Inspection on 13/05/05 for Fairholme

This inspection was carried out on 13th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Fairholme 08/08/07

Fairholme 04/05/06

Fairholme 02/11/05

Fairholme 25/01/05

Fairholme 10/06/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Fairholme Roskear Camborne Cornwall TR14 8DN Lead Inspector Lynda Kirtland Diana Martin Announced 13 May 2005 09.30 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. Fairholme D52-D04 S8893 Fairholme V215920 130505 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Fairholme Address Roskear Camborne Cornwall TR14 8DN 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) 01209 714491 01209 711169 Mr Jaspal Singh Mangat & Mrs Bhupender Kaur Mangat Care Home 60 Category(ies) of Old age, not falling within any other category registration, with number (60), Physical Disability (60), Terminally ill (60) of places Fairholme D52-D04 S8893 Fairholme V215920 130505 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: Service users to include up to 60 adults of old age (OP) some of whom may have nursing needs Service users to include up to 60 adults with a physical disability (PD) some of whom may have nursing needs Service users to include up to 60 adults with a terminal illness (TI) some of whom may have nursing needs Total number of service users not to exceed a maximum of 60 Date of last inspection 25 January 2005 Brief Description of the Service: Fairholme Nursing Home has been operating since 1988. The home is registered to provide residential and nursing care to sixty service users who are in need of personal care by virtue of being elderly, or adults some of whom may have a physical disability or a terminal illness. The home provides long term and respite placements. The home aims to avoid emergency admissions wherever possible. The home was a former purpose built children’s home. Therefore the structure of the building is challenging in attempting to meet the needs of this current service users group. The home is spread over two floors, lifts allow access to the first floor. The home has ramps to allow access for people with a physical disability but some parts are difficult to access in a wheelchair due to the narrow corridors and size of rooms. The grounds have been developed to improve access to the garden areas. Fairholme has undergone a major building and redecoration programme which has improved the entrance to the home, lounge areas, updated some bedrooms some of now have en suite facilities and new office space. Fairholme is located near the town centre of Camborne and has access to local amenities with good transport links. Fairholme D52-D04 S8893 Fairholme V215920 130505 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. CSCI inspectors, Lynda Kirtland and Diana Martin, visited fairholme Nursing Home on the 13 May 2005 and spent the day at the home. This was an announced visit. On the day of inspection 42 service users were resident in Fairholme. The inspectors met with 16 service users and 4 representatives, a number of staff and the registered providers to gain their views on the service that Fairholme provide. In addition the inspector examined records, policies and procedures and toured the building. This report summarises the findings of this inspection. What the service does well: What has improved since the last inspection? Fairholme has made many positive changes since the last inspection. The previous inspection identified 22 requirements and 4 recommendations. Of these the registered providers have complied with 19 requirements and 3 recommendations. The others are in process of being met. The commitment to improve standards in the home has been evidenced throughout this inspection. Some examples of the improvements made are as follows: • Feedback from service users and their representatives is positive. They have commented that staff are skilled to be able to meet their care needs in a sensitive and professional manner. • With the implementation of service users and their representatives meetings, they feel more able to voice concerns and provide ideas for Fairholme D52-D04 S8893 Fairholme V215920 130505 Stage 4.doc Version 1.20 Page 6 • • • • • • improvements that the home could make. Service users stated that the registered provider listens to these ideas and where possible takes appropriate action. Staff commented that due to their job descriptions being amended, plus the implementation of supervision and regular staff meetings the expectations of their role is clearer. This they feel has lead to an improvement in the quality of care that they are now providing to service users, which was confirmed by them. Staff feel that they are consulted in the future development of the home. Staff feel that they are able to voice concerns, that they will be listened too and that appropriate action will be taken. The home has undergone a period of building works, refurbishment and redecoration. Service users, their representative’s and staff all commented on the improvements in the home. The registered providers have reviewed a number of the homes policy and procedures and will ensure that staff will be trained in the changes. The registered providers are in the process of developing a website so that service users and their representatives can gain more information about the home and the