Inspection on 20/07/06 for Fairhaven, Swindon

This inspection was carried out on 20th July 2006.

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 30/12/05

Fairhaven, Swindon 14/06/05

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 Pauline Lintern Key Unannounced Inspection 20th July 2006 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 DS0000003205.V302959.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 DS0000003205.V302959.R01.S.doc Version 5.2 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 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) Swindon Old People`s Housing Association Mrs Lynn Plumstead Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Fairhaven DS0000003205.V302959.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th December 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 on 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. The highest fee at Fairhaven is £460. 50p for one week. Fairhaven DS0000003205.V302959.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection began at 10.00am and lasted five and a half hours. All key standards were inspected. The inspector met with the manager, the responsible individual, three staff members, one relative, the cook and six service users during the visit. 15 surveys were sent out to service users, 8 were returned. 15 comment cards were sent to relatives, 11 were returned. 2 comment cards were sent to GP’s and none were returned. 1was sent to a service user’s representative and was returned. Generally all comments returned were of a positive nature. During the visit various documents were sampled, these included: health and safety, staff recruitment files, care plans, risk assessments, medication and accident records. The inspector toured the building whilst observing the environment. What the service does well: What has improved since the last inspection? Risk assessments for the upstairs windows, without restrictors, are now completed monthly to ensure the health and safety of service users is maintained. The manager reported that they are in the process of arranging to Fairhaven DS0000003205.V302959.R01.S.doc Version 5.2 Page 6 have the 20 upstairs windows replaced with double glazed ones, in keeping with the rest of the house. 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. Fairhaven DS0000003205.V302959.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 DS0000003205.V302959.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 A full assessment is completed prior to offering a service to ensure that the service user’s needs can be met. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The inspector met with one service user who has very recently moved into Fairhaven. They confirmed that an assessment of their needs was completed, but most discussion with regard to their move was between with their relative and the manager and they were happy with this. One service user reported to the inspector that they had requested to move into the home as they had heard how good it was. Examination of a recent assessment showed that the manager had visited the service user in their last home and discussed areas such as health, mobility, communication, cultural needs, personal care, likes and dislikes and hobbies. The service user enjoys playing the piano and it was arranged for them to have this brought into Fairhaven so that they can continue to enjoy playing. Fairhaven DS0000003205.V302959.R01.S.doc Version 5.2 Page 9 The manager identified that there was a need to arrange for two people’s spiritual needs to be met and therefore has arranged for Holy Communion to be delivered regularly. The manager confirmed that all new service users are provided with a service user guide and the statement of purpose. Fairhaven DS0000003205.V302959.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9,10 and 11 Each service user has an individual plan of care. Service users have access to healthcare professionals when required. The homes policies and procedures ensure that service users are protected where possible when medication is administered. Service users are treated with courtesy and respect. Death and dying is treated with sensitivity. Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to the service. EVIDENCE: Care plans set out clear information on how the service users’ needs should be met. Care plans sampled indicate that they are regularly reviewed. There is evidence that service users are able to participate and communicate their views to the development of their care plan and the review process. Feedback and involvement is a monthly ongoing process. The manager confirmed that senior staff and the key worker are also involved in the review of care plans. Staff confirmed to the inspector that they are always kept informed of any changes to individual plans. Each plan includes a risk Fairhaven DS0000003205.V302959.R01.S.doc Version 5.2 Page 11 assessment for falls and manual handling. All records provide clear and relevant information for the reader. The manager explained that she is in the process of arranging for some staff to attend dementia training to ensure a good underpinning knowledge. Discussion with staff and the manager indicates that the staff already have a sound base knowledge on this subject. Quality monitoring systems include obtaining the views of the service users and identifying if they wish for changes to be made. One person had expressed a desire to have their bedroom redecorated; a two-month timescale had been given for completion and the manager confirmed that this was achieved. The inspector spent time talking to service users