CARE HOMES FOR OLDER PEOPLE
Fairhaven Residential Home 3 High Park Road Ryde Isle Of Wight PO33 1BP Lead Inspector
Janet Ktomi Unannounced Inspection 1st April 2008 09:45 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 Home DS0000069898.V361318.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 Home DS0000069898.V361318.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Fairhaven Residential Home Address 3 High Park Road Ryde Isle Of Wight PO33 1BP 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) 01983 568929 01983 568705 H & W Coastal Ltd Mrs Tracey Anne Sansom Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (0), Physical disability (0) of places Fairhaven Residential Home DS0000069898.V361318.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) 2. Physical disability (PD). The maximum number of service users to be accommodated is 21. Date of last inspection New service Brief Description of the Service: Fairhaven is an extended detached house in a residential area of Ryde within reasonable walking distance of all amenities. Fairhaven is registered to provide care and accommodation for a total of twenty-one people over the age of sixtyfive years. The home is on two levels and stair lifts enable access to all areas. With the exception of three twin bedrooms all bedrooms are for single occupancy, some bedrooms have en-suite facilities. The home also provides day care up to five people per day and has two bedrooms designated for respite care arranged via social services. The home is owned by H and W Coastal Ltd and managed by the registered manager Mrs Tracy Sansom. Weekly fees range from £369.25 to £452.51 dependant on assessed needs. Fairhaven Residential Home DS0000069898.V361318.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes.
This report contains information gained prior to and during an unannounced visit to the home undertaken on the 1st April 2008. All core standards and a number of additional standards were assessed. The visit to the home was undertaken by one inspector and lasted approximately six hours commencing at 09.45 am and being completed at 4.30 p.m. The inspector was able to spend time with the registered manager and staff on duty. The inspector was provided with free access to all areas of the home, documentation requested, visitors and people who live at the home. Prior to the inspection visit the manager had completed the homes Annual Quality Assurance Questionnaire (AQAA), this was received at the Commission within the required timescales and information from it is included in this report. Information was also gained from the home’s file containing notifications of incidents in the home. What the service does well:
The service has comprehensive admission procedures that should ensure that only people whose needs can be met at the home are admitted. People have a detailed plan of care that related to the persons assessment. The care plans are person centred and written in plain language providing detailed information as to how needs should be met. Risk assessments in care plans viewed appeared appropriate to the persons needs. Observations of staff interactions indicated that people are treated with respect and their right to dignity maintained. People confirmed that staff listen and act on what they say. The routines for daily living and activities made available are flexible and varied to suit people’s individual needs. Family and friends are able to visit. People receive a balanced diet. People and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. People are protected from abuse.
Fairhaven Residential Home DS0000069898.V361318.R01.S.doc Version 5.2 Page 6 The home employs appropriate numbers of care staff that ensure that the needs of people living at the home are met. Staff have received training. Good recruitment procedures are in place. The home now has a registered manager who is supported by the providers to improve the service. What has improved since the last inspection? What they could do better:
This was the first inspection of a service that has been registered for six months. The manager was aware that there is still work to be done, and some issues are identified within the evidence section of the report however requirements have not been made in respect of many of these as the manager or providers demonstrated that they are already addressing, or have plans to address these areas of need. The following requirement is made following this inspection. The home must ensure that medication is stored securely at all times. The medication trolley key must be kept separately from the trolley. Medication stored in the fridge must be kept in a lockable box. The controlled medications storage must conform to the misuse of drugs act regulations 2001 (as amended). Medication for day care people must be stored securely until administered.
