Inspection on 22/08/07 for Fairhaven Lodge

This inspection was carried out on 22nd August 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Fairhaven Lodge 09/08/06

Fairhaven Lodge 08/02/06

Similar services:

Chirnside House

Emmaus House

East Croft Grange

Craignair

Croston Park Nursing Home

Conifers Nursing Home

Cloisters

Elmsdene Care Home

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

CARE HOMES FOR OLDER PEOPLE Fairhaven Lodge 7/9 Fairhaven Road St Annes Lancashire FY8 1NN Lead Inspector Lesley Plant Unannounced Inspection 22nd August 2007 9:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Fairhaven Lodge DS0000064686.V341394.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Fairhaven Lodge DS0000064686.V341394.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fairhaven Lodge Address 7/9 Fairhaven Road St Annes Lancashire FY8 1NN 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) 01253 720375 F/P 01253 720375 Dr Morgiana Muni Nazerali Carol Elizabeth Williams Care Home 25 Category(ies) of Dementia (25) registration, with number of places Fairhaven Lodge DS0000064686.V341394.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service is registered to accommodate a maximum of 25 service users in the category DE (Dementia) 9th August 2006 Date of last inspection Brief Description of the Service: Fairhaven Lodge is registered to accommodate 25 residents who have a diagnosis of dementia. The home is situated close to both the sea front and the centre of St Annes, meaning that local amenities and facilities are easily accessible. Accommodation is split over three floors, with a stair lift enabling access to the upper floors. Most bedrooms have their own ensuite facilities. There is space at the front of the home for parking and a small, enclosed rear garden where people can sit out in the summer months. There is an activity programme in place, providing motivation and stimulation for those living at the home. Fairhaven Lodge DS0000064686.V341394.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. At the time of this unannounced inspection there were 24 people resident at the home. All of the key national minimum standards, plus the standard relating to staff supervision, were assessed. Time was spent talking to and observing people living at the home. All those living at Fairhaven Lodge have various degrees of cognitive impairment therefore some conversations were brief and limited. The inspector spoke to the manager; the deputy manager, the chef, a care assistant and a relative who was visiting. Records were viewed and a tour of the building took place. Information was also gained from the Annual Quality Assurance Assessment completed by the manager. Questionnaires inviting feedback about Fairhaven Lodge were sent to a selection of individuals who have connections with the home. Four were received from GP’s and nine from relatives. Seven people living at Fairhaven Lodge returned questionnaires, the majority having been assisted to complete this, by a relative. Time was also spent observing staff and people living at the home, engaged in daily activities. Since the last inspection, the Commission for Social Care Inspection has approved an application to increase occupancy at the home from 24 to 25 people. What the service does well: The personal history form, completed by relatives as part of the admission process, gives a good picture of the individuals’ life experiences and this information feeds into the care plan, promoting a person centred approach. Relatives provided much positive feedback about the quality of care provided at Fairhaven Lodge. Comments included; “I am more than pleased with the care my Mother receives at Fairhaven Lodge. I have always been satisfied and mum has been there over 3 years,” and “Dad has been extremely settled and happy at the care home. His mood and behaviour can at times be challenging and staff are sensitive in their management of his care.” Health care professionals in contact with the home made positive comments about the way health needs are met. One GP stated that Fairhaven Lodge is; “a superb care home”. Although mental impairment may limit the ability of some people to make informed choices, the staff try hard to encourage autonomy. Individual Fairhaven Lodge DS0000064686.V341394.R01.S.doc Version 5.2 Page 6 discussions regularly take place with the people living at the home, to try to ascertain choices in certain areas. This individual approach has proved successful and it was evident that decisions made were followed through. It is clear that concerns are taken very seriously and that good efforts are made to resolve any issues. Relatives made a number of positive comments regarding the qualities of the staff team, including; “ always available and visible in communal areas, very approachable and understanding.” Fairhaven Lodge is very well managed. The management team works well, with clearly defined roles and boundaries. Procedures are followed and there are very good systems in place to ensure the smooth running of the home. There are excellent quality assurance systems in place, ensuring that those living at the home and their relatives have every opportunity to air their views and influence life at Fairhaven Lodge. These external and internal qualitymonitoring systems have been consistently applied over a period of time and demonstrate a strong commitment to service development and continuous improvement. What has improved since the last inspection? What they could do better: Although there have been a number of improvements made to the decoration and furnishing of the home, there is still work to be done in this area. Some bedrooms, toilets and the landing areas of the home particularly require attention. Discussions confirmed that there are established plans to continue with the refurbishment programme, and this is evident from the progress already made. Fairhaven Lodge DS0000064686.V341394.R01.S.doc Version 5.2 Page 7 NVQ training needs to be monitored, so that progress is made with achieving the target of having 50 of care staff qualified at NVQ level 2 or above. The inclusion of more focussed and formalised infection control training would improve the staff training at the home. The manager should complete the Registered Managers Award. This is the recognised qualification for her role and would endorse the extensive skills and experience already obtained. 