Inspection on 14/06/05 for Fairhaven, Swindon

This inspection was carried out on 14th June 2005.

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, Swindon 20/07/06

Fairhaven, Swindon 30/12/05

Fairhaven, Swindon 10/02/05

Fairhaven, Swindon 18/10/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Fairhaven 99 Bath Road Old Town Swindon Wiltshire SN1 4AX Lead Inspector John Hurley Unannounced 14th June 2005 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 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 D51 D01 s3205 Fairhaven v233299 140605 Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Fairhaven Address 99 Bath Road Old Town Swindon Wiltshire SN1 4AX 01793 535293 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Swindon Old Peoples Housing Association Mrs Lynn Plumstead Care Home 18 Category(ies) of OP Old Age 18 registration, with number of places Fairhaven D51 D01 s3205 Fairhaven v233299 140605 Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th February 2005 Brief Description of the Service: Fairhaven is a voluntary, non-profit making residential home offering accommodation and personal care to 18 service users over the age of 65 who require care through old age. Fairhaven was first registered with the current provider Swindon Old Peoples’ Housing Society in 18th December 1986. The home is situated in Old Town, Swindon and is within easy walking distance of the local shops and amenities. There is also a regular bus service to Swindon town centre, which stops outside the home. Limited parking facilities are available to the front of the property. The accommodation provides service users with all single bedrooms, which are located on the ground and first floor levels, and those bedrooms on the first floor can be reached by the use of a new stair lift. Fairhaven D51 D01 s3205 Fairhaven v233299 140605 Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over four hours. The inspector viewed all areas of the home and met with some service users individually and as a group. The inspector spoke with four members of care staff, the chef and the registered manager. A number of records were examined including a sample of service users care plans, risk assessments and health and safety records. What the service does well: What has improved since the last inspection? What they could do better: Swindon Old Peoples’ Housing Society need to be very clear as to the status of the tenants. They need to produce or make available a contract of residency which the registered manager has sight of. They need to carry out a risk assessment with regards to these arrangements and take any action to minimise the risks identified through this process. The Society needs to ensure that it deals with estate matters, ie those matters that affect the tenants such as maintence, and not the registered manager. The statement of purpose and service users guide needs to reflect the current tenancy arrangements within the home. Fairhaven D51 D01 s3205 Fairhaven v233299 140605 Stage4.doc Version 1.30 Page 6 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 D51 D01 s3205 Fairhaven v233299 140605 Stage4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Fairhaven D51 D01 s3205 Fairhaven v233299 140605 Stage4.doc Version 1.30 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 standard(s) 1 The statement of purpose and service user guide needs to make reference to the current tenancy arrangements. EVIDENCE: The home has not had any admissions since the last inspection. The registered manager informed the inspector that the statement of purpose and service users guide does not mention the shared occupancy of the building. This being where the gardener/security officer and his wife are tenants occupying part of the first floor and the entire second floor. The home does not provide intermediate care. Fairhaven D51 D01 s3205 Fairhaven v233299 140605 Stage4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 The care plans contain good, accurate details relating to how the individuals wish their needs to be met. The ongoing reviews are robust and evaluated against the original plan. EVIDENCE: Three service user files were examined. The care plans observed give good details with regards to the health and social care needs of the service users. These plans are reviewed on a monthly basis and the effectiveness of any interventions evaluated against the original plan and any longer term aims of the individual. The care plans have been agreed with service users. A service user told the inspector of the basis of their care plan. This was to help them get up and assist them with a wash. They went on to say that the staff can be very helpful and do not rush them, this they felt was important. The staff that the inspector spoke with had good knowledge of the contents of the care plans. The records viewed indicate key dates when service users need to have on going health checks and out patient appointments were necessary. One record demonstrates that staff had identified emerging mental health needs, alerted Fairhaven D51 D01 s3205 Fairhaven v233299 140605 Stage4.doc Version 1.30 Page 10 the appropriate professionals and family and ensured that the planned intervention was carried through. A group discussion with the service users after lunch informed the inspector that individuals felt that they can approach staff if they do not feel well and that they will take action on their behalf. The management of the home are changing their approach to risk management and are now using a computer based database. These risk assessment documents are comprehensive and once all of them have been updated should give a clear and concise picture. The service user said they felt safe living at the home. At present no service users are responsible for their own medication. The records clearly state the reasons why the home has taken responsibility for this action. Fairhaven D51 D01 s3205 Fairhaven v233299 140605 Stage4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13,15 The routines of the home are unhurried and appear to suit the individuals needs. The food on offer is tailored to meet individual’s needs and requirements. EVIDENCE: Service users told the inspector of the activities on offer. They said that they appreciated the activities carried out by the staff such as bingo and singing. One service user told the inspector that they enjoyed being able to go out in the garden during the warmer days. Although at the time of the inspection no relative appeared to be visiting, the group of service users told the inspector that friends and family can visit at any reasonable time. The lunchtime meal was briefly observed. The service users commented that the food was good and in sufficient quantities. A service user explained that if they did not like what was on offer an alternative would be provided. They also said that this rarely happened as they, (the staff) knew what they liked. The chef told that inspector that they continue to refine the menus based on the individual’s needs and wishes. They said that the budget was sufficient to provide the planned menus. Fairhaven D51 D01 s3205 Fairhaven v233299 140605 Stage4.doc Version 1.30 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) This group of standards were not inspected EVIDENCE: Fairhaven D51 D01 s3205 Fairhaven v233299 140605 Stage4.