Fairhaven Residential Home DS0000069898.V361318.R01.S.doc Version 5.2 Page 7 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 Home DS0000069898.V361318.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fairhaven Residential Home DS0000069898.V361318.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The statement of purpose, service users guide and terms and conditions of residency (contract) are being re-written by the provider so people do not yet receive written information about the home. All people are assessed prior to moving into the home to determine that their individual needs can be fully met. People, or their representatives, are able to visit the home prior to admission to assess the quality, facilities and suitability of the home. Standard 6 is not applicable, as the home does not provide intermediate care. EVIDENCE: As this was the first key inspection for a new service the inspector requested copies of the statement of purpose, service users guide and sample contract/terms and conditions of residency. The manager stated in the homes AQQA that the statement of purpose was being re-written and confirmed this
Fairhaven Residential Home DS0000069898.V361318.R01.S.doc Version 5.2 Page 10 during the inspection. One of the providers is re-writing the statement of purpose, service users guide and contract/terms and conditions of residency. The inspector was shown on the manager’s computer the almost completed documents. A requirement is not made as regards the absence of written information for people who live at the home however copies of the re-written documents should be forwarded to the commission once completed as required under Regulations 4 and 5 of the Care Homes Regulations 2001. The manager confirmed that she would ensure this occurred. The registered manager explained the homes admission procedure and two pre-admission assessments were viewed, both for people admitted shortly before the inspection visit. The inspector was able to speak with people about their admission to the home and discussed admissions with care staff. If an initial enquiry from either social services or from a person or their family indicates that the home would be able to meet the persons needs the manager will arrange to visit the person, either at their home or in hospital. A comprehensive pre-admission assessment is completed including where possible members of the persons family and professionals involved in their care. Care manager assessments were seen with the assessment forms completed by the manager. The person is provided with verbal information about the home and where practicable is invited to visit the home before making the decision as to whether to move in on a four week trial basis. When the person is unable to visit the home a relative is invited to view the available room and facilities at the home. The manager stated that people often have day care prior to commencing respite and that this often leads onto a longer term placement as peoples needs change. The home has an assessment tool that covers all the relevant areas necessary for the home to decide if it is able to meet a prospective persons needs. The manager was clear about the level of care needs the home can accommodate. The same procedures are used for respite as well as longer term care. The records for one person who was admitted for respite were viewed and confirmed that the above admission procedures had occurred. Discussions with care staff confirmed that they felt they had enough information about new people admitted to the home. Residents at Fairhaven tend to be long term, however the home does have two single bedrooms dedicated as respite care. These are funded by the local social services department for one or two week respite breaks. The home also provides a day service for up to five people per day. There was no evidence that this arrangement had any negative impact on people who live long term at the home. The home does not provide dedicated accommodation for, intermediate care or specialised facilities for rehabilitation.
Fairhaven Residential Home DS0000069898.V361318.R01.S.doc Version 5.2 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s health, personal and social care needs are set out in an individual plan of care that clearly states how peoples needs should be met. The home needs to ensure information is always passed on and action upon and records fully maintained. Medication must be correctly stored. People are treated with respect and their dignity maintained. EVIDENCE: Four care plans were viewed two for people recently admitted to the home and the others for people who had been living at the home for a longer time. These included both respite and people who are living at the home permanently. The inspector discussed with staff and people who live at the home how care needs were met. The inspector spoke with a health professional who regularly visits the home and spent time in the homes lounge/dining room. People have a detailed plan of care that related to the persons assessment. The care plans are person centred and written in plain language providing
