Inspection on 12/04/06 for Fairhaven Residential Care Home

This inspection was carried out on 12th April 2006.

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 10/11/05

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 Tim Inkson Unannounced Inspection 12th April 2006 09:30 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.V288440.R01.S.doc Version 5.1 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.V288440.R01.S.doc Version 5.1 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.V288440.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 10th November 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. Information about the service provided at the home is made available to potential residents by providing a copy of the home’s Service Users Guide and brochure. A notice is on display in the hall of the home informing people that a copy of the last inspection of the home by the Commission for Social care Inspection is available to see. On the 12th April 2006, the home’s fees ranged from £410 to £421 per week. Fairhaven Residential Care Home DS0000012067.V288440.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was unannounced beginning at 09:10 and finishing at approximately 16:00 hours. During the inspection, records and documents were examined, an opportunity was taken to tour the premises and staff working practice was observed. In addition residents (5), a visiting healthcare professional (1), and staff (4) were spoken to. At the time of the inspection there were no vacancies with 13 residents being accommodated although 2 were in hospital of these 12 were female and 1 was a male and their ages ranged from 73 to 98 years. There were no residents from ethnic minority groups. A comment card received from a relative also influenced the findings set out in the report below. What the service does well: What has improved since the last inspection? What they could do better: Each resident must have a comprehensive plan of care that describes in detail the actions staff must take to meet their assessed needs and these must include among other things the social, leisure and religious needs of the persons concerned. Fairhaven Residential Care Home DS0000012067.V288440.R01.S.doc Version 5.1 Page 6 The home’s written procedures concerning the management and administration of medication must reflect the actual practice in the home and records must be kept of the ordering and receipt of all medicines. Some staff practices and systems should be addressed to ensure that residents’ privacy and dignity is not compromised. At least 50 of the home’s care staff must be qualified to at least National Occupational Vocational Qualification at level 2 in care or it’s equivalent. A system for monitoring the quality of the service the home provides must be implemented to ensure that the home is run in the best interests of the residents. 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.V288440.R01.S.doc Version 5.1 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.V288440.R01.S.doc Version 5.1 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had systems and procedures in place for identifying the needs of potential and existing residents. EVIDENCE: The records of 4 residents were examined including one individual who had been admitted to the home since the last inspection on 10th November 2005. All of the persons concerned had been referred to the home through “care management arrangements” and copies of the assessments of the individuals’ needs completed by staff working for the local authorities concerned were readily available. A further assessment identifying and recording details of the help and support that individuals’ needed was also done when they actually moved into the home. There was evidence that risks to residents’ health and well-being were reviewed regularly e.g. nutrition and falls. Fairhaven Residential Care Home DS0000012067.V288440.R01.S.doc Version 5.1 Page 9 One resident spoken to confirmed that the home’s owner had visited her before she moved into Fairhaven to ascertain whether the home could meet her needs. “He came to see me when I was in Reading to talk to me about the home and that….”. The home did not provide intermediate care. Fairhaven Residential Care Home DS0000012067.V288440.R01.S.doc Version 5.1 Page 10 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Individual plans of care lacked important details about residents’ needs and how they would be met. There were systems in place to ensure that residents had access to health care services. The homes practice for the administration of medication was not in accordance with its written policies and procedures. Residents’ privacy and dignity was not always fully upheld because of some poor staff practice and management information systems. EVIDENCE: The care plans for 4 residents were examined. The registered manager explained that new care plan documents had been developed and were being implemented. He said that he intended to introduce them to all the staff without delay but as a result the information in the documents had not been fully completed. The new documents indicated with tick boxes where an individual may need the assistance and support of staff with a range of personal care tasks such as washing dressing, eating and included the opportunity to refer to their dietary preferences but not to other lifestyle preferences such as getting up and going to bed. They did however lack reference to individuals’ leisure interests, social and spiritual needs. Fairhaven Residential Care Home DS0000012067.V288440.R01.S.doc Version 5.1 Page 11 There was very little information in the documents examined, both old and new, setting out in detail how the specific help or supervision an individual needed was to be provided e.g. how reassurance was to be given to someone who was anxious; what