facilities that it provides. What they could do better: From this inspection some aspects of practice have been identified for further development. These areas are to: • The registered provider and staff to continue to develop care plans. The care plan must cover all service users care needs and identify what staff interventions are needed. • That the registered provider audits the numbers of falls/ accidents in the home and proposes an action plan as to how to minimise further incidents. • Some policies for example adult protection and the management of service users monies are amended and relevant training provided to staff. • The registered manager post is recruited too as is a deputy manager post. • Continued commitment to provide updated staff training and development in order for staff to absorb and adopt the new practices and expectations that are required. • That the call bell system continues to be monitored in order that response times by staff to service users care needs is managed within an appropriate time frame. • Continued investment in the homes facilities to promote a comfortable home and atmosphere for all service users resident at the home. Fairholme D52-D04 S8893 Fairholme V215920 130505 Stage 4.doc Version 1.20 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Fairholme D52-D04 S8893 Fairholme V215920 130505 Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection Fairholme D52-D04 S8893 Fairholme V215920 130505 Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5 Fairholme has comprehensive information, which informs service users and their representatives about the services that Fairholme provides. Prior to admission, service users and their representatives participate in a pre admission assessment with members from the management team to identify individual care needs. A trail period of stay within the home is offered. Emergency admissions are avoided wherever possible. EVIDENCE: The registered providers have updated Fairholme Statement of Purpose and Service Users Guide to reflect the services that Fairholme provides. The registered providers agreed to review the presentation of these documents so that they can be accessible to a larger audience. The registered provider stated that the home is currently setting up a web site page for service users and their representatives to be able to access the site to gain further information on the services that the home provides. Fairholme D52-D04 S8893 Fairholme V215920 130505 Stage 4.doc Version 1.20 Page 10 From discussion with service users and their representatives, plus inspection of four service users files it was evident that they are consulted in Fairholme pre admission assessment. Service users confirmed that they met with a nursing member of staff prior to admission and that where possible they occur in the community. Care needs identified by the referring professional assessments were incorporated in the assessment process and transferred to care plans This assessment is detailed and the majority of files identified service users individual physical, emotional, social, educational and leisure needs and how the home would aim to address them. A months trail period is offered to all new service users after which a review is held with all parties present to consider if the placement is appropriate and if so a long-term placement will be provided. Service users and their representatives commented that the preadmission and ‘moving in period’ are carried out sensitively by staff and could not see how this process could be improved. Service users and their representatives commented that they felt that they received a ‘nice welcome’ to the home. From inspection of recently admitted service users to Fairholme this demonstrated the ‘moving in/settling in’ period and what support/assistance was provided. Financial expectations and accountability are clearly stated in the service users contract with the home, which has been signed, by the service users or their representatives and the home, or referring local authority. Throughout the inspection the inspector observed staff that displayed skill in communicating and providing personal and emotional care to service users. Staff training is a priority to Fairholme and the staff commented that they have received training in the areas of dementia, palliative care, continence, tissue viability and medication recently. Documentation seen also supported this. Staff commented that the recent training they have received has assisted them in their daily work. Fairholme D52-D04 S8893 Fairholme V215920 130505 Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,10, Care plans must be expanded to ensure that they identify service users physical, emotional, social, educational and leisure pursuits and the interventions expected of staff to approach the care need in a consistent manner must be recorded. Health needs are met in a satisfactory manner. The registered provider must audit the number of falls in the home and ensure appropriate actions are taken to minimise further falls. Service users commented that the majority of staff at the home approaches them with dignity and privacy. EVIDENCE: The inspectors acknowledged that work on developing care plans remains in progress. From the four service users files inspected it was evident that care plans focused on current care needs