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 Lodge DS0000064686.V341394.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fairhaven Lodge DS0000064686.V341394.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. Thorough assessments ensure that people are not admitted to Fairhaven Lodge unless their needs can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Interested parties are welcome to visit the home, to look around and meet staff, prior to making any decision regarding living at Fairhaven Lodge. Assessments are undertaken by the manager or deputy manager, who are both experienced in this area. Assessments normally take place in hospital or in the person’s home. The files for two people resident at the home were viewed. Assessment information includes details of medical history; self help skills; such as ability to use the telephone, social skills, mobility, speech, appetite, Fairhaven Lodge DS0000064686.V341394.R01.S.doc Version 5.2 Page 10 memory and orientation. Information is also gained from other professionals, such as social workers, as appropriate. Relatives are fully involved and are given a personal history form to complete on behalf of the individual concerned. This asks for important information such as; former occupation, hobbies and outstanding achievements. The personal histories viewed on files help to give a picture of the individuals’ life experiences and this information feeds into the care plan, promoting a person centred approach. Relatives are given an introductory pack containing; the Statement of Purpose, complaints procedure, philosophy of care, residents’ bill of rights, draft contract, the most recent Fairhaven Lodge newsletter and the latest CSCI report. Discussions with the manager confirmed that people are not admitted to the home unless there is confidence that all needs can be met. For example, as a stair lift provides access to a number of the bedrooms, these are only suitable for individuals with specific mobility abilities. People are not admitted to Fairhaven Lodge solely for intermediate care. Fairhaven Lodge DS0000064686.V341394.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. Care plans are regularly reviewed, helping to ensure that health and personal care needs are met. Individuals at the home are protected by policies and procedures for dealing with medication. Privacy and dignity are promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans for three people living at the home were viewed. Care plans detail how needs, identified through the assessment process, are to be met and include social care needs as well as any practical assistance. For one person it was identified that the nominated staff key worker should regularly spend time discussing topics of interest to the individual concerned and also identified the practical assistance required regarding mobility. The deputy manager reviews all care plans at least every month. Each person has a personal care and hygiene chart in their bedroom detailing the support needed and completed by care staff to confirm that personal care such as shaving, has Fairhaven Lodge DS0000064686.V341394.R01.S.doc Version 5.2 Page 12 been attended to. Daily records completed by staff two or three times during each 24-hour period, give a good picture of how each person has been. There is also a good system of annual review, where relatives are invited to discuss all aspects of the persons’ care and support. This is in addition to the more informal discussion that takes place with relatives when they visit the home. Comments from feedback questionnaires completed by relatives included; “I am more than pleased with the care my Mother receives at Fairhaven Lodge. I have always been satisfied and mum has been there over 3 years,” and “My husband suffers from Alzheimer’s badly and they take great care of him. He always looks clean and well cared for and he seems very happy there.” The assessment process addresses health care needs such as nutrition and pressure care. Weight is monitored weekly and records maintained. Health concerns are monitored and good records are kept of any input from health care professionals, such as district nurses and GP’s. A physiotherapist visits the home each week to facilitate a group exercise session, as happened on the day of this inspection. This appeared to be a popular, fun activity, with a high percentage of residents joining in the session. A chiropodist regularly visits the home. Four GP’s completed questionnaires providing feedback about Fairhaven Lodge. Comments were all positive and included; “ a superb care home”, “good knowledge of individual needs and try hard to meet these,” and “ Fairhaven Lodge seems to be a well run establishment. I’ve not encountered any problems.” Risk assessments are in place and these also reviewed regularly. Risk assessments were viewed, which address a range of potential risks, such as mobility, falls, going out alone, bathing and eating. Medication is safely