Fairhaven Residential Home DS0000069898.V361318.R01.S.doc Version 5.2 Page 12 detailed information as to how needs should be met. Care plans included specific information as to what people could do for themselves and that which they required assistance with. An example being ‘ X is able to wash her own hands and face’, another saying ‘carer needs to put toothpaste on brush and give clear instructions’. Plans are generally reviewed on a monthly basis. Some care plans had photographs others did not, this was discussed with the manager who showed the inspector a new camera and sets of photographs waiting to be added to care plans and medication administration records. Care plans contained relevant risk assessments and management plans including nutrition, falls and any individual risks such as resulting from age related memory loss. Risk assessments in care plans viewed appeared appropriate to the persons needs. The inspector was able to talk with some people who live at the home who stated that they always received the care and support (including medical care) they need. Care plans contained individual manual handling assessments and guidelines. The inspector observed care staff using wheelchairs without footplates placing people at risk of having their feet injured. The inspector was able to talk to a visiting health professional who confirmed that they were frequently at the home. The health professional stated that the home followed their advice and guidelines and that they had no concerns as to the health care needs of the people who live at the home. The inspector read in one persons care plan that a doctor had visited, the note stated ‘routine visit from doctor but blood pressure high, need to phone surgery in three weeks to get blood pressure checked’. This had occurred seven weeks prior to the inspectors visit and there was no evidence that the follow-up had occurred. This was discussed with the manager and head of care who had been unaware of the care record entry or need to request a follow-up visit. This was organised for the day following the inspection. Within care plans were forms for recording when people had had baths and their bowels open. These had either not been fully completed or that peoples needs had not been met. The home does have systems for recording and passing on information however these are not being always followed. Discussions with a professional visitor and people who live at the home during the inspectors visit indicated that they felt that staff always treated them with dignity and respect. Observations of staff interactions indicated that people are treated with respect and their right to dignity maintained. People confirmed that staff listen and act on what they say. The home provides mainly single bedrooms with twin rooms containing screens to ensure privacy during personal care tasks. Care staff confirmed that they had sufficient time to meet people’s needs and discussions indicated that they had a good understanding of individual peoples
Fairhaven Residential Home DS0000069898.V361318.R01.S.doc Version 5.2 Page 13 needs and how these should be met. Care staff have received training to meet the specific needs of people with the visiting health professional stating that health guidance and advise re the management of specific health needs is followed. The manager stated that she is aware of how to obtain equipment people may require and that the providers have authorised equipment to be purchased when there may be a delay in obtaining this from the NHS. At the time of the inspection visit nobody was self administering his or her medication. Medication is stored in the homes treatment room in a locked medications trolley, which is secured to the wall when not in use. The key to the medications trolley was attached to the trolley via a cable. At lunchtime the medications trolley was moved to the lounge/dining room and although locked the key was accessible to anyone. Medication that should be kept cool is stored in the homes kitchen fridge in a plastic, non-lockable container. The inspector was in the homes lounge/dining room at lunchtime. At one point a carer asked who had the medication for a day care person? This was produced by another carer from her uniform pocket in an envelope provided by the persons relative. This was then given to the person. The controlled drugs storage facility does not comply with the regulations for medication storage. The security arrangements for medication were discussed with the manager who stated that she would address these issues. With the exception of liquids the local pharmacist dispenses most medication into weekly blister packs for people living permanently at the home. The home uses medication administration record sheets supplied by the pharmacist that are pre-printed. These were viewed and found to contain a few gaps. Care staff confirmed that they have undertaken medications training. Fairhaven Residential Home DS0000069898.V361318.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The routines for daily living and activities made available are flexible and varied to suit people’s individual needs. Family and friends are able to visit. People receive a balanced diet at times convenient to them. EVIDENCE: The inspector spent time talking with people in the homes lounge/dining room, met people who had chosen to remain in their bedrooms and observed the lunchtime meal. The routines for daily living and activities made available are flexible and varied to suit people’s individual needs. Residents confirmed to the inspector that they are able to choose where in the home they spend their day; many were seen to spend time in the homes lounge/dining room. Many of the people living at Fairhaven have age related memory loss and care plans contained life history information and recorded peoples likes and dislikes.