that had been identified as a ‘problem’ and what action was needed to address them. Inspectors commented that the care plans should cover all care needs as specified in the national minimum standards so that an overall assessment of service users skills, strengths and where specific assistance is required is identified. Some assessments such as nutrition, social, educational and leisure pursuits were absent. Inspectors commented that the nighttime care plan was comprehensive and would enable all night staff to be clear as to the expectations of care for individual service Fairholme D52-D04 S8893 Fairholme V215920 130505 Stage 4.doc Version 1.20 Page 12 users during this time. The registered provider agreed to review the current care plans. Service users and their representative’s participation in the implementation and subsequent review of their care plans was in the majority of cases recorded as occurring. From discussion with service users they commented that they felt that they received satisfactory care. The previous inspection required that risk assessments, in particular regarding nursing service users on a mattress on the floor and the health and safety risks this imposes were now present on service users files. Advice form service users and their representatives and medical professionals have been gained to look at alternatives before this action is taken. The registered provider agreed that this is not an ideal way to care for a service user and that they will continue to gain advice in this area. In addition bed rails assessments are now being undertaken with consent gained from service users, their representatives and medical professionals. Some service users commented that they liked the reassurance of bed rails at nighttime. From inspection of the accident book it was noted that there has been a number of falls/ incidents involving service users. The registered providers have monitored the number of falls and stated that when a service user has five falls they then reassess that individuals care plan. Inspectors recommended that the registered provider undertakes an audit of all falls / accidents within the home and attempt to identify how these incidents can be minimised in the future. CSCI require that this be reviewed. A recommendation was identified at the previous inspection that Fairholme should have a policy, procedure and guidance documents which inform the ‘key worker role for staff. This was inspected and was satisfactory. Service users and their representatives confirmed that there is access to health professionals. Records in individual service users files evidenced advise provided by health professionals in the care of service users. Fairholme has a physiotherapist and care plans in respect of physio care are identified. Identified staffs have recently attended training in the areas of pressure care, tissue viability and continence. Records in respect of these care needs were maintained to a good standard. On the day of inspection no service users had pressure care needs. Policies in respect of these areas of care were inspected and were satisfactory. Specific equipment for example to assist in moving and handling of service users are available in the home and staff receive training in how to use this equipment form the physiotherapist. Staff confirmed that specialised mattresses and other equipment are gained form health service. The Fairholme D52-D04 S8893 Fairholme V215920 130505 Stage 4.doc Version 1.20 Page 13 registered provider commented that in the majority of occasions these are gained before a service users admission to the home. Fairholme has a comprehensive policy in respect of privacy and dignity and is referred to in the homes statement of purpose and service users guide. Inspectors noted that the atmosphere of the home and service users appeared to be relaxed. Service users and their representatives commented that there had been ‘major improvements’ since the last inspection. Comments such as staff ’ were ‘kind’, and that the management team ‘listen’ were made. From inspectors observations of staff throughout the inspection it was noted that staff approached and interacted with service users in a professional yet sensitive manner. Service users confirmed that in the main they have a choice as to when to rise/ retire to bed, receive their mail unopened, have access to a private phone and can receive visitors in private. Fairholme D52-D04 S8893 Fairholme V215920 130505 Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15 Fairholme provides a programme of activities to promote and encourage the pursuit of service users social, educational and leisure needs. Service users visitors are encouraged to visit their relative. Service users are encouraged to retain links with the local community Fairholme must consult with service users about the provisions of meals in the home. The dining facilities must be updated. EVIDENCE: From discussions with service users the majority commented that there is ‘enough to do’ during the day at Fairholme. Service users recalled a variety of activities that are provided: i.e. film club, entertainers, celebrations, games and pastoral services. Service users are also encouraged to share their hobbies with others i.e. organising lottery club and bingo. The inspector observed a variety of activities occurring during the