stored in a locked trolley, with surplus stock being stored in a locked cupboard in the basement area, only accessible by staff. Medication requiring refrigeration is kept in the drinks kitchen, which is kept locked. Staff who administer medication have undertaken appropriate training and the medication file contains a record of each staff members sample signature. The member of staff who has specific responsibility for ordering medication explained that the dispensing pharmacist can be approached for advice and gave an example of when this had proved useful. The dispensing pharmacist also carries out an annual audit of medication arrangements at the home. A record is kept of all unused medication returned to the pharmacist. The pharmacist provides the majority of medication in blister packs. The medication administration records viewed were being appropriately maintained, with any handwritten records of prescribed medication being Fairhaven Lodge DS0000064686.V341394.R01.S.doc Version 5.2 Page 13 checked and signed by two staff members. Each record contains a photograph of the individual concerned. The manager explained that arrangements were in place should controlled drugs be prescribed. These would be stored and recorded separately, with only the manager or deputy manager taking this responsibility. The privacy and dignity of those living at the home is given a high priority during the introduction and induction of new staff, as well as being addressed during NVQ training programmes. Screens are used in the double bedrooms, to ensure privacy during times of personal care giving. During the inspection staff were observed spending time talking and listening to individuals at the home and responding with sensitivity, when carrying out their duties. All the residents were nicely dressed, with staff clearly recognising the importance of this in relation to maintaining dignity. In response to the question, “what do you feel the care home does well?” a relative responded, “Treats residents as individuals and respects their rights and privacy.” Another relative commented, “Dad has been extremely settled and happy at the care home. His mood and behaviour can at times be challenging and staff are sensitive in their management of his care.” Feedback from relatives was extremely positive, however two relatives commented that they would like to see better care of clothing and possessions. Some people who live at the home are prone to wandering and occasionally enter others bedrooms and it has been known for some residents to “swap” items they are wearing, such as cardigans. This was discussed with the manager and deputy manager of the home, who are working hard to address any problems. Recent improvements to the laundry arrangements have also been introduced and the care of clothing is discussed during management reviews. Fairhaven Lodge DS0000064686.V341394.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. Social contacts and activities are encouraged and visitors are made welcome. Individuals are supported to make decisions. The menu is varied, with individual preferences being respected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Routines in the home are flexible, with individual preferences being responded to. One person chooses to eat in their bedroom and another prefers to stay in her bedroom during the morning and choices such as these are supported. Details of personal interests are gathered during the assessment process, with the personal history information provided by relatives feeding into the care plan. There is a weekly programme of activities within the home, which includes hairdressing, physiotherapy exercises, bingo, singing and board games. People living at the home are given regular manicures and several ladies showed pleasure at the colour of their nail varnish. Trips out are also Fairhaven Lodge DS0000064686.V341394.R01.S.doc Version 5.2 Page 15 arranged and a singer comes to the home once each month. The activity programme is displayed in the hallway of the home. The home is well placed for accessing local amenities such as shops and cafés. A staff member spoken to explained that people are also supported to go out for short walks and that special consideration is given to those people who do not have regular visitors, or opportunities to go out with their family. Each file contains a communication sheet, where staff record visits from relatives or friends and trips out. Visitors are made welcome, as was evident during the inspection and special occasions, such as birthdays are celebrated. Individuals can entertain visitors in their bedroom, in one of the lounges or in the dining room, which has a corner furnished with easy chairs. Although mental impairment may limit the ability of some people to make informed choices, the staff try hard to encourage autonomy. One person, had her room decorated and was wearing clothing to reflect her favourite colour, which was confirmed by her relative who was visiting at the time of the inspection. Preference discussions take place every month, with records kept. This involves individual discussions with the people living at the home, to try to ascertain choices in certain areas. Each month one or two themes are discussed. Previous discussions have included what flowers people would like in the home, what type of film people prefer and options regarding supper snacks. This individual approach has proved successful and it was evident that decisions made were followed through. A trip to the zoo had been arranged to support an individuals’ liking for animals, certain DVD’s purchased and soup introduced to the suppertime snack menu. These examples illustrate that peoples’ views