specific help someone needed with bathing, washing and dressing. At 2 previous inspections on 23/06/05 and 10/11/05 lack of detail in care plans was brought to the attention of the registered manager. Timescales were agreed for improving the tool that should provide clear and comprehensive information to staff to enable them to give residents the help and assistance that they need. These timescales of 31/10/05 and 10/01/06 were not met. The registered manager was advised that should the timescale agreed on this occasion concerning this matter again not be met that the Commission for Social Care Inspection may consider enforcement action. Despite the matters referred to above all residents spoken to that were able to converse meaningfully felt that the staff looked after them well and gave them the help and care that they needed. • “The staff are very good. If you are concerned you can go to them. Staff help me with bathing”. • “I am pretty independent the only thing they need to do is wash my back and hair for me. They look after my tablets and a gel that I need for my knee”. Records examined, discussion with residents and observation indicated that healthcare of residents was promoted by the home. There were entries in records that corresponded with visits from doctors, district nurses, chiropodists and opticians. The registered manager said that the help of specialist healthcare professionals such as community psychiatric nurses or psychogeriatricians was available and could be arranged if required. One resident said, “I have seen a doctor. If you need a doctor they will arrange it for you. My stomach was bloated and one came to see me. I see a chiropodist and I saw an optician and got 2 new pairs of glasses”. A visiting general practitioner spoken to at the time of the inspection said that the home contacted the surgery appropriately and that staff followed instructions that they were given concerning any treatment prescribed for residents. At the last inspection of the home on 10th November 2005, a number of weaknesses were identified with the home’s management of medication and the home was required to correct these by implementing a robust and safe system for the ordering, receipt, handling and administration of medication by 10th February 2006. On this occasion it was noted that the home had 2 different written sets of written procedures concerned with the management of medication and neither accurately reflected the actual practice that the home had adopted. The home used a monitored dosage system with most medicines kept in blister packs apart from those that could not be stored in that manner because they would “spoil”. Medicines were stored in 3 separate locked cupboards. The procedures however referred to one cupboard, with an internal cupboard Fairhaven Residential Care Home DS0000012067.V288440.R01.S.doc Version 5.1 Page 12 suitable for controlled drugs. They also referred to the use of 2 specific containers for carrying medicines around the home when administering them and also the uses of a prescription book. These were not in place or being used. It was apparent that the procedures were part of a set that had been purchased “off the shelf” and had not been sufficiently personalised/adapted for use in the home. Medication Administration Records (MAR sheets) were up to date for the giving of medicines to residents but the part of the document to be “signed off” confirming the receipt of the medication from the pharmacist had not been completed. It was noted that medicines were kept securely and any requiring storage at a cool temperature were kept in a separate container in the home’s refrigerator. Also containers in which eye-drops were kept were dated when they were opened. Staff confirmed that they had received training in the management and administration of medicines form the pharmacist that supplied the home. There were no residents that had been assessed as able to self medicate at the time of this inspection. As a number of weaknesses with the home’s management of medication were identified again at this inspection the requirement referred to above was repeated. The home attempted to address the privacy and dignity of residents with some success. The home has more single than double/shared rooms with 9 of the former and 2 of the latter and shared rooms had screens fitted in the area of their wash hand-basins. All rooms were fitted with suitable locks that would enable residents to keep them secure and maintain their privacy. The home assessed an individual’s ability to manage a key and there was evidence from records that one resident until she had recently mislaid her key had been locking her bedroom door. It was suggested that the registered manager devise a written policy about shared rooms indicating what would occur in the event of a vacancy arising in a shared room and the remaining resident chose not to share with anyone else. Staff were observed knocking on bedroom doors and waiting for a response before entering and residents spoken to said that staff usually knocked before they entered their rooms. At the last inspection of the home on 10th November 2005, a cupboard in one bedroom was being used to store spare bedding and linen compromising the privacy of the residents occupying those rooms. This had subsequently been remedied and linen was no longer stored in the room. There were some matters that were observed and brought to the notice of the manager that could compromise/undermine the privacy and dignity of residents. • The identity of several residents who had diabetes was clearly on display on a whiteboard in the dining area of the home. Fairhaven Residential Care Home DS0000012067.V288440.R01.S.doc Version 5.1 Page 13 A number of chairs in the lounge area had very obvious incontinence covers/sheets on them “sending out a clear message” to anyone coming into the room about the persons using those particular chairs. During the inspection a member of staff was clearly heard in a crowded lounge asking a resident if she wanted to go to the toilet. • Fairhaven Residential Care Home DS0000012067.V288440.