inspection and saw information on display advertising future events. The registered provider stated that an activity coordinator is in post and consults with service users about what activities to promote. Some service users attend clubs, societies in the community i.e. Parkinson group, Dysphasia Society and local churches. Fairholme D52-D04 S8893 Fairholme V215920 130505 Stage 4.doc Version 1.20 Page 15 Service users have opportunities to access advocates and some choose to have relatives act on their behalf. Relatives and service users stated that the home is welcoming to them. The visitor’s book demonstrated that visits to the home occur at all times of the waking day and appear to have increased in number. Mealtimes were not inspected in detail on this occasion. However service users commented that the quality of meals ‘varied’ with ‘more good days than bad’. The majority of service users acknowledged that it is difficult for the catering staff to accommodate for all service users individual tastes and felt that on the whole the food was ‘satisfactory’. Service users commented that the breakfast was the ‘best meal’ and how much they enjoyed the cooked breakfasts. Service users commented that the menu cards that promote a choice in menu have been viewed positively. Service users commented that the management team have consulted them in respect of the provision of meals and felt that their comments have been listened too and acted upon. The Head of Catering in discussion with the inspector was aware of service users likes/dislikes and of special diets. The registered providers are reviewing the design and layout to improve the dining room facilities. This statutory requirement remains within timescale for compliance. Fairholme D52-D04 S8893 Fairholme V215920 130505 Stage 4.doc Version 1.20 Page 16 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) 16,17,18 Fairholme has an appropriate complaints and whistle blowing policy. The management team encourage service users, their representatives and staff to voice any concerns so that they can be addressed. The registered provider ensures that service users are protected from all forms of abuse. The policy must be amended. EVIDENCE: Fairholme has a comprehensive complaints procedure. This will investigate written and verbal complaints. From inspection of Fairholme complaint book this documented that they are now investigating expressions of concern that are brought to their attention. Since the unannounced inspection in January 2005, the home and CSCI have investigated a number of complaints, of which the majority were not upheld or partially substantiated. There have been significant staffing and organisational changes in the home over the last seven months. From discussion with service users, their representatives and staff they commented that with some of the recent changes to the home structures they felt more able to approach the registered providers directly if they had any concerns. With the implementation of service users and their representatives meetings, regular staff meetings and supervision, plus service users commenting that the registered provider ‘pops in on a weekly bases to see me to catch up’ has been viewed positively. All stated they felt more able to voice concerns/ ideas for improvement to the current management team. The registered provider has clearly focused on this standard of care, the home are now receiving a increase in the number of compliments for the care and support that service users and their relatives are receiving. Fairholme D52-D04 S8893 Fairholme V215920 130505 Stage 4.doc Version 1.20 Page 17 From discussion with some service users they confirmed that they had a postal vote to use in the forthcoming general Election. They also confirmed that there is access to local advocacy groups, solicitors or that family members will act on their behalf. Fairholme has a comprehensive adult protection policy. Inspectors commented that this policy could be used as a training tool as it is complex. The inspectors advise that as the document is so detailed the registered provider implements a flowchart of what action staff need to undertake if there was an adult protection issue. The registered provider agreed to undertake this. The registered provider agreed to ensure that a copy of the DOH’ No Secrets Guidance’ is purchased and available for staff as well as a copy of the Local Authorities Adult Protection Procedure. The registered provider stated that staffs have received training in the area of abuse. The home has a policy in respect of managing challenging behaviour that was not inspected at this time. The previous requirement to ensure training in this area of care is in the process of commencing for staff. Fairholme D52-D04 S8893 Fairholme V215920 130505 Stage 4.doc Version 1.20 Page 18 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) 22,25,26 Fairholme have invested in the homes furnishing and décor to improve the facilities in the home, and this remains in progress. The call bell system has been reviewed and continues to be monitored. The home is clean. EVIDENCE: The inspectors noted that the registered providers have invested significantly into the fabric of the home. The entrance hall, lounges, some service users bedrooms have all been redecorated and had new furnishings, lighting and in some cases