are encouraged and acted upon. People are able to bring personal possessions into the home and for one person this included her three quarter sized bed. Personal possessions are on display in bedrooms. Due to cognitive impairment, the people living at Fairhaven Lodge are not able to manage their own finances. For most people a relative will do this on their behalf or in some instances a legal representative manages finances. Feedback from relatives confirmed that they are kept informed of important matters. Comments included; “ They always phone or speak in person about any issues.” A three weekly menu is in place, although the chef explained that this was flexible, with alterations being made according to changing preferences. The chef has written information regarding any food dislikes or allergies, and explained how alternative meals are provided as appropriate. Birthdays and special occasions are celebrated and party food provided. Fairhaven Lodge DS0000064686.V341394.R01.S.doc Version 5.2 Page 16 A new kitchen is planned as part of the improvement programme at the home and this may include an open serving hatch, which would allow for residents to observe the kitchen activities. Fairhaven Lodge DS0000064686.V341394.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. There are good procedures in place for responding to concerns. Policies, procedures and good practice promote the protection of those living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A complaints procedure is in place and a copy is given to relatives. Records are kept of any concerns raised and these records were viewed. It is clear that concerns are taken very seriously and that good efforts are made to resolve any issues. The six monthly management review looks at various aspects of the service provided and includes a formal review of any concerns raised and how these have been addressed. There are good opportunities for relatives to air their views, either informally, during the day-to-day operations at the home or during the process of annual care plan review. All efforts are made to support those living at the home to express their views, preferences and opinions. Information from the feedback questionnaires confirms that relatives know how to raise any concern. Training regarding abuse and the protection of vulnerable adults now forms part of the core training programme for all staff and this is also addressed Fairhaven Lodge DS0000064686.V341394.R01.S.doc Version 5.2 Page 18 within NVQ programmes. A member of staff, in post for five months confirmed receipt of this training. Appropriate protection and whistle blowing policies are in place. Staff read these and discuss their content as part of their induction training at the home. Recruitment files show that appropriate checks are undertaken prior to staff being employed at the home. There are good arrangements in place for the safekeeping of money. Fairhaven Lodge DS0000064686.V341394.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. Some furnishings and parts of the home are in need of attention, in order that Fairhaven Lodge provides an attractive place for people to live. The home is clean. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Improvements continue to be made to the decoration and furnishings at Fairhaven Lodge. Since the last inspection two bathrooms have been refurbished to provide a wet room/shower room on the ground floor and a bathroom with assisted bath on the first floor. New bedding and curtains have been purchased for the bedrooms and a number of the bedrooms have also been fitted with new flooring. New curtains and light fittings have been Fairhaven Lodge DS0000064686.V341394.R01.S.doc Version 5.2 Page 20 provided for the two lounges and the rear garden area has been made more attractive, with a greenhouse now in place. The main kitchen has been provided with a new cooking range and keypads have been fitted to the door of this main kitchen and also to door of the smaller kitchen used for making drinks. These provide added safety for those living at the home. A corner of the dining room has been furnished with easy chairs, providing an alternative area for people to sit or talk to visitors. Following the last inspection a request was made for the fire safety agency to visit the home to provide advice regarding the use of the stair gates, access on the third floor and access to the kitchens. The fire safety agency reported that they were satisfied with the arrangements in place. A recommendation was made to renew some of the door seals and this has been promptly attended to. There are clear plans in place for the refurbishment of the home to continue, with new lounge and dining furniture soon to be delivered. There are plans to refurbish the main kitchen, improve access to the rear garden, redecorate the hallway and doors and renew the ground floor toilets. Consideration is also being given to the building of a conservatory. The planned redecoration, particularly of the landing areas and remaining bedrooms, and the refurbishing of the ground floor toilets, will greatly improve the appearance of the home. Relatives commented via feedback questionnaires that they were pleased with the improvements being made to the building and furnishings. The manager is aware of the need to liaise with the relevant agencies regarding any structural changes at the home. There are no domestic staff employed at the home. The chef takes responsibility for cleaning the kitchen and the night staff clean the main communal areas of the home. Care staff also undertake domestic duties during the day and a cleaning schedule is in place. All areas of the home appeared clean and fresh. The laundry facilities are sited in the basement and are only accessible to staff. Fairhaven Lodge DS0000064686.V341394.