Inspection on 30/12/05 for Fairhaven, Swindon

This inspection was carried out on 30th December 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 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 Unannounced Inspection 30th December 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Fairhaven DS0000003205.V270590.R02.S.doc Version 5.0 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.V270590.R02.S.doc Version 5.0 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.V270590.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th June 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. Fairhaven DS0000003205.V270590.R02.S.doc Version 5.0 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 service users and staff members. There was an opportunity for the inspector to meet with one service users’ family. The manager was on leave at the time of the inspection. The deputy was on duty and able to meet with the inspector. The inspector could not access some files, as they are stored in the managers’ office. A number of records were examined including care plans, health needs and health and safety records. What the service does well: What has improved since the last inspection? The Service users guide has improved and now accurately reflects the current arrangements in the home. There is now a shift plan in daily use, which ensures that duties are delegated fairly. Risk assessments have now been conducted and findings are now recorded. Fairhaven DS0000003205.V270590.R02.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Fairhaven DS0000003205.V270590.R02.S.doc Version 5.0 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.V270590.R02.S.doc Version 5.0 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 All prospective service users needs are fully assessed prior to being offered a place at the home. EVIDENCE: The deputy reported that there have been no new admissions since the last inspection. Service users’ files showed that full assessments have been completed prior to admission. These included all physical, cognitive, healthcare and social needs. Fairhaven DS0000003205.V270590.R02.S.doc Version 5.0 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 the following standard(s): 7, 8, 10 and 11 Service users’ have an individual plan that outlines their health, personal and social care needs. It appears that health care needs are fully met. Service users have the opportunity to discuss bereavement if they wish. Service users are treated with respect and their privacy is upheld. EVIDENCE: Files sampled contained information on individuals’ healthcare, personal and social needs. There is evidence that care plans are reviewed monthly with the service user and a senior care assistant. Any changes required to the care plan are then identified and service users have the opportunity to suggest any changes they may require for their activity programme or changes needed for their bedrooms. Service users sign, to confirm that they approve the contents of their care plan. Care plans include a dependency profile which provides information on mobility, pressure sores, hearing, sight, communication, orientation, memory, sociability, transfers, dressing, breathing, bathing and feeding. Service users who spoke to the inspector confirmed that their health care needs are being met. The inspector met with one service users family while they were visiting. They confirmed that they were’ very happy with the service and that their relation looked fitter since being at the home’. The home Fairhaven DS0000003205.V270590.R02.S.doc Version 5.0 Page 10 provides hospital beds if they are required, for comfort and to reduce the risk of pressure sores to individuals. Each service user is registered with a local GP. At the time of the inspection a call to the GP had been made, requesting a home visit for a service user who was unwell. One service users records showed that they required a chiropody service and that this had been arranged. When visitors call on service users they have the opportunity to meet in privacy. There is a little lounge, dining room or the individual’s own bedroom to entertain their guests in. The inspector observed staff treating service users respectfully and offering assistance when necessary. No service user appeared to be rushed or placed under undue pressure to complete tasks. Service users confirmed that staff address them using their preferred title and that they are treated well. There is evidence that when a service user refused their medication in tablet form, it was reported to the GP, who arranged for it to be prescribed in a liquid form, which was easier to swallow. The deputy reported that service users do have the opportunity to discuss bereavement if they wish to do so. Any specific wishes are identified at the time of the initial assessment with the service user and their family. Fairhaven DS0000003205.V270590.R02.S.doc Version 5.0 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 the following standard(s): 12, 13 and 14 Service users confirm that the home meets their expectations with regard to social, cultural, religious and recreational needs. Regular contact with families and friends is encouraged by the home. Service users make choices about their lives and how they wish to live them where possible. EVIDENCE: Service users report they are regularly consulted on the activities and