carpeting fitted. Service users and their representatives were positive about the changes to the home with one person commenting ‘this is the best it ‘s looked’. The registered providers have an ongoing refurbishment programme and the next major works will be to redesign the dining and kitchen areas. The home is registered to accommodate 60 service users with some new en suite bedrooms now available. The medication/ treatment room has been updated, as has office space. Fairholme D52-D04 S8893 Fairholme V215920 130505 Stage 4.doc Version 1.20 Page 19 Only the previous requirements and recommendation in respect of the environmental standards were inspected on this visit. It was noted that compliance has been achieved in respect of the cleanliness of the home. Radiator covers have been fitted in the main lounges and are being installed in service users bedrooms. The home has installed a call bell system. From comments form service users some commented that there has been an improvement in staff response times to the call bell system, others held the opposite view. Fairholme is a large building and ensuring that staffs are available in all parts can be challenging. To assist with the call bell system staffs’ now have the addition of a ‘walkie talkie’ which assists in locating where staff are and quickens the response to the call bells as staff are no longer looking for each other to assist with specific elements of care. Staff felt that this had improved their response times to service users. The registered provider has monitored this area and it is recommended that this area continue to be monitored. Fairholme D52-D04 S8893 Fairholme V215920 130505 Stage 4.doc Version 1.20 Page 20 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) 27,28,29 Fairholme ensure that suitable trained staffs are employed in sufficient numbers at all times. EVIDENCE: On the day of inspection six carers, 2 qualified nurses a dining room assistant, plus domestics, handyperson, kitchen staffs, laundress, administrator and registered providers were on duty. Staffing ratio during waking hours is aimed to be 1:6. At night there are three waking night staff plus one qualified nurse and a manager on call. The registered provider stated that when they need to provide additional staff cover they look to their part time workers to provide this to ensure consistency of care, some of who work for an agency. The registered provider stated that there are currently no staffing vacancies in these areas in the home. The registered providers are in the process of recruiting for the registered manager post. They aim to advertise the post of deputy manager when the registered manager has been appointed. The registered provider stated that as the number of service users resident at the home is not at full capacity that current staffing levels reflect this. However they stated that when service users numbers rise that staffing hours would be increased. Fairholme D52-D04 S8893 Fairholme V215920 130505 Stage 4.doc Version 1.20 Page 21 In discussion with service users, their representatives and staff, the majority felt that whilst staff were ‘busy’ there was sufficient staff on duty. Domestic staff stated that there are sufficient in number, as is maintenance and kitchen staffs. Service users and their representatives made positive comments to the inspectors about staff approach and manner in how they provide care. Some stated that staff approach had improved. Staff commented to the inspectors that they have a clear job description and that that the expectations of their role have been clearly explained to them via supervision. Some staff commented that ‘expectations of our work have gone up’ and stated that initially they were concerned as to if the management expectations could be achieved. The majority of staff commented that they are ‘pleased’ that the expectations have risen, as they now feel more ‘competent’, ‘proud’ and ‘confident’ in their work. From the inspectors observations of staff they interacted with the service users in a positive manner and demonstrated good communication skills in working with and caring for service users and their representatives. From inspecting staff files and in discussion with staff it was evident that the staff team had a variety of experience, skills and qualifications. Service users and their representatives in the main spoke positively about the staff team. The registered provider confirmed that currently the number of staff to achieve NVQ level 2 is on target to meet the requirement of 50 . Fairholme has prioritised staff training and from discussion with staff and inspection of staff files this demonstrated a commitment to staff updating their training. Staff files inspected demonstrated that they meet the requirements as set in the national minimum standards. Al staff have applied for CRB /POVA clearance prior to commencement of employment. From inspection of recently recruited staff files they evidenced that appropriate employment checks have been completed. Fairholme has detailed recruitment policies. Fairholme D52-D04 S8893 Fairholme V215920 130505 Stage 4.doc Version 1.20 Page 22 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) 32,33,35,37 The registered providers have promoted a management structure, which creates an open, positive and inclusive atmosphere. The home has many