Fairhaven Residential Home DS0000069898.V361318.R01.S.doc Version 5.2 Page 15 Care plans contained individual information such as times people like to get up and particular food likes and dislikes, one seen stated ‘loves lemonade’ another dislikes ‘early mornings and being rushed’. People confirmed to the inspector that they are given choice over their meals. Bedrooms seen contained personal items brought into the home. Care plans and assessments include information about leisure activities, hobbies/interests, catering and religious needs. People stated that they are able to get up and go to bed at times of their choosing. The home has external activities provider Independent Arts who visit the home approximately twice a week with six visits in March 08. Discussions with the home manager and information in the homes AQAA stated that they are trying to offer more structured activities. The home has some equipment for care staff to undertake activities. Staff stated that they do some activities with people. Whilst viewing care plans and daily records there were no recordings about how people had spent their day or what activities they had undertaken. The home also maintains a separate activities record, however this only contained three entries for March 08, the month preceding the inspector’s visit. The manager stated in the homes AQAA that the home planned to introduce an activities organiser within the home and increase the number of reminiscence classes over the next twelve months. Information about religious needs is included in care plans and the manager stated that she has contact details and would arrange visits from appropriate ministers/clergy if this were requested/identified as a need. The home does not have a private room for visitors. The manager identified that this was something that should be improved with the planned extension to the home, which would include additional communal rooms as well as bedrooms. People stated to the inspector that they could have visitors. The home does not have a separate dining room but has one large and one smaller dinning tables in the large lounge/dining room. Staff assisted people to move to the table to eat, however there would be insufficient space at the tables should everyone wish to sit to table to eat. Other people had their lunch sat in the lounge chairs with small tables in front of them. Some people had their meals in their bedrooms with staff seen taking meals to them. People stated that the food is always/usually good and choice provided. The inspector was present for the main lunchtime meal. People stated it tasted good. Drinks and snacks are also available throughout the day with people confirming this as well as the inspector observing people being given morning and afternoon hot drinks and biscuits. The need for special diets or supplements is recorded pre-admission. The pre-admission form included information about people’s food likes and dislikes. The cook was aware of the dietary needs of people with diabetes. Staff were observed assisting and encouraging people to eat and adapted cups were provided to people who would require these to maximise independence. During the afternoon staff were observed asking people what they wanted for their evening meal.
Fairhaven Residential Home DS0000069898.V361318.R01.S.doc Version 5.2 Page 16 The manager stated that the home had recently been inspected by environmental health and awarded five stars (the maximum) for food hygiene. Fairhaven Residential Home DS0000069898.V361318.R01.S.doc Version 5.2 Page 17 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. People are protected from abuse. EVIDENCE: The home has a clear complaints policy and procedure and a copy is available in the hallway. People stated that they would say if they had any concerns or complaints but had no issues they wished to raise to the inspector. Discussions with staff confirmed they were aware of what to do if a person complained or raised an issue. The manager identified in the homes AQAA that the home had received no complaints since the home was registered under new owners in October 2007. The commission had received one complaint regarding the service that was unsubstantiated following being investigated by social services under safeguarding procedures. The home has a policy and procedure relating to safeguarding adults and ensuring that people are not at risk of abuse. Care staff have had safeguarding adults training as part of their induction and as specific update training as seen in the homes training matrix, individual training records and confirmed by staff. Discussions with care staff indicated they had an understanding of adult protection and would report concerns to the manager, however none
Fairhaven Residential Home DS0000069898.V361318.R01.S.doc Version 5.2 Page 18 mentioned that they could also report concerns directly to Social Services under the local safeguarding procedures. This was discussed with the manager who is to ensure that staff receive additional training such that they are fully aware of local reporting procedures. The homes policies and procedures in respect of people’s personal finances and recruitment should ensure that people will not be financially abused. Fairhaven Residential Home DS0000069898.V361318.R01.S.doc Version 5.2 Page 19 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that meets the needs of the people who live there. The home is comfortable, and has a planned programme to improve the decoration, fixtures and fittings and significant work has been undertaken since the new owners purchased the home in October 2007. EVIDENCE: Fairhaven is an extended older property located in a residential area close to amenities in Ryde. Fairhaven is domestic in style and provides comfortable and homely accommodation. There is limited off road parking to the front of the home with additional parking available in the road outside the home. The home has a large rear garden, mainly laid to lawn with a patio area and gazebo to provide some protection from the rain or sun for people who smoke.