who all confirmed that they are treated with respect and dignity. One service user commented ‘the staff would do anything for us and we would do anything for them’. Some service user’s are unable or choose not to leave their bedrooms. One person told the inspector that they’ prefer to be on my own but if I pull the call bell staff come straight away’. The home now holds an oxygen cylinder to ensure they meet the needs of one service user. The manager confirmed that she has arranged for a service check and that she has informed Wiltshire Fire Brigade that oxygen is now at the home. They are waiting for a notice to go onto the bedroom door where it is kept to inform people that there is oxygen inside. Staff confirmed to the inspector that they feel competent when handling the cylinders. Only staff who are trained to do so administer medication. No one was choosing to self-administer his or her medication at the time of the inspection. Medication records were examined and they appeared to be maintained well. There are systems in place to safeguard service users where possible. At the time of the inspection the home was not holding any controlled drugs. Any ‘as required’ medication is recorded when administered. All medicines are securely locked. Two service users medication records were sampled during the visit. All service users have access to healthcare services. Daily notes and discussion with service users demonstrated that staff support individuals to appointments with the GP, optician, podiatrist and to the hospital. The manager confirmed that the community nurse regular visits the home. The surveys sent out to service users ask if they are happy with the care and support that they receive; 100 said ‘yes always’. When asked if they receive the medical support they need seven responded ‘yes’ and one said ‘usually’. Eight relatives commented that they were consulted on their relatives care if they are unable to make decisions, two did not answer this question and one said no. The registered manager reported that she often works ‘hands on’ with the staff, which enables her to be involved in the day to day practices. She told the inspector ‘I wouldn’t ask any one to do anything that I was not prepared to do myself’. The manager and the inspector discussed how service users and their families could be empowered to make decisions with regard to death and dying. The Fairhaven DS0000003205.V302959.R01.S.doc Version 5.2 Page 12 manager is going to consider how this subject could be approached sensitively, to enable their wishes to be recorded within their care plan. The manager reported that if the staff have been involved in end of life care in the past, they have always ensured that the service user has 24 hour care and support. She confirmed that staff have always treated service users with respect and have take care to ensure that people are comfortable in their last days. Personal care is always delivered in the privacy of the bathroom or bedroom. There is one male member of staff at present working at the home. The manager confirmed that all female service users are asked if they are happy for him to assist with their personal care; this is then documented in the care plan. Service users told the inspector that personal care is delivered carefully and respectfully. Service users are encouraged to be as self-managing as is possible. One service user reported that they are completely independent with their dressing and personal care. Daily notes demonstrated where in the best interests of a service user, staff now assist with their shaving as the person was experiencing difficulties. Fairhaven DS0000003205.V302959.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Service users are able to choose whether they participate in activities or not. Service users have the opportunity to meet their visitors in private if they wish to do so. Service users are encouraged to make choices and live their lives how they wish. Meals provided are nutritious and varied, and mealtimes are flexible. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Service users who met with the inspector reported that they can choose to participate in arranged activities if they wish or they can decide not to join in. One service user said that they had ‘enjoyed the singsong’ the previous day. One person said that they preferred to play cards on their own, another that they did not like ‘joining in’. Twice a week a qualified therapist visits and offers gentle movement sessions or a quiz. Due to the hot weather on the day of the inspection they decided on a quiz. Service users confirmed that they enjoy these sessions and commented that ‘Beryl is really good’. Service users who are unable to leave their rooms or choose not to, informed the inspector that staff keep popping in to chat with them so they are not left alone. Fairhaven DS0000003205.V302959.R01.S.doc Version 5.2 Page 14 Regular church services take place at the home. As stated previously provision has been made for Holy Communions to also be provided. The home now has two service users who originate from Poland. They are able to communicate to eat other in their native tongue. There is a staff member who is also able to speak Polish, who will soon be returning from maternity leave. The manager has confirmed that neither has requested any other cultural needs. Families and friends are encouraged to visit the home. At the time of the visit one service user went out with their family. One service user said that their friend who also takes them out frequently visits them. Another person stated that they ‘are very lucky as their daughter visits