quality assurance systems in place to monitor the quality of the home a summary of these must be sent to the commission. The administration of service users monies needs to be reviewed. EVIDENCE: For the last seven months the registered providers have undertaken an active role in the home and implemented organisational staffing, work practice changes and amended policies and procedures. This inspection has demonstrated that the organisational systems that the registered providers have implemented have been positive as service users, their representatives and staff have provided positive feedback in how expectations in the area of care has risen. This coincides with the increase in staff training/ supervision and consultation with service users and their representatives and staff. Fairholme D52-D04 S8893 Fairholme V215920 130505 Stage 4.doc Version 1.20 Page 23 Service users and their representatives confirmed that they have all met the registered providers and have shared their view on the services that Fairholme provides and that Mrs Mangat had rectified any concerns/issues that they raised. The majority of service users spoke positively about the changes in the home. Comments were made such as ‘it’s the best organised I’ve seen’. Staff were also in the main positive about the differing management style and changes within the home. It is hoped that with the appointment of a registered manager that these changes will be able to be maintained. The registered providers have promoted and encouraged more ‘openness’ in the home. Regular meetings for service users and their representatives and staff have commenced. Staff and relatives felt that these meetings were beneficial and also commented that they felt consulted in the future developments of the home. The notice of the CSCI inspection was on display and CSCI received 2 comment cards from relatives about the service that the home provides. The registered provider has implemented quality assurance surveys in the provision and quality of care that Fairholme provides. It is required that a summary of these findings is forwarded with an action plan to CSCI. Fairholme has a policy in the administration of service users monies. This explains the philosophy of service users rights in managing their own money. Inspectors required that this policy be reviewed so that the process of managing monies is explained clearer i.e. how you deposit and withdraw monies, how you can view your accounts, times you can access money etc. In addition the registered provider agreed to record when he has audited the records with the administrator and to gain written consent from either the service users or their representatives that they can look after a persons money or belongings. From inspection of service users monies records were accurate and tallied. Records held by the home are stored in a confidential manner and in line with the Data protection Act. Fairholme D52-D04 S8893 Fairholme V215920 130505 Stage 4.doc Version 1.20 Page 24 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION x x x 2 x x 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 2 x 3 2 x 2 x 3 x Fairholme D52-D04 S8893 Fairholme V215920 130505 Stage 4.doc Version 1.20 Page 25 yes 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 Op7 Regulation 15(1) (2) Requirement Care plans must identify all service users care needs as specified in the National Minimum Satandards 3.3 The registerd provider must audit the number of falls within the home and provide a action plan as to how to minimise furhter accidents/incidents. This must be forwarded to CSCI the registerd provider must send to CSCI plans in respect of the redesign of the dining areas. Training in the area of managing aggressive/ challenging behaviour must be provided. the adult protection process must be amended and this cascaded to all staff. the registerd provider must appoint a registrerd manager and follow the homes recruitment proceddure. The findings of the FAirholme quality assurance survey must be sent to the commission. This is re- notified to you. the policy on the administration of service users money must be amended to specify the process of the scheme. Timescale for action 30/08/05 2. OP8 13 (4)(a)(b)( c) 30/08/05 3. 4. 5. 6. OP15 OP18 OP18 OP31 16(2)(i) 23(2)(h) 13 (6)(7)(8) 13 (6) 8(1)(a)(b) (ii) (iii) 24(2) 30.12.05 30/09/05 30/09/05 30/06/05 7. OP33 30/09/05 8. OP35 20, 17, Sch 4(9) 30/10/05 Fairholme D52-D04 S8893 Fairholme V215920 130505 Stage 4.doc Version 1.20 Page 26 9. OP22 16,23 The call bell sytem must continue to be monitored to ensure prompt responses by staff to service users care needs. 30/07/05 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. 2. 3. Refer to Standard OP25 OP35 OP35 Good Practice Recommendations The planned installation of radiator covers on surfaces that service users have access to should continue. The registerd provider should demonstrate that he has audited service users monies the registerd provider should gain permission form service users or representatives prior to managing monies on behalf. Fairholme D52-D04 S8893 Fairholme V215920 130505 Stage 4.doc Version 1.20 Page 27 Commission for Social Care Inspection John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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. 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