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home promotes residents lifestyle choices, organises some activities and ensures that the nutritional needs of residents are met. EVIDENCE: Residents spoken to said that they were able to determine when they got up and went to bed and this was also reflected in a statement made by the registered manager. • “There are about 4 of us that sit up in the evenings until about 9:00 o’clock. I like to watch Eastenders, Holby City and The Bill…I lay the tables and I play things like snakes and ladders. They have had a lady come a couple of times and she sings popular songs. The staff have taken me out shopping for clothes and shoes and we stop for a cup of tea when we are out” (resident). • “Sometimes I go to bed late it depends how I feel” (resident). • “You just can’t put them to bed” (manager). During this inspection as on the last 2 inspections of the home on 23rd June and 10th November 2005 residents said that there were board games available and staff were observed organising one to one and small group activities to provide stimulation and interest. Records were seen of the “activities and events” in which individuals participated. However this aspect of the support and care the home provides could be improved by ensuring that there was Fairhaven Residential Care Home DS0000012067.V288440.R01.S.doc Version 5.1 Page 15 reference in individual care plans as to how the specific leisure interests, social or religious needs of the person concerned could be met (see standard 7 above). A record of visitors to the home was kept and it was apparent that residents were able to maintain contact with their relatives and friends. The home had an “open house” visiting policy with no restrictions. At the time of the inspection no residents were handling their own financial affairs and the home was not looking after any money on behalf of any resident. The manager said that to avoid any complications or difficulties he asked relatives to take responsibility for such matters and when services or items were purchased for residents e.g. hairdressing, the home paid and relatives were subsequently invoiced. All bedrooms were furnished by the home but several contained small items or personal possessions that residents had brought with them e.g. pictures and ornaments. There were no records available of these personal possessions. Sensitive information about residents was kept securely locked in the home’s office. On this occasion as at the last inspection of the home on 10th November 2005 the main meal of the day was well presented and residents spoken to were complimentary about the food provided by the home. There was evidence of the ready availability of fresh fruit and staff described how they provided a choice of meals in the evening. The records of the food provided indicated that there was variety and some choice of main meals. There were substantial stocks of food in the home including meal supplements that had been prescribed for individuals with poor appetites. The main meal of the day was observed. It was unhurried and staff were observed assisted some individuals who had difficulty feeding themselves. The inappropriate practice of one member of staff was drawn to the attention of the manager. She was observed standing over the resident concerned rather than sitting down at the same level. Comments about the food included: • “Food is quite good. You get plenty” (resident). • “The food is very good, no grumbles there” (resident). • “The food is very good. I am glad someone else is doing it. There is plenty and I have cut down because I don’t want to get too fat” (resident). • “I ask people what they want, different sandwiches and things like spaghetti, baked beans, soup, rice pudding and so on. They can have what they want” (staff member). Fairhaven Residential Care Home DS0000012067.V288440.R01.S.doc Version 5.1 Page 16 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): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were procedures in place for managing residents concerns and protecting vulnerable adults. EVIDENCE: At the last inspection of the home on 10th November 2005 the home’s written complaints procedure had been updated to include a timescale for responding to concerns that were raised, but it did not include details of the Commission for Social care Inspection. This had subsequently been remedied. Residents spoken to were confident about taking their concerns to the staff. A comment card received from a relative indicated that she was unaware of the home’s complaints procedures. A suggestion was made at the last inspection that it be prominently displayed in the home. The suggestion was repeated on this occasion. The staff spoken to were aware of how to respond if they suspected or knew that abuse had occurred in the home and all spoken to had attended formal training in adult protection and there was documentary evidence confirming this. A copy of the local authority’s adult protection guidelines was readily available. The home had written policies and procedures concerning adult protection including reference to whistle blowing and gifts and bequests. The home exercised good practice regarding the imposition of any restrictions and one resident said: “I signed an agreement about my smoking and cigarettes, because if I had them I would smoke them all in no time”. Fairhaven Residential Care Home DS0000012067.V288440.R01.S.doc Version 5.1 Page 17 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were systems in place to ensure that the building was in a good state of repair