Fairhaven Residential Home DS0000069898.V361318.R01.S.doc Version 5.2 Page 20 The manager showed the inspector round the home, which was clean and tidy throughout, and there were no unpleasant odours. At the time of the visit the home was comfortably warm. People who live at the home confirmed that the home is always warm and clean. The home employs a cleaner. The home has mainly single and three twin bedrooms. The inspector viewed a number of bedrooms. These vary in size; some have ensuite facilities, with bathrooms and WC’s located around the home and convenient to the communal areas and bedrooms. People able to respond sated they were happy with their bedrooms and these were seen to contain personal items. The home has communal space in the form of a large lounge/dining room with a range of seating suitable for everyone who lives at the home. The home has the necessary moving and handling equipment and the baths are fitted with hoists. Grab rails are provided around the home. Stair lifts are provided to access all bedrooms on the first floor. One of the stair lifts has been replaced, and the other serviced since the new owners purchased the home in October 2007. The manager listed the improvements made since the home was purchased in the AQAA. These included radiators covered and room dividers installed in twin bedrooms. Carpets have been professionally cleaned, redecoration of rooms and replacement of curtains has commenced and a maintenance person employed. Dining room chairs have been covered and new tablecloths purchased. Signs have been placed on WC doors and new toilet seats fitted. The manager also stated that the home has purchased a pressure-relieving mattress for one person who required this. The manager explained that the new providers have further plans to improve and update the homes environment and are considering an extension in the future. Discussions with the manager indicated that she is fully aware of areas of the home that need attention and the providers have commenced work on some of these. Therefore no requirements are made in respect of the environment. The manager stated on the AQAA that new industrial washing machines with sluice function, and alcohol gel dispensers have been fitted around the home. Members of staff spoken with confirmed they had received infection control training and had access to all the necessary equipment to prevent any risk of cross infection such as disposable gloves and aprons, supplies of which were seen during the visit to the home. Substances hazardous to health (COSHH) were stored securely. Fairhaven Residential Home DS0000069898.V361318.R01.S.doc Version 5.2 Page 21 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home employs appropriate numbers of care staff that ensure that the needs of people living at the home are met. Staff have received training. Good recruitment procedures are in place. EVIDENCE: All comments from people who live at the home and professionals were positive about care staff. People living at the home stated ‘I am very happy and very well looked after’, ‘friendly caring staff at all times’, ‘everyone is very kind’, and ‘everyone is very nice’. Duty rotas were seen during the visit to the home. Duty rotas stated that three care staff are provided throughout the day and two care at night. The home also employs a cook, cleaner and has maintenance staff available. In addition to care staff the manager is present weekdays. During the inspectors visit staff on duty corresponded to those on the duty rota. Care staff stated that they generally have sufficient time to meet people’s needs and throughout the inspection care staff appeared to have time to meet people’s needs. Fairhaven Residential Home DS0000069898.V361318.R01.S.doc Version 5.2 Page 22 The manager provided training and qualification information during the inspection and on the AQAA. The home has eight care staff with at least NVQ level 2 in care with an additional five staff undertaking their NVQ in care and others waiting to start. The home employs a total of twenty-one care staff. Once all staff undertaking their NVQ have achieved this qualification the home will have more than half their staff with at least an NVQ level 2 in care. The inspector spoke with care staff who confirmed that they had either got, or were to undertake their NVQ. Care staff stated that they felt they had the necessary skills to meet people’s needs and were not expected to undertake activities for which they had not been trained. A training plan has been produced to ensure that all staff have undertaken all the necessary training. This was viewed during the inspection visit; this showed that some training is overdue but that the manager is addressing this. The manager stated in the AQAA that staff training is mandatory and whilst there is in house training all assessments are done through an outside agency. The manager also stated that they have commenced staff assessments and a training programme individualised for each staff member is being developed. The manager identified in the homes AQAA that there has been a high turnover of staff at the home. The manager and providers are aiming to address this with a retention policy and procedure with incentives for career progression. The recruitment records for the two people recruited in February and March were viewed. These contained all the required information and confirmed that all staff are fully checked including references, CRB and POVA checks prior to commencing employment at the home. The manager explained the homes induction procedure that includes the Skills for Care induction. Induction