Inspection on 13/04/07 for Fairhaven Residential Care Home

This inspection was carried out on 13th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Fairhaven Residential Care Home 12/04/06

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 Craig Willis Key Unannounced Inspection 13th April 2007 09:40 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.V333028.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 Residential Care Home DS0000012067.V333028.R01.S.doc Version 5.2 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.V333028.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th September 2006 Brief Description of the Service: Fairhaven is registered to provide care and accommodation to 13 older people, including those with dementia. The home is 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. 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. The manager reported that on 3 April 2007 the home’s fees were £421 per week. Fairhaven Residential Care Home DS0000012067.V333028.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The evidence used to write this report was gained from a review of the information the provider sent to the Commission for Social Care Inspection (CSCI) following the last inspection including a pre-inspection questionnaire and a site visit to the home on 13 April 2007. During the site visit the inspector spoke with residents, care staff and the manager. A tour of the building was made and the inspector observed the care that staff were providing to residents. Documents relating to the running of the home were inspected during the visit. CSCI carried out a random inspection of Fairhaven on 18 September 2006 to follow up on requirements that had been made in the last key inspection. During this visit it was found that improvements had been made to the home’s medication systems, the way staff were maintaining the privacy and dignity of people living at the home and staff had received additional training in dementia care. There were still improvements needed to the system for reviewing care plans, staff qualifications and the development of a quality monitoring system. What the service does well: What has improved since the last inspection? The needs of people are now set out clearly in care plans that are regularly reviewed and updated. Staff have received specific training in dementia care and are now able to complete National Vocational Qualifications in care. A quality monitoring system has been introduced. This helps the manager to assess the quality of the service provided and plan improvements. Fairhaven Residential Care Home DS0000012067.V333028.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Fairhaven Residential Care Home DS0000012067.V333028.R01.S.doc Version 5.2 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.V333028.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good systems to assess the needs of people before they move into the home, which assures residents that their needs can be met. EVIDENCE: The records of four people who live in the home were inspected during the visit. Prior to admission to the home the manager completes a full assessment of prospective residents to ensure that their needs can be met. This covers physical, psychological, social and cultural needs. Information is obtained from the person, their family and other health professionals involved in their care. Following the assessment, the manager decides whether or not the home can meet the needs of that prospective resident. The needs identified during this assessment form the basis for the care plans that are written when the person moves into the home. The assessments were seen in care files for the four people whose care was tracked. Since the last inspection a new assessment Fairhaven Residential Care Home DS0000012067.V333028.R01.S.doc Version 5.2 Page 9 and planning system has been introduced and assessments for people already living in the home have been updated. The home does not provide intermediate care and therefore standard six is not applicable. Fairhaven Residential Care Home DS0000012067.V333028.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The details recorded in care plans, support to access health services and take medication and the way staff support residents ensures that they are treated with dignity and respect and their needs are met. EVIDENCE: A random inspection visit was carried out on 18 September 2006. The inspector found that improvements had been made to the care plans, although they were not being regularly reviewed. Requirements made in the previous key inspection that there must be a safe medication system and people’s privacy and dignity must be maintained had been met. The care plans of four people were viewed during this visit. These documents set out how their assessed needs should be met and were reviewed every month. Where people’s needs had changed the care plan had been amended to reflect this. The home’s compliance manager has introduced a new care Fairhaven Residential Care Home DS0000012067.V333028.R01.S.doc Version 5.2 Page 11 planning system and the plans viewed contained clear information about how needs should be met. The compliance manager said she was currently training other staff to complete these documents, although would ensure that she and the manager signed off documents before they were used. Residents’ records showed that they were supported to attend a range of health services, including GP, optician, district nurse and chiropodist. Residents spoken with said they were able to see their doctor when they needed to. The home uses a monitored dosage system, with the majority of medication supplied by the pharmacist in blister packs. Medication was securely stored and administration records had been fully completed. Records were available of medication that had been returned to the pharmacist to be destroyed. All staff responsible for administering medication have received training. Residents spoken with said that staff treat them well and provide support in a manner that maintains their dignity. During the visit staff were observed interacting with residents in a friendly and professional manner. Where people needed reminders or assistance to use the toilet, staff provided this discreetly. Fairhaven Residential Care Home DS0000012067.V333028.R01.S.doc Version 5.2 Page 12 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): Standards 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides good support to residents to take part in social activities and visitors are made to feel welcome. A choice of good food is provided for residents and meal times are a relaxed, social occasion. EVIDENCE: Residents spoken with said that they enjoyed the activities provided in the home. Activities that are organised include skittles, arts and crafts, games and watching films. Residents’ interests are recorded as part of their initial assessment before moving in to the home. The home maintains links with local churches and a minister visits every six weeks. The compliance manager reported that none of the current residents are members of a non-Christian religion, although arrangements to meet other spiritual needs would be made if necessary. Residents spoken with said their friends and relatives were able to visit at any time and were made to feel welcome. The home has an open visiting policy and records showed that there were regular visitors. Fairhaven Residential Care Home DS0000012067.V333028.R01.S.doc Version 5.2 Page 