every other day’. Surveys returned from relatives confirm that 100 feel that they are made welcome at Fairhaven. One survey commented that ‘there is not always enough chairs for us to sit on when we arrive’. The majority of service users feel that there are enough activities taking place at the home. The inspector spoke to the cook, who confirmed that although there is a set menu, this is flexible and during the recent spell of hot weather some of the desserts have been altered to provide a cooler alternative. All service users who spoke to the inspector confirmed that the food was good and that they enjoyed their meals. Food was sampled at the time of the inspection and was fresh and of a high quality. Service users and staff confirmed that they are provided with ample fluids and refreshments are regularly offered. The dining room is pleasant and not cramped. There is plenty of room to manoeuvre around the tables. Meals can be taken in individuals’ own rooms if required. Snacks and drinks are always available. The cook reported that they had recently planned to have a barbeque, but the weather changed and they were unable to go ahead with it. Service users were observed sitting outside in the garden, and it was noted that staff were very aware of the possibility of it becoming too hot for service users. Fairhaven DS0000003205.V302959.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Complaints are listened to and taken seriously. Where possible service users are protected from any form of abuse. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. EVIDENCE: There have been no complaints since the last inspection. The home has a complaints log and a complaints policy and procedure. The inspector spoke to a relative of a new service user, who confirmed that they had been told about the complaints procedure and they felt confident that any concerns would be dealt with appropriately. Surveys show that nine out of eleven relatives say that they have never had to make a complaint. One said that they had but it was a ‘minor’ issue. One relative reported that they had raised a concern about their relative and it had been acted upon straight away, they were happy with the outcome. Eight relatives reported that they are aware of the complaints procedure; three said that they were not. The manager reported that all service users and their representatives are provided with information on the complaints procedure. Service user surveys state that eight people know who to talk to if they are not happy and one said there has been no reason to complain yet. All service users who met with the inspector had a good understanding of how the complaints procedure works. A referral to the Vulnerable Adults unit was made in March 2006 to ensure the safety of a service user. Discussion with the manager indicates that the situation is continually monitored by the home to safeguard the individual. Fairhaven DS0000003205.V302959.R01.S.doc Version 5.2 Page 16 Staff confirm that they attend abuse awareness training and have a knowledge of the Swindon and Wiltshire’s guidance ‘No Secrets’. Staff informed the inspector that they understand the protocols for reporting suspected and would have no hesitation in doing so if they had any concerns. The home ensures that service user’s monies are stored securely and all transactions are recorded. Fairhaven DS0000003205.V302959.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Fairhaven provides a safe and well-maintained environment for the service users who live there. At the time of the inspection the home was clean and hygienic with no unpleasant odours. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. EVIDENCE: On the day of the inspection some service users were taking advantage of the well-kept gardens, by sitting outside and enjoying the sunshine. The grounds are easily accessible for service users. As stated earlier in this report, there are plans to replace twenty windows on the first floor. One relatives survey reported that ‘they are sometimes a bit lax over cleaning of the wc’s’, however at the time of the inspection toilets and bathrooms were clean and hygienic. Service user surveys reported that seven people felt that the home is always clean and fresh and one said that it was usually clean. Fairhaven DS0000003205.V302959.R01.S.doc Version 5.2 Page 18 The inspector spoke to a service user who had recently moved to Fairhaven and they confirmed that they are happy with their room and had a fan to keep cool. They told the inspector that they had brought their own television with them. The manager confirmed that red alginate bags are used for transporting washing to the laundry to control risk of infection. The washing machine has a sluice and disinfection facility. The laundry floor and walls were noted as being clean. Staff are provided with anti-bacterial hand gel to keep on them at all times, gloves and two different coloured aprons depending on the task being carried out. Staff are not encouraged to wear open toed shoes for safety reasons. One staff member reported that ‘Lynn is very particular about infection control’. The inspector toured the building and found it to be clean and hygienic throughout with no offensive odours. Fairhaven DS0000003205.V302959.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28,29 and 30 There appears to be sufficient staff on duty at all times. Staff are trained to ensure that they can meet the needs of the service users. The homes recruitment procedures and policies protect service users where possible. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Discussion with the manager confirmed that there is always at least three staff on duty during the day; some days there are four. Staff members and service users report that there are sufficient staffing levels. The inspector met with the three staff on duty at the time of the inspection. They all confirmed that they had received an induction period. One staff member reported that they had completed a foundation course, health and safety, abuse awareness and mandatory training such as manual handling, fire awareness and basic food hygiene. The manager reports that the home has not had to use agency staff for the past two years, as the compliment of permanent staff has been fairly consistent. The manager confirmed that all staff receive mandatory training. Service user’s comments with regard to the staff include ‘Staff are wonderful’, staff have made me feel very welcome and helped me settle in’, ‘I am happy with the staff and the home’ and ‘ they are nice staff and they treat me well’. Three staff recruitment records were examined and demonstrated that two references had been sought and satisfactory checks with the Criminal Records Fairhaven DS0000003205.V302959.R01.S.doc Version 5.2 Page 20 Bureau (CRB) completed before commencement of employment. Checks are also made against the Protection of Vulnerable Adults list to safeguard individuals. There is evidence that new starters are provided with terms and conditions of employment and the set Codes of Practice. Fairhaven DS0000003205.V302959.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Fairhaven is well run and managed by a competent and qualified manager. The home has developed quality monitoring systems to enable service users to share their views. The manager maintains an open and transparent service, with everyone working together. Service users’ finances are safeguarded where possible. Where possible the health and safety of service users is protected and promoted. Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to the service. EVIDENCE: There is evidence that indicates that the home is well managed by a qualified manager. The paperwork at Fairhaven is of a high standard and is regularly reviewed to ensure that standards are met. The manager holds her Registered Manager’s award and her NVQ level 4 in care. She reported that she has just employed another deputy, which means that two experienced deputies now Fairhaven DS0000003205.V302959.R01.S.doc Version 5.2 Page 22 support her. Comments made to the inspector with regard to the manager’s capabilities include ‘ Lyn is spot on and has really made a difference since she came here’. Staff also report that their manager is ‘helpful and supportive’. Discussion with the manager demonstrates that she has a good knowledge of the ageing process and is able to share this with her staff members. The home ensures that service users have the opportunity to share their views. The care plans sampled demonstrate that service users are involved in the process and there is evidence that their comments are acted upon. The home has a quality audit questionnaire. This is sent out to families, service users, health professionals and care managers. On examination: responses appeared generally positive for example ‘the standard of care is extremely high’. The manager has created an open, transparent and inclusive atmosphere within the home. Management and the staff appear to ‘pull together’ when necessary to maintain consistency for the service users. The manager appears to be well respected. Following a requirement set at the last inspection, the upstairs windows that do not have window restrictors are risk assessed monthly to minimise any potential risk to service users whose bedrooms are on that floor. The manager commented that when the new windows are fitted they will be contacting Wiltshire Fire Brigade to ensure they comply with the regulations. These changes will include two upstairs fire doors as well. The fire log showed that the last fire drill was completed in May 2006 and the last fire instruction was carried out in June 2006. The home holds a Fire safety certificate, which is dated May 2006. Fire fighting systems have been serviced. The risk assessment for fire was dated 17/03/06. Accidents records were examined and there is evidence that they are completed and filed securely in accordance to the Data Protection Act. To protect service users from the hot surfaces of radiators; all are covered. There is a file, which contains all the data on toxic materials used within the home. All such materials are securely locked away. Staff members confirmed that they all attend manual handling training and follow up refresher courses. Each service user has a manual handling risk assessment within their care plan. There is evidence of these having been regularly reviewed. Fairhaven DS0000003205.V302959.R01.S.doc Version 5.2 Page 23 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 X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 2 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 4 3 3 X 3 X X 3 Fairhaven DS0000003205.V302959.R01.S.doc Version 5.2 Page 24 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. 1. Refer to Standard OP11 Good Practice Recommendations It is recommended that the manager develops a format to enable service users and their families to ensure that their wishes, with regard to end of life care are documented where possible. Fairhaven DS0000003205.V302959.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 DS0000003205.V302959.R01.S.doc Version 5.2 Page 26 - 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. 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