Inspection on 10/11/05 for Fairhaven Residential Care Home

This inspection was carried out on 10th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 Residential Care Home 13/04/07

Fairhaven Residential Care Home 12/04/06

Fairhaven Residential Care Home 11/10/04

Fairhaven Residential Care Home 17/05/04

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

CARE HOMES FOR OLDER PEOPLE Fairhaven Residential Care Home 76 Cambridge Road Aldershot GU11 3LD Lead Inspector Debbie Oliver Unannounced Inspection 10th November 2005 10:30 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 Residential Care Home DS0000012067.V267135.R01.S.doc Version 5.0 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 Residential Care Home DS0000012067.V267135.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Fairhaven Residential Care Home Address 76 Cambridge Road Aldershot GU11 3LD 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) 01252 322 173 Mr Robert Allan Mrs Colette Allan Mr Robert Allan Care Home 13 Category(ies) of Dementia - over 65 years of age (13), Old age, registration, with number not falling within any other category (13) of places Fairhaven Residential Care Home DS0000012067.V267135.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd June 2005 Brief Description of the Service: Fairhaven is a privately owned and run care home situated in a residential area within a mile of Aldershot Town Centre The home is adjacent to a number of local shops and other facilities and within easy travelling distance of Fleet and Farnborough. Accommodation is for up to thirteen persons over 65 years of age including those with Dementia. Fairhaven Residential Care Home DS0000012067.V267135.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over six hours and during the visit the manager, the senior staff member and the other staff on duty assisted the two inspectors. An opportunity was taken to look around the home, view some records and talk to staff and service users. The inspectors spoke with four staff members and seven service users. There were no visitors on the day of the inspection. What the service does well: What has improved since the last inspection? What they could do better: Fairhaven Residential Care Home DS0000012067.V267135.R01.S.doc Version 5.0 Page 6 The home must ensure each service user moving in to the home has a detailed assessment of their needs to determine whether the home can meet their needs. The home must ensure each service user has a care plan and all plans must be current and reflect the changing needs and personal goals of the individual. They must be reviewed regularly to ensure they remain up to date to enable staff to support individuals appropriately. The home must ensure there is a robust and safe system for handling and administering medication to protect service users. The home must have the correct documentation in the home to show staff have received training in abuse and can protect and support service users. The environment must be suitable and safe for the needs of service users including the upstairs toilet being repaired and the downstairs toilet seat to be replaced and a risk assessment must be in place for the extremely hot water from bath and sink hot water taps. The linen that is kept in a service user’s bedroom and accessed by staff is not appropriate. An alternative must be found, so privacy can be maintained. Each staff member must have the relevant checks including criminal records bureau checks to ensure they are competent to work with vulnerable people. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Fairhaven Residential Care Home DS0000012067.V267135.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fairhaven Residential Care Home DS0000012067.V267135.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 The home does not have a system of assessment for all service users, so are unable to identify prospective or current service users needs and how they will be met. EVIDENCE: Of the three plans sampled two service users had a detailed assessment. The other plan seen did not contain an assessment and so there was no information as to how this service user should be supported. It was discussed with the manager that an assessment needs to be in place for all service users to enable information to be transferred to care plans so staff can support individuals appropriately. It was also discussed that any new referrals must have an assessment prior to moving in so the manager knows whether they would be able to meet their needs. Fairhaven Residential Care Home DS0000012067.V267135.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Service user’s health and personal needs are not always being met and this needs to be fully reflected in their plans with regular reviews ensuring service users are supported appropriately. Service users are treated with respect at all times but privacy is not always upheld. Better recording is needed to ensure service users are protected when being supported with medication. EVIDENCE: The inspector viewed three service user plans and two care plans were detailed but one service user had no care plan even though it was in the Doctors notes that this service user had leg ulcers and cellulitis. The district nurse was visiting but again the notes were limited. In another service user’s assessment it stated they needed assistance with washing and bathing but there was no care plan in place. Two service users did not have risk assessments but both had had recent falls. All information seen did not show any evidence of reviews being undertaken. Fairhaven Residential Care Home DS0000012067.V267135.R01.S.doc Version 5.0 Page 10 It was discussed with the manager that all service users should have detailed