entertainment available at the home. They are given the opportunity to make suggestions and give ideas regarding activities that they may wish to do in the future and feedback on things they like and don’t enjoy so much. Regular activities and entertainment includes ‘sing-along’, karaoke, movement, bingo, cards, scrabble and draughts. The Statement of Purpose, which is displayed on the notice board in the hallway, informs the reader that magazines and newspapers are available. Each service user has a television in their bedroom unless they request otherwise. It is noted that many service users have their own personal possessions with them; this includes items of furniture in their bedrooms. A hairdresser visits weekly and service users are able to book to have their hair done when required. Spiritual needs are met by a monthly church service within the home and there is the provision for service users to receive Holy Communion if they wish. Fairhaven DS0000003205.V270590.R02.S.doc Version 5.0 Page 12 Service users confirmed that they are satisfied that their spirituals needs are met. Contact with family and friends are encouraged by the home. During the inspection one service users family visited and were observed being made to feel welcome by the staff on duty. Service users who spoke to the inspector confirmed that they often go out with their family shopping or to the park. They reported that ‘staff are helpful and will often make small purchases for them if they are unable to go themselves’. Mealtimes are flexible and service users have the opportunity to request alternatives from the set menu if they wish. Discussion with the chef confirmed that staff know which foods are liked and which are not. Tables in the dining room are situated in a way that allows ample room for people to manoeuvre around easily, whilst still enabling them to have a conversation with each other if they wish to do so. Service users are enabled to make personal choices. All service users are given the opportunity to hold a key to their bedroom, however no one chooses to do so at the present time. There is evidence that one service user made a choice that they did not wish a certain item to be in their bedroom and alternative arrangements were made for them. Fairhaven DS0000003205.V270590.R02.S.doc Version 5.0 Page 13 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 Service users report that they feel confident their complaints will be listened to and taken seriously. Recruitment procedures are in place to protect service users where possible from any form of abuse. EVIDENCE: Family members confirmed they knew the procedure for making a complaint if necessary. One person commented that ‘ they knew what to do but was very happy with the service being provided’. Five service users reported that they knew the complaints procedure and felt confident that their concerns would be listened to and acted upon. They said that they felt confident that the manager would take any comments seriously. A copy of the complaints procedure is displayed on the service users notice board and each person has his or her own individual copy. This details that a full investigation will be made into the complaint and they will respond within a 28-day timescale. They also advise that CSCI can be contacted. One service user confirmed that they have signed to say they had a copy of the procedure and that their family was also provided with a copy. Evidence that the complaints procedure is discussed with service users at their review meeting is in their care plans. The home has a ‘whistle blowing’ policy, which staff confirmed they would use if they suspected abuse of any kind. Staff told the inspector that they have received training in adult protection and have seen a copy of Swindon and Wiltshire’s guidance ‘ No Secrets’. Staff reported that any purchase made on behalf of a service user is always accompanied with a receipt. Fairhaven DS0000003205.V270590.R02.S.doc Version 5.0 Page 14 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): 24 and 26 Service users are provided with comfortable bedrooms and have their personal possessions around them where possible. The home was clean and hygienic throughout at the time of the inspection. EVIDENCE: At the time of the inspection the home was found to be clean and hygienic. The Christmas tree, decorations and personal cards displayed all added to the pleasant homely environment. A tour of the building showed that all bedrooms viewed were of a good standard and equipped to provide comfort and privacy for the service users. All rooms have a call system to alert staff if assistance is needed. Service users confirm that staff respond quickly to the call. At the time of the inspection no service user was choosing to hold a key to their bedroom, however they could do so if they wished. Service users have the opportunity to have a locked cupboard in their bedrooms for small items of value if they wish. Fairhaven DS0000003205.V270590.R02.S.doc Version 5.0 Page 15 The laundry facilities were observed and the deputy confirmed that soiled laundry is transported in red alginate bags to prevent the risk of infection. Protective clothing is available for staff and staff were observed using gloves and aprons. Sluicing facilities are available and are located away from any food preparation areas. Fairhaven DS0000003205.V270590.R02.S.doc