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,23,25 The areas of the home inspected were safe and well maintained. Service users’ expressed satisfaction with the environment. The impact the tenants have on the environment is not recognised in a risk assessment framework or the homes documentation. EVIDENCE: The inspector briefly toured the building and looked at service user rooms at random. They were observed as clean and well maintained. The rooms contained many personal items such as photographs, ornaments and some items of furniture. Service user’s said that they have comfortable rooms and confirmed that they feel safe. One service user said that they particularly like the views of the garden from their large room. Several areas have been updated and redecorated including some toilet areas and the laundry. A new stair lift has been installed but at the time of the inspection it was not working properly. There was sufficient evidence that this Fairhaven D51 D01 s3205 Fairhaven v233299 140605 Stage4.doc Version 1.30 Page 14 issue was being addressed with the installation company, the architect and the homes management. Part of the 1st floor and all of the 2nd floor of the building is occupied by tenants, one of the tenants works as a gardener and security officer. The tenants share the communal access to the building and have their own keys. These areas were not inspected during this unannounced visit. Fairhaven D51 D01 s3205 Fairhaven v233299 140605 Stage4.doc Version 1.30 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 Staff are well trained and deployed in numbers sufficient to meet the needs of the service user group. EVIDENCE: The rotas viewed indicate that there are sufficient staff on duty to meet the service users’ needs. The inspector spoke with five members of staff. One member of staff considered that there are good training opportunities at the home and that they have undertaken training in such areas as manual handling, first aid, mental health issues, safe administration of medication and vulnerable adults training. The well-kept records further evidence that training is ongoing and the management have good systems in place to monitor that the training is up to date. Fairhaven D51 D01 s3205 Fairhaven v233299 140605 Stage4.doc Version 1.30 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,37 The home is well managed and provides a needs-led service. The Committee must demonstrate that they manage the relationship between the tenants and home by introducing written protocols that ensure the safety of the service users and clearly set out the responsibilities placed on each party. EVIDENCE: The manager has been in post for over two years and informed the inspector that they are close to completing the registered managers award. They have continued to update their own training on an as and when basis. Service users are able to identify the manager and have a good understanding of the manager’s role. The staff the inspector spoke with said that the manager was approachable and fair, often working with them and the service users. The records observed evidence that staff are being supervised on a formal basis. Fairhaven D51 D01 s3205 Fairhaven v233299 140605 Stage4.doc Version 1.30 Page 17 Whilst the inspector was at the home the inspector became aware of a degree of conflict between the tenant and the manager. This related to a water pipe allegedly overflowing and causing the tenant a sleepless night. Whilst the manager attempted to inform the tenant of the steps they had taken to address the issue, it was quite clear that the tenant was not satisfied. Through discussion with the manager the inspector established that there are no written protocols relating to the relationship between the tenants and the home. The registered manager further indicated that they had not seen a contract between the tenant and the association. Fairhaven D51 D01 s3205 Fairhaven v233299 140605 Stage4.doc Version 1.30 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x x x x x 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 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x 3 x 3 x STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 3 3 x x x x 2 x Fairhaven D51 D01 s3205 Fairhaven v233299 140605 Stage4.doc Version 1.30 Page 19 no Are there any outstanding requirements from the last inspection? 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 1 Regulation schedule 1 Requirement The registered person must ensure that the statement of purpose and service users guide accuratly reflects the current arrangements in the home. This is with specific reference to the tenants. Risk assessments must be conducted relating to the tenants. Significant findings of the risk assessments must be recorded and acted upon in a timely fashion. Timescale for action 10/08/05 2. 37 13 4(a)(c) 10/08/05 3. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 31 Good Practice Recommendations The registered person should consider introducing written protocols relating to the tenants and the home. This should cover areas such as maintence, fire safety, health and safety, risk assessments, codes of conduct and expected behaviour of each party. Fairhaven D51 D01 s3205 Fairhaven v233299 140605 Stage4.doc Version 1.30 Page 20 Commission for Social Care Inspection Suite C, Avonbridge House Bath Road CHIPPENHAM Wiltshire SN15 BB 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 D51 D01 s3205 Fairhaven v233299 140605 Stage4.doc Version 1.30 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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