care plans and risk assessments relevant to their needs, enabling staff to support them. There was also lots of other paperwork in place that had not been filled in and it was discussed that this information either needs to be completed or if no longer applicable removed from the file. Service users spoken to said staff promote their independence and they are ‘great and very kind’ The issue remained with staff accessing a linen cupboard in a service user’s bedroom so privacy cannot be maintained and it was made clear that an alternative must be found, as this is not acceptable. The medication cupboard was viewed and the home is about to change systems and the manager confirmed the pharmacists would train staff. An adjacent cupboard contained tubs of prescribed cream. Storage advice on the label states this should be stored in a cool place. The cupboard is situated in the laundry, above the tumble drier, and a senior member of staff was requested to find more appropriate storage. There had been an issue raised through the care manager about the use of analgesics and the fact this was being given too many times during the day. The manager has spoken with the staff team to prevent re-occurrence. On viewing records there were issues with omissions of signatures when administering medication. Additionally the stock levels did not match and there was no system of recording or auditing stock levels. The manager agreed to investigate the issue relating to the omissions of signatures and feedback to the inspector. It was also made clear a system must be put in place to record stock levels and it was suggested the medication policy is run through at the next staff meeting. Staff have received training by the manager but it was agreed that further training is required. Fairhaven Residential Care Home DS0000012067.V267135.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 The dietary needs of service users are well met with a balanced and varied selection of food. EVIDENCE: The service users had lunch during the visit and it looked colourful and appetising. Service users spoken to said the food was ‘very nice’ and ‘lovely’. The inspector looked at the menus that were planned for the week and it showed varied and nutritional meals. There was also plenty of fresh fruit available in the home. Throughout the visit staff were observed to offer help, support and interaction including involving service users in a game of skittles. Fairhaven Residential Care Home DS0000012067.V267135.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Arrangements for protecting service users and responding to concerns are generally satisfactory. EVIDENCE: Since the last inspection the complaints procedure has been updated and now contains timescales as to when complaints are responded to but the details for the Commission for Social Care Inspection remains out of date. The manager was informed this needs to be updated so service users are clearly aware who to respond to. The manager also agreed to prominently display the procedure in the hallway. Service users and staff spoken to knew what to do if they have a complaint. The manager confirmed that staff have now all received training in abuse but there was no documentation in place to show this has happened. The manager needs to ensure the appropriate training records are available at the home. The manager was also advised to obtain a copy of the ‘no secrets’ guidance. Fairhaven Residential Care Home DS0000012067.V267135.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Much work is required to ensure the home provides service users with safe, comfortable surroundings. EVIDENCE: Since the last inspection the manager has completed much work including replacing the television stand, cutting back the bush that was blocking people’s view into the garden, covering the radiators, the wall in the hallway has been redecorated and the ceiling has been re-plastered in one service user’s bedroom. The toilet upstairs had still not been repaired so service users cannot use it and the toilet downstairs also had the seat missing making it uncomfortable to use. The water in the baths and sinks remain very hot to touch and there was still no risk assessment in place to protect service users in the event of using the hot water without assistance. Some bedrooms still had curtains that were not hanging properly and had curtain hooks missing. Fairhaven Residential Care Home DS0000012067.V267135.R01.S.doc Version 5.0 Page 14 Additionally in one service users bedroom there was water damage to the window sill and this had lead to mould on the sills and the wall near the window sill. The linen cupboard in the service user’s bedroom had uncovered hot water pipes that are accessible to service users. It was agreed a lock will be fitted to the cupboard and a risk assessment put in place until the lock has been fitted. There was a loose carpet between the lounge and dining room and the manager was advised this needs to be addressed, as this is a trip hazard to both service users and staff. The laundry room was seen and although small had a washing machine, tumble drier, soap dispenser and paper towels. There was an unlocked cupboard that contained bleach and this was locked immediately when a staff member was informed. The home was clean and tidy on arrival. It was discussed with the manager the issue relating to one service user having lunch in the lounge rather than sitting up at the table. He stated room could be made available at the dining tables but some service users choose to sit in the lounge for their lunch, this was confirmed by service users spoken to during the visit. As discussed at the last inspection service users said they found the environment to be clean and homely but did state it needed ‘some tender loving care.’ Fairhaven Residential Care Home DS0000012067.V267135.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29 and 30 The recruitment process, employment checks and support systems are not robust to ensure the protection of service users. The service is provided by a committed workforce but the lack of some documentation does not show that adequate training is being provided to ensure staff have the right skills to support service users. The staffing levels are adequate to meet the needs of individuals. EVIDENCE: During the inspection there were three staff on during the morning and two in the afternoon and they were interacting and engaging with service users throughout the day. The manager confirmed some training had been undertaken including dementia and food hygiene and the certificates for these were seen. Other training such as medication and abuse had also taken place but there was no documentation in place to show exactly what this consisted of. It was made clear to the manager that records must be in place to show training has happened. Three staff files were seen and the induction booklets had still not been completed and staff had not received any formal induction but have been working at the home for six months. The three staff files seen did not have the relevant pre-employment checks in place such as an application form, criminal records bureau check or references. The manager stated he obtains his staff from an agency and it was discussed they should be putting in writing the checks they have undertaken. Additionally Fairhaven Residential Care Home DS0000012067.V267135.R01.S.doc Version 5.0 Page 16 even though most of the staff team have only been in the country for six months a criminal records bureau check is still required. Fairhaven Residential Care Home DS0000012067.V267135.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 and 38 The health, safety and welfare of service users is not fully promoted but staff did show a sound knowledge within the areas of health and safety. Service users views are sought to ensure they are involved in the selfmonitoring, reviewing and development of the home. EVIDENCE: All policies and procedures relating to health and safety are available in the home and the staff spoken to knew where and how to access them and had a satisfactory understanding of health and safety. Staff have also received the relevant training in areas such as fire safety and food hygiene and the records for this were seen. Service users spoken to said staff do health and safety checks and they feel the home is safe to live in. Fairhaven Residential Care Home DS0000012067.V267135.R01.S.doc Version 5.0 Page 18 However there are issues relating to the hot water and the loose carpets that need to be addressed within the area of health and safety. The inspector saw there are relevant records and certificates in place to ensure the environment is safe and secure, this includes the gas safety check and the portable appliance testing. The windows also now have restrictors to prevent service users from falling out of them. The home has a quality assurance policy in place and the inspector saw this. The manager has also just compiled an audit and this will be undertaken six monthly. Questionnaires have been devised for service users and their relatives. Service users spoken to said the home is ‘excellent’ and ‘they like living here’. The home does not take responsibility for any money belonging to service users. Fairhaven Residential Care Home DS0000012067.V267135.R01.S.doc Version 5.0 Page 19 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 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 2 Fairhaven Residential Care Home DS0000012067.V267135.R01.S.doc Version 5.0 Page 20 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 OP3 Regulation 14 Requirement The registered manager must ensure each service user moving in to the home has a detailed assessment of their needs. The registered person must ensure each service user has a plan and all plans must be current and reflect the changing needs and personal goals of the individual. They must be reviewed regularly to ensure they remain up to date. (THIS IS AN OUTSTANDING REQUIREMENT FROM THE LAST INSPECTION 31/10/05) The registered manager must ensure there is a robust and safe system for the ordering, receipt, handling and administering of medication. The registered manager must have the correct documentation in the home to show staff have received training in abuse. The registered manager must repair the toilet upstairs, put a new seat on the toilet DS0000012067.V267135.R01.S.doc Timescale for action 10/01/06 2 OP1 15 (1) (2) 10/01/06 3 OP9 13 (2) 10/02/06 4 OP18 13(6) 10/01/06 5 OP19 23 10/06/06 Fairhaven Residential Care Home Version 5.0 Page 21 6 OP29 19 (5) downstairs, put a risk assessment in place for the hot water, ensure all the bedroom curtains hang properly, repair the window sills that have water damage, cover the pipes in the linen cupboard and fit a lock, with a risk assessment put in place until this has been completed and repair the loose carpet in the lounge and dining room. Each existing staff member 08/12/05 must have the relevant checks including criminal records bureau checks to ensure they are competent to work with vulnerable people. The provider must ensure that no new staff are in post until all checks are completed. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Fairhaven Residential Care Home DS0000012067.V267135.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Fairhaven Residential Care Home DS0000012067.V267135.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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