workbooks were seen along with certificates for courses staff had attended. New care staff confirmed that the above recruitment procedures had been undertaken. Fairhaven Residential Home DS0000069898.V361318.R01.S.doc Version 5.2 Page 23 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager has the necessary skills and experience to ensure that the home is appropriately managed and run in the best interests of the people who live there. People’s financial interests are safeguarded. Staff are supervised. Records are not always well maintained. The health, safety and welfare of people and staff are promoted. EVIDENCE: The manager who has NVQ level 4 in Care and the Registered Managers Award was registered by the commission as registered manager for the home in January 2008. Throughout the inspection visit the manager demonstrate
Fairhaven Residential Home DS0000069898.V361318.R01.S.doc Version 5.2 Page 24 knowledge of the people who live at the home and the mechanisms by which support can be obtained when necessary. The manager works full time. Care staff and people who live at the home were clear that they felt able to discuss any issues/concerns with the manager. The manager confirmed that she has access to the necessary budgets and the providers support her requests for essential expenditure such as on pressure relieving equipment. Discussions with the manager throughout the inspection showed that she is aware of what is required to ensure the home meets the required standards and is working towards improvements in many areas. These are identified in the relevant sections of this report. The manager stated that the providers visit the home most weeks and have regular telephone contact. The providers must ensure that they record visits as directed under Regulation 26 of the Care Homes Regulations 2001. The manager has commenced some formal quality assurance work with monthly audits seen. Questionnaires have been sent to people who live at the home, including those who access the day and weekly respite service and to visitors. The responses were shown to the inspector and the manager stated that she will soon commence collating the responses and then the service provided will be reviewed if any areas are identified. The manager stated that other stakeholders such as visiting professionals would be surveyed in the future. The AQAA was completed by the providers and manager. It contained relevant information and was received at the commission within the required timescales. The manager is not the appointee for anyone living at the home. The manager stated that most people have a lockable facility in their bedrooms however most tend not to use this and that the home holds small amounts of money for some people (this is used for small personal expenses such as hairdressing and newspapers). The records and storage for this were seen. The systems in place and records seen re people’s personal money are robust and well maintained. The AQAA stated that the homes accountants monitor the records of peoples personal money held by the home. Care staff confirmed during discussion that they are appropriately supported and supervised with an on call system in place when the manager is not at the home. The manager stated that the home has a supervision policy and procedure, and that at present she is catching up with staff supervisions. Some staff files seen contained records of supervision. Various records were viewed during the inspectors visit. All records were appropriately stored with access only available to people who should have access. As identified in the relevant sections of this report not all records relating to care were fully maintained. During the inspection visit there were no significant concerns in respect of health and safety identified. Care staff must ensure that footplates are always
Fairhaven Residential Home DS0000069898.V361318.R01.S.doc Version 5.2 Page 25 used on wheelchairs. The home is generally well maintained and clean, with staff having relevant training to meet people’s needs. The home has contracted with an external company who undertake weekly checks of the fire detection equipment, emergency lighting and provide staff training in relation to fire awareness. Portable Electrical Appliance Tests (PAT) have not been undertaken and the manager stated that the homes new maintenance person is to train to undertake PAT tests. Electrical wiring and gas certificates were seen as part of the homes registration process. The local environmental health department has awarded the home five stars (the maximum) for food hygiene. Fairhaven Residential Home DS0000069898.V361318.R01.S.doc Version 5.2 Page 26 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 2 2 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 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 3 2 3 Fairhaven Residential Home DS0000069898.V361318.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement The home must ensure that medication is stored securely at all times. The medication trolley key must be kept separately from the trolley. Medication stored in the fridge must be kept in a lockable box. The controlled medications storage must conform to the misuse of drugs act regulations 2001 (as amended). Medication for day care people must be stored securely until administered. Timescale for action 01/06/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Fairhaven Residential Home DS0000069898.V361318.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Home DS0000069898.V361318.R01.S.doc Version 5.2 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!