Version 5.0 Page 16 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): 29 and 30 Recruitment records were not available for inspection, however, later discussion with the manager confirmed that all recruitment procedures are in place to protect service users where possible. Staff receive training to enable them to be competent to carry out their duties. EVIDENCE: Although the recruitment files and copies of Criminal Bureau checks were unavailable on the day of the inspection, later discussion with the manager confirmed that all staff have to receive a satisfactory CRB check before commencing employment at Fairhaven. Five staff confirmed that they had provided two references and had not commenced work until their CRB had been returned. Staff reported they received a robust six week period induction, which covered areas such as; fire, an introduction to service users, first aid, care planning, basic food hygiene, health and safety, adult protection, drug awareness, manual handling and infection control. All new staff are provided with a handbook, which outlines terms and conditions of employment, complaints procedure and the principles of care, along with other information. Staff confirmed that they feel the training provided is good and that they are hoping to attend dementia training soon. The deputy confirmed that this is planned for January. Fairhaven DS0000003205.V270590.R02.S.doc Version 5.0 Page 17 Staff informed the inspector that they enjoyed working at the home and that they felt they worked well as a team. They felt that service users are well looked after. Staff have the opportunity to complete their NVQ’s and the house keeper reported that she had been encouraged by the manager to gain an NVQ qualification also. The deputy has NVQ level 4 and is also an NVQ assessor. Fairhaven DS0000003205.V270590.R02.S.doc Version 5.0 Page 18 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): 35, 36, 37 and 38 The home ensures service users finances are safeguarded where possible. Staff receive regular supervision. The health and safety of service users and staff are protected where possible. Where possible service users are protected by the homes’ policies and procedures. EVIDENCE: Documents show that monthly room checks are carried out to identify any health and safety requirements. All hazardous materials are securely locked away and there is a file containing all relevant COSHH data. Records show that fire alarms and emergency lighting tests were last completed on 12/12/05. Records evidence that maintenance of electrical systems and equipment take place. Staff receive training in all aspects of health and safety. Radiators are protected with covers. Some bedroom windows on the first floor do not have restrictors on them. This has been raised at previous inspections Fairhaven DS0000003205.V270590.R02.S.doc Version 5.0 Page 19 and the manager confirmed that the windows meet the fire regulations. She reported that risk assessments are in place to support this. It is required that risk assessments, in relation to these windows are reviewed on a monthly basis or more frequently if residents conditions change and are recorded and acted upon immediately to reduce risk. Records of fire drills and fire inspections appeared to have not taken place for the period of Oct/Dec. However, after discussion with the manager, it was confirmed that the home has received instruction for both, recently from the fire officer and the signature was in the wrong column. The manager and the deputy confirmed that all risk assessments are in place, however they were not available at the time of the inspection. The kitchen facilities were observed as being clean and safe. The chef when preparing food in the kitchen area wore protective clothing. Staff all reported to have regular supervision from the senior staff. The staff appeared confused as to the frequency of team meetings, however discussion with the deputy confirmed that they do take place. Staff reported that the manager informs them of any new policies and procedures. These are placed on the notice board and staff are expected to read and sign to say they understand them. It is recommended that all entries in service users’ daily notes and the communication book are made without any gaps left between them. Fairhaven DS0000003205.V270590.R02.S.doc Version 5.0 Page 20 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 3 8 3 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X 3 X 3 STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 3 3 3 Fairhaven DS0000003205.V270590.R02.S.doc Version 5.0 Page 21 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 OP38 Regulation 13(4)© Requirement The registered manager must complete monthly reviews of risk assessments with regard to the windows without restrictors located on the first floor, or more frequently if residents’ conditions change. Timescale for action 30/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard OP37 Good Practice Recommendations 1. It is recommended that all daily records and the communication book be completed without any gaps between entries. Fairhaven DS0000003205.V270590.R02.S.doc Version 5.0 Page 22 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.V270590.R02.S.doc Version 5.0 Page 23 - 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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