13 During the visit a mealtime was observed. Staff were observed providing appropriate support to residents that needed it, spending time with them to help them eat in a relaxed manner. Residents spoken with said that the food was good and they could have something different if they wanted it. There is a planned menu that provides a varied and balanced diet and alternative meals are available if requested. Fairhaven Residential Care Home DS0000012067.V333028.R01.S.doc Version 5.2 Page 14 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): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has good systems to investigate complaints and protect residents from abuse. This gives residents confidence that their concerns will be taken seriously and acted upon. EVIDENCE: The home’s complaints procedure is supplied to residents and their relatives with the service users’ guide and following a suggestion at the last inspection is displayed on a notice board in the home. Residents spoken with said that they were aware of the home’s complaints procedure and were confident that any complaints would be taken seriously and responded to appropriately. No complaints have been received by the home or CSCI since the last inspection. Staff have received training in adult protection issues and those spoken with demonstrated a good understanding of issues of abuse and action they should take if they witness or suspect abuse. A copy of the local authority’s adult protection guidelines is available in the home. Fairhaven Residential Care Home DS0000012067.V333028.R01.S.doc Version 5.2 Page 15 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): Standards 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, safe and provides a comfortable and homely environment for residents. EVIDENCE: A tour of all the communal areas of the home was made during the visit. The home is clean throughout and there are no unpleasant odours. Residents spoken with said that the home was always kept clean. The compliance manager reported that there were plans for the stair well and dining room to be decorated due to some scuff marks. During the inspection it was noted that one of the window restrictors in the upstairs hallway had come loose and the carpet in one of the bedrooms was uneven. The compliance manager said she would ensure prompt action was taken to resolve these problems and ensure residents were kept safe. Fairhaven Residential Care Home DS0000012067.V333028.R01.S.doc Version 5.2 Page 16 The home has a separate laundry room and there are infection control procedures in place and protective clothing is available for staff, who were observed using it appropriately. Fairhaven Residential Care Home DS0000012067.V333028.R01.S.doc Version 5.2 Page 17 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): Standards 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Robust recruitment procedures, staff training and the deployment of staff in sufficient numbers help to ensure that residents are protected and their needs are met. EVIDENCE: A random inspection was carried out on 18 September 2006 and found that a requirement from the previous key inspection that staff must receive training in dementia care had been met. However, a requirement that there must be an action plan setting out how and when 50 of the staff would achieve the National Vocational Qualification (NVQ) level 2 in care had not been met. The home has a rota, which showed that there are at least three carers between 8am and 2pm, two carers between 2pm and 8pm and one carer awake between 8pm and 8am, with a member of staff on-call. Residents spoken with said there were sufficient staff to meet their needs. Since the last inspection five staff have started work on the NVQ level 2 in care. Two staff also have an overseas nursing qualification, which the compliance manager reported had been assessed for visa purposes as a similar level as the NVQ level 3 or 4. There are seven staff in total. Fairhaven Residential Care Home DS0000012067.V333028.R01.S.doc Version 5.2 Page 18 The recruitment records of three members of staff were inspected during the visit. These were found to contain all of the required checks, including a Criminal Records Bureau disclosure and two written references. Staff undertake an induction when they start work and other courses, including fire safety, moving and handling, first aid, food hygiene, adult protection, dementia care and medication. Further training is planned in the provision of activities in a care setting and nutrition. Staff spoken with said they enjoyed the training they have completed and felt it helped them to meet the needs of residents. Fairhaven Residential Care Home DS0000012067.V333028.R01.S.doc Version 5.2 Page 19 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): Standards 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and has good systems to keep residents and staff safe and monitor the performance of the home. EVIDENCE: A random inspection was carried out on 18 September 2006 and found that a requirement made at the last key inspection that the provider must implement a quality monitoring system had not been met. The registered manager is a registered mental health nurse and was at one time a charge nurse and clinical tutor and has 30 years experience working in “special hospitals” in the National Health Service. Since the last inspection the Fairhaven Residential Care Home DS0000012067.V333028.R01.S.doc Version 5.2 Page 20 registered manager has employed a compliance manager to help improve standards at the home. The registered manager said he comes into the home each day, but the compliance manager carries out much of the day-to-day management. The registered manager said he was considering whether the home needed to be managed on a full time basis due to his other business commitments, including a number of other care homes. Staff spoken with said they receive good support and direction from both the registered manager and the compliance manager. Since the last inspection a new quality assurance system is being used in the home. This includes audits of the environment, health and safety procedures, medication and accident records. Questionnaires have been received from residents, visitors, GPs, district nurses, the hairdresser and chiropodist. The compliance manager reported that the information gained from the quality assurance system would be used to create an annual development plan. The compliance manager reported that the home did not hold any money on behalf of residents. Records demonstrated that regular checks were being undertaken of the home’s fire alarm system and fire equipment, the gas system, stair lift, and water systems. Chemicals were kept in locked cupboards when not in use and assessments had been completed for chemicals used in the home. Staff have received health and safety training. A record is kept of accidents that occur in the home. Fairhaven Residential Care Home DS0000012067.V333028.R01.S.doc Version 5.2 Page 21 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 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Fairhaven Residential Care Home DS0000012067.V333028.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Fairhaven Residential Care Home DS0000012067.V333028.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Residential Care Home DS0000012067.V333028.R01.S.doc Version 5.2 Page 24 - 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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