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. The home is staffed appropriately and NVQ (National Vocational Qualification) training is being promoted, providing opportunity for staff to develop further skills in their work. Recruitment procedures promote the protection of those living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff rotas were viewed and show that four care staff are on duty each morning, three staff each evening and two night staff are on working duty during the night. These staffing arrangements were in place on the day of this unannounced visit. The manager and/or the deputy manager are on duty each day and can provide additional direct care support if required. The chef generally covers kitchen duties until the afternoon and then carries out maintenance or gardening tasks. There are no domestic staff employed, with care staff carrying out cleaning duties as part of their role. The working night staff are responsible for cleaning the communal areas of the home. The manager explained that additional staffing arrangements are put in place if required, such as if an individual is ill and needs more support. Fairhaven Lodge DS0000064686.V341394.R01.S.doc Version 5.2 Page 22 Feedback from relatives was positive, with a number of people commenting on the personal qualities of staff. One relative stated; “staff always behave professionally and appropriately,” “staff seem to enjoy an affectionate and therapeutic relationship with ***” and “ always available and visible in communal areas, very approachable and understanding.” NVQ training is promoted and at the last inspection over half of the care staff team were NVQ qualified at level 2 or above. There have been a number of staff changes during the past year and several qualified staff have left the home, either for promotion elsewhere or to move to other parts of the country. This turnover of staff was discussed with a relative who was visiting at the time of the inspection visit, who confirmed that changes in staffing did not appear to have had any detrimental affect. However a relative who completed a feedback questionnaire commented that, “too many changes unsettles residents.” The inspector discussed the staff turnover with the manager, who confirmed that the changes had been due to matters out of her control, such as two staff who had left the area. It is anticipated that the current staff team will remain settled, although future changes cannot be guaranteed. The manager and deputy manager regularly review the staffing arrangements at the home. At present there are four members of the team who are qualified at NVQ level 2 or above and seven staff are currently enrolled on NVQ programmes. Both the manager and deputy manager aim to qualify as NVQ assessors, which would help progress in this area. The recruitment records for a recently appointed member of staff were viewed. Appropriate checks take place and good recruitment procedures are followed. Checks include references, a criminal records bureau (CRB) disclosure and a check against the protection of vulnerable adults (POVA) register. A POVA check was in place for this new staff member and she was working under supervision until the full CRB disclosure had been received. Staff are supplied with a copy of the General Social Care Council code of conduct. New staff meet with the manager, prior to their first duty at the home, in order to discuss important induction information. This initial induction includes information regarding the home, employment details, safety issues such as the fire procedure and the standard of work expected. There then follows a structured induction programme, whereby staff read policies and procedures and the corresponding training papers for each topic, are observed in their work practice and asked questions to check their understanding. A senior member of staff, confirms competency and understanding of the topic and signs off each area. Records of these inductions were viewed. There is also a core programme of external training courses, which staff attend. These include; health and safety, food hygiene, medication, moving and handling and POVA. Discussion with a member of staff in post for five Fairhaven Lodge DS0000064686.V341394.R01.S.doc Version 5.2 Page 23 months confirmed that the structured induction programme had been completed and that two of the core training courses had been attended, with three more courses planned shortly. Dementia training now forms part of this core-training programme and is provided by a health care professional from the local hospital. The majority of staff attended a dementia course in March of this year, with another course planned in September, which will mean that all staff, even the latest recruits have received this specialist training. Infection control is addressed during the induction period, with staff reading the policy, the training notes and answering questions to check their knowledge. Infection control also forms part of the food hygiene programme attended by all staff. However, as care staff at Fairhaven Lodge carry out a range of tasks, including cleaning, personal care and some food handling, it is important that specific training is in place. The deputy manager explained that their had been difficulties in finding an available infection control course but that this should soon be resolved. Generally staff training appears to be well organised, with a good induction programme and basic training programme in place. The inclusion of more focussed and formalised infection control training would improve the staff training at the home. Fairhaven Lodge DS0000064686.V341394.