and that it was kept comfortable and safe for residents and staff. EVIDENCE: Considerable improvements to the home’s environment had been made since the last inspection of the home on 10th November 2005. This included: • All bathrooms and WCs had been refurbished with floors tiled and new suites installed and storage cupboards fitted. • A cupboard used as a linen cupboard in a resident’s room had been locked as required because it contained the home’s hot water storage container/tank (see also standard 10 above). • Water ingress causing damage to a windowsill and its surrounding area had been remedied. • New flooring had been fitted in 2 bedrooms and carpet in the lounge area had been made safe. Fairhaven Residential Care Home DS0000012067.V288440.R01.S.doc Version 5.1 Page 18 Thermostatic mixer valves had been fitted to all hot water outlets accessible to residents to ensure that hot water was delivered at around 43°C. • Curtains in all bedrooms were hanging properly. • New lighting had been installed in some corridors. At the time of the inspection the external areas of the building were being repainted and tumble dryer was being removed from the small laundry room/sluice to a new shed that had been erected in the garden. Some minor maintenance matters were discovered during the inspection concerning electromagnetic door releases on 2 bedroom doors and a radiator guard in one room. During a telephone conversation with the manager the day following the inspection he confirmed that these had been remedied. One matter that could be addressed to improve the environment is the damaged paintwork on the wall in the dining room caused by the backs of the dining chairs. Also the appearance of some bedrooms could be improved where there are sets of curtains that do not match in rooms with more than one window. The manager stated that he had always had a 5-year plan for the improvement of the premises based on priorities that he had identified. There were no recent reports about the home from either the local fire and rescue service or environmental health officer. Residents spoken to were pleased with their accommodation. • “I have a lovely room, they look after it for me, they keep the room clean”. • “My room is very nice”. • “I have my own room it is very pleasant” The home had clear and comprehensive written infection control procedures and protective clothing was readily available and staff were observed using it appropriately. The premises were clean and free from offensive odours at the time of the inspection. Residents said that the building was kept clean. • Fairhaven Residential Care Home DS0000012067.V288440.R01.S.doc Version 5.1 Page 19 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, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had procedures and systems in place to ensure staff were recruited properly and that there were always enough staff on duty. Staff training needs to be improved to ensure that all staff have the necessary skills and knowledge to meet the complex needs of residents accommodated in the home. EVIDENCE: Residents spoken to were of the view that staffing levels in the home were sufficient and that the staff were able to look after them properly. A comment card received form a relative also indicated satisfaction with the care the home provided and the level of staffing. “There is nothing I could find fault with. The people here are very good to us You depend on the nurses doing things for you” (resident). “I think there are enough staff and if they think you need something they will help you. They are very considerate” (resident). “All staff are friendly and helpful” (relatives comment card). At the time of the inspection the home employed 11 care staff and none had a qualification to at least NVQ level 2 in care or equivalent. The number of staff on duty was in accordance with the published rota and staffing levels were as follows: 8-2 2-8 8-8 Wakeful 3 2 1 Sleeping 1 Fairhaven Residential Care Home DS0000012067.V288440.R01.S.doc Version 5.1 Page 20 The lack of staff qualified to at least NVQ level 2 in care was discussed with the registered manager and he was required to produce an action plan to indicate how and when he intended to achieve a level of at least 50 of all care qualified to that level. At the last inspection of the home on 10th November 2005 the records examined of 3 staff members that were recruited overseas did not include Criminal Record Bureau (CRB) certificates’ as these checks had not been applied for at that time. This had subsequently been done. No new staff had been employed to work in the home since the last inspection. It was suggested that the manger arrange for a CRB check at an appropriate level to be made of the person working in the home doing maintenance and repair work because he had some contact with and access residents. There was evidence from both discussion with staff and an examination of staff records that staff training and development was promoted by the home. There was however no evidence of a formal structure in place for this and while some staff had attended training in dementia care others had been unable to do so because of their working/shift patterns. It was suggested that as the home was registered to provide care for people with dementia that all staff must attend relevant training to ensure that they had the necessary skills and knowledge to meet the complex needs of the home’s residents. Fairhaven Residential Care Home DS0000012067.V288440.R01.S.doc Version 5.1 Page 21 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): 31, 33, 35 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Requirements from previous inspections had not been complied within timescales. The home’s quality monitoring system had not been implemented. Health and safety was generally managed adequately ensuring the welfare