were asked felt that health and safety was well managed in the home. The fire logbook provided evidence of tests and drills taking place at reasonable intervals. The manager had completed a fire risk assessment in November 2006, although this was not looked at during this visit. Records were seen for weekly vehicle checks and for monthly health and safety audits. There was also documentary evidence of routine checks on equipment and on gas and electrical appliances (although PAT testing appeared to be due again around the time of the visit). Fridge and freezer temperatures were sampled and looked to be in order. There was a copy of a ‘Safer Food – Better Business’ pack in the kitchen. The AQAA referred to plans to fully implement this. The senior care worker had been on training about it and described how, following a self-audit, she would be rolling out training and updated kitchen procedures. The above had been one of the recommendations from an Environmental Health visit in November 2006. The home had achieved three stars, equating to ‘good’. It was also recommended that new chopping boards be purchased. Staff confirmed that this had been done. There was a suggestion to fit an insect killing device. This had been obtained but some electrical work needed doing before fitting. This had been reported to the Housing Association. Fairhaven DS0000066990.V349502.R01.S.doc Version 5.2 Page 29 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 2 x 3 3 4 x 5 x 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 ENVIRONMENT Standard No Score 19 2 20 x 21 x 22 x 23 x 24 x 25 x 26 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 x 33 3 34 x 35 3 36 x 37 x 38 3 Fairhaven DS0000066990.V349502.R01.S.doc Version 5.2 Page 30 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 2 Standard OP1 OP19 Regulation 6 23 (2) Requirement Timescale for action 31/12/07 3 OP19 23 (2) Review and, where appropriate, revise the Statement of Purpose and Service Users Guide. Undertake necessary work on 31/03/08 the first floor shower facility such that it is safe to use and meets the needs of the people living in the home. Undertake work on the kitchen 30/04/08 such that it is hygienic, safe and fit for purpose. 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 2 3 Refer to Standard OP3 OP7 OP8 Good Practice Recommendations The manager should consider ways of gaining increased confidence in the handling of referrals and admissions. Revisit and rewrite older risk assessments, particularly where there have been many handwritten changes which may compromise clarity. Complete hospital assessments and health profiles (or equivalent Gloucestershire Health Action Planning format) DS0000066990.V349502.R01.S.doc Version 5.2 Page 31 Fairhaven in order that there is full and up to date information for each person living in the home. Revisit whether some people may be due routine healthcare checks as described in text. Arrange appointments if necessary. Ensure that all documents have an author and date, such as PRN protocols. Consider obtaining an up to date BNF. Family members could be reminded of their right to complain and how to do this, in order that they are confident about how to raise issues formally if necessary. Review the whistle blowing procedure dating from 2000. Work should be undertaken on the laundry area to make it easier to clean and more fit for purpose. The letterbox on the front door should be draught proofed. The light switch in the garage should be moved, or another fitted, so that the light can be turned on when people enter the room from the laundry area. Consider replacing the radiator in the ground floor bathroom. Arrange for cleaning of any light shades which are becoming dirty/full of insects. Touch up damaged paintwork around the home, e.g. on some skirting boards. Review and update the policy on recruitment and selection to take into account changes to legislation and practice. Make sure that training files form a complete record of people’s training. Consider whether the team may benefit from further specialist training related to the needs and conditions of people living in the home, such as OCD or pressure care. Undertake necessary electrical work such that the insect killer can be fitted in the kitchen. 4 OP9 5 6 7 OP16 OP18 OP19 8 9 OP29 OP30 10 OP38 Fairhaven DS0000066990.V349502.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection 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. Fairhaven DS0000066990.V349502.R01.S.doc Version 5.2 Page 33 - 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. 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