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is good. People benefit from living in a very well managed home. Policies, procedures and good practice help to ensure that the quality of the service is monitored and that individuals are supported to air their views. Individuals’ financial interests are safeguarded and health and safety is promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager is registered with the CSCI and has extensive experience within the care sector. The manager provides strong leadership at the home, has achieved NVQ level 4 and is soon to complete the Registered Managers Award. Fairhaven Lodge DS0000064686.V341394.R01.S.doc Version 5.2 Page 25 The completion of this qualification will mean that the manager meets the formal requirements of the CSCI. The deputy manager, who carries out certain managerial responsibilities, supports the manager in her role. This management team works well, with clearly defined roles and boundaries. Procedures are followed and there are very good systems in place to ensure the smooth running of Fairhaven Lodge. There are excellent quality assurance systems in place, ensuring that those living at the home and their relatives have every opportunity to air their views and influence life at Fairhaven Lodge. As well as informal day-to-day opportunities for relatives to share their views, there are more formal systems in place. Relatives are invited to annual care plan reviews and a feedback form is given out when an individual leaves the home. Feedback questionnaires are distributed every six months, with three people at the home able to complete these and the remainder being sent to relatives for completion on behalf of the individual. A quarterly newsletter is also distributed to all relatives. The monthly preference discussions, which take place on an individual basis work extremely well and promote decision making for people who may have difficulty in expressing their desires or wishes. There is a formal six monthly management review, with detailed minutes being kept. The registered provider, manager and deputy manager meet to review all aspects of the service provided, with an action plan being set. The registered provider carries out monthly audits and produces a report, which is sent to the CSCI. The home has also achieved ISO 9000 certification, which is an externally accredited quality monitoring system. The robust supervision arrangements provide good opportunity to give staff feedback regarding work performance and so promote quality within the home. These external and internal quality-monitoring systems have been consistently applied over a period of time and demonstrate a strong commitment to service development and continuous improvement. There are good procedures in place regarding the management of finances. There are arrangements in place for a small amount of money to be held in safekeeping for each person, for such things as hairdressing costs and incidental items. Money is safely held, with good records maintained. The account and money held for one person was viewed and checked, with the balance held being correct. Each person living at the home has an account sheet and an account book. People are given a receipt for any money they leave for their relative. A record is kept of all income and expenditure and each month a copy of the account is sent to the named relative. Fairhaven Lodge DS0000064686.V341394.R01.S.doc Version 5.2 Page 26 The manager carries out all staff supervisions at Fairhaven Lodge. Records show that supervisions take place every two months. A staff member, in post for five months, confirmed that she had had two such meetings and that she felt they were extremely valuable and had been useful to her as a new staff member, particularly to gain feedback about her work performance. The in house induction and the core training programme, address health and safety issues. A fire risk assessment is in place and there is a good system of regularly assessing the knowledge of staff regarding fire safety. Records viewed included, fridge and freezer temperatures, hot water temperatures, the gas safety certificate, the electrical installation certificate, the testing of electrical appliances, and records of fire equipment and the stair lift being maintained. Risk assessments are in place and there is a separate risk assessment for each room in the building. Fairhaven Lodge DS0000064686.V341394.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 4 X 3 3 X 3 Fairhaven Lodge DS0000064686.V341394.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? YES 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 OP19 Regulation 16 and 23 Requirement Bedrooms in need of decoration/refurbishment must be attended to. (Previous timescale not met.) Bathrooms/shower rooms in need of redecoration/refurbishment must be attended to. (Previous timescale not met.) Timescale for action 31/01/08 2. OP19 23 30/04/08 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. Refer to Standard OP28 OP30 Good Practice Recommendations Progress with NVQ training should be monitored and the home achieve the target of having 50 of care staff qualified at level 2 or above. The inclusion of more focussed and formalised infection control training would improve the staff training at the home. DS0000064686.V341394.R01.S.doc Version 5.2 Page 29 Fairhaven Lodge 3. OP31 The manager should gain the Registered Managers Award. Fairhaven Lodge DS0000064686.V341394.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 Lodge DS0000064686.V341394.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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