of all people living and working in the home. EVIDENCE: The registered manager is a registered mental health nurse and was at one time a charge nurse and clinical tutor and has some 30 years experience working in “special hospitals” in the National Health Service. He has other businesses that include an interest in 3 other care homes in the Southampton area. Despite being involved in these other ventures both staff and residents said that he present was in the home most days and always available and supportive. Fairhaven Residential Care Home DS0000012067.V288440.R01.S.doc Version 5.1 Page 22 He had developed/implemented some helpful systems for monitoring and recording information such as a kitchen book that included details of the temperatures of the refrigerators and freezers and the meals provided. There was some discussion with the registered manager about the inadequate degree of information in individuals plans of care and that although he delegated the task of completing care plans to care staff he needed to check on their contents to ensure they were completed fully and satisfactorily. Residents, a relative and staff commented on the general living and working atmosphere in the home • “I like it here – it is very nice. The people are so friendly, it makes a lot of difference” (resident). • “All staff are friendly and helpful” (relative) • “I love it, I have been in a number of homes and this is the best for residents other home were run for the staff” (staff member). The home had a written policy and procedure concerned with monitoring the quality of the service that the home provided. There was however no evidence that these had ever been implemented. The manager said that he had sent out consumer satisfaction surveys but none had ever been returned. The procedures included audit documentation for assessing areas such as catering and “nursing care” but there was no evidence that such audits had ever been done. The manager was reminded of the legal obligation to implement a quality monitoring system. The home had a range of written policies and procedures in place and staff confirmed that they were readily available to refer to for guidance and that they found them helpful. A number of the policies and procedures had been reviewed and updated. There were 6 requirements arising from the last inspection of the home on 10th November 2005 and 4 of these had been actioned. The home did not look after any monies for residents (see also standard 14 above). The home had written health and safety policies and procedures. There were written risk assessments in place and also of the premises and working practices carried out in the home. There was evidence from both discussions, records and certificates of qualification/attendance on display in the home, that all staff working in the home had received training in health and safety subjects that were relevant to their role in the home. These included, fire safety, food hygiene, moving and handling, and control of substances hazardous to health. Records indicated that systems and equipment in the home were tested and serviced at intervals and with the frequencies either required according to relevant regulations or with good practice. These included: • Fire safety equipment • Electrical wiring • Boilers and central heating Fairhaven Residential Care Home DS0000012067.V288440.R01.S.doc Version 5.1 Page 23 • • • Portable electrical appliances Stair lift Temperatures of refrigerators, freezers and cooked meats. The home was keeping a record of accidents and there had been 16 since the last inspection of the home with one requiring admission to hospital. At the time of the inspection no member of staff had a current or appropriate first aid certificate. The manager stated that he would arrange first aid training by June 2006. Fairhaven Residential Care Home DS0000012067.V288440.R01.S.doc Version 5.1 Page 24 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 1 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 1 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 X X 2 Fairhaven Residential Care Home DS0000012067.V288440.R01.S.doc Version 5.1 Page 25 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 OP1 Regulation 15 (1) (2) Requirement 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 and cover matters other than physical needs.They must be reviewed regularly to ensure they remain up to date. (THIS IS AN OUTSTANDING REQUIREMENT FROM THE LAST 2 INSPECTIONS 31/10/05 and 10/01/06) The registered person must ensure there is a robust and safe system for the ordering, receipt, handling and administering of medication. The home’s written polices and procedures accurately reflect the practice and systems in the home. (THIS IS AN OUTSTANDING REQUIREMENT FROM THE LAST INSPECTION 10/02/06) The registered person must make suitable arrangements to ensure that the care home is conducted in a manner which DS0000012067.V288440.R01.S.doc Timescale for action 30/06/06 2. OP9 13 (2) 30/06/06 3 OP10 12(4)(a) 30/06/06 Fairhaven Residential Care Home Version 5.1 Page 26 4 OP27 18(1) 5 OP28 18(1) 6 OP33 33 respects the privacy and dignity of service users. The registered person must ensure that all staff are trained in Dementia Care to ensure that they can meet the needs of all the categories of service users for which the home is registered. The registered person must produce and submit an action plan setting out how and when of 50 of the care staff will be qualified to at least NVQ level 2 in care. The registered person must implement a quality monitoring system. 30/06/06 30/06/06 30/06/06 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.V288440.R01.S.doc Version 5.1 Page 27 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.V288440.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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