Inspection on 02/11/05 for Fairholme

This inspection was carried out on 2nd November 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 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 13/05/05

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 Unannounced Inspection 2nd November 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 Fairholme DS0000008893.V258511.R01.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. Fairholme DS0000008893.V258511.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Fairholme Address Roskear Camborne Cornwall TR14 8DN 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) 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 (57), Terminally ill (57) of places Fairholme DS0000008893.V258511.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 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 57 adults with a physical disability (PD) some of whom may have nursing needs Service users to include up to 57 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 13th May 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 childrens 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 DS0000008893.V258511.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors visited Fairholme Nursing/ Residential Home on the 2 November 2005 and spent 12 hours at the home. This was an unannounced visit. The purpose of the inspection was to gain an update on the progress of compliance to the requirements that were identified in the last inspection report dated 13 May 2005. In addition the inspector focused on the following key areas of care: choice of home, care planning, health care, leisure, environment, complaints, staffing and some management areas. On the day of inspection 47 service users were resident in the home. The methods used to undertake the inspection are to meet with a number of residents, staff, the manager and registered provider to gain their views on the services that Fairholme offer. Fairholme records, policies and procedures were examined and the inspector toured the building. This report summarises the findings of this inspection. Since the previous inspection Douglas Hastings has been appointed as manager at Fairholme and has applied to CSCI for the registered manager position and this is being processed. What the service does well: The registered providers continue to implement organisational changes at Fairholme. These changes have resulted in the registered providers taking on a more active role in the day-to-day management and operation of the home. The consequence of this being that the organisational and staffing structures, job descriptions, policies and procedures has been reviewed and where appropriate amended in the aim to improve the standard of care that Fairholme can provide. Staff training has increased as has consultations with staff via individual and group meetings. Service users and their representatives stated that Fairholme provides good quality care and accommodation. Additional comments were made about staff such as; they are ‘kind’, ‘caring’ and ‘patient’. Residents commented that they felt that they were consulted about their care needs which staff ‘ met at all times’. Residents and staff commented that there are sufficient staffing levels on duty. Residents commented that they have access to health care and felt that all their health needs were met to a ‘good’ standard. The storage, administration and disposal of medication is undertaken by designated staff to a good standard. Fairholme DS0000008893.V258511.R01.S.doc Version 5.0 Page 6 Residents confirmed that there was a varied and stimulating programme of activities that is provided by the home and local community. These were observed during the inspection. Residents felt their visitors were welcomed to the home. Residents, relatives and staff stated that if there were any issues they felt able to approach the registered provider directly and that their ideas would be listened to and where appropriate acted on. Fairholme continues to strive to improve its practice and is keen to comply with the requirements and recommendations identified at the last inspection. What has improved since the last inspection? Fairholme has made many positive changes since the last inspection. The previous inspection identified nine requirements and three recommendations. Of these the registered providers have complied with six requirements and two 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 residents 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. The staff team is more stable and therefore there is consistency in the delivery of care for residents. • Care planning has developed and records residents care needs and abilities in a user-friendly document. It was also evident that residents and their representatives are involved in the formation and subsequent review of their care plans. • The manager has implemented a differing system for monitoring residents. This has resulted in the number of falls that residents experience reducing significantly. If a resident has experienced a number of falls, a new risk assessment is undertaken to address why this has occurred and identify actions to minimise further falls for the individual. • With the implementation of residents and representatives meetings, plus staff meetings all stated they feel able to voice concerns and provide ideas for improvements that the home could make. All commented that the registered provider listens to their ideas and where possible takes appropriate action. This is also reflected in that the number of complaints that CSCI and the home receive has reduced significantly and the number of compliments increased. • Staff continue to feel that they are consulted in the future development of the home. • Training in the area of managing aggressive/challenging behaviour has occurred. • 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. Fairholme DS0000008893.V258511.R01.S.doc Version 5.0 Page 7 • • • • • The registered providers have reviewed the policy in respect of managing residents money and have improved its auditing of this system. The registered providers have reviewed a number of the homes policy and procedures and will ensure that staff will be trained in the changes. Fairholme continually invest in the environmental aspects of the home, so that a continual redecoration and refurbishment of the home is ongoing. Residents commented that in the main the call bell is answered promptly. Due to the system being updated this has made it easier for staff to respond to calls correctly. The managers continue to monitor the response times to call bells. On the day of inspection the Head of Care post was successfully recruited too. Therefore with the newly recruited manager, the management team has expanded and are now all in post. 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. Fairholme DS0000008893.V258511.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fairholme DS0000008893.V258511.R01.S.doc Version 5.0 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 the following standard(s): 1,3,4,5 Fairholme must amend its statement of purpose to ensure that the information accurately reflects the services they provide. 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. Staff are experienced to meet service users care needs. EVIDENCE: It is acknowledged that Fairholme has undergone a period of management and procedure changes in the home. Therefore Fairholme statement of purpose must be updated to ensure that it accurately reflects the current organisational and staffing structures, pre admission and care planning processes. The registered providers and manager agreed to review this document. Following which the registered providers agreed to review the presentation of these documents so that they can be accessible to a larger audience. Fairholme DS0000008893.V258511.R01.S.doc Version 5.0 Page 10 From discussion with residents and their representatives, plus inspection of four residents files it was evident that they are consulted in Fairholme pre admission assessment. Residents 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 residents 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. Residents commented that the preadmission and ‘moving in period’ are carried out sensitively by staff and could not see how this process could be improved. Residents commented that they felt that they received a ‘nice welcome’ to the home. From observations of staff, plus inspection of forthcoming training programme and records it was evident that the staff team are experienced in the area of older peoples care and receive training to update their knowledge in this area. Throughout the inspection the inspector observed staff that displayed great skill in communicating and providing personal and emotional care to residents. Fairholme DS0000008893.V258511.R01.S.doc Version 5.0 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 the following standard(s): 7,8,9,10,11 Residents and their representatives are consulted in the implementation and subsequent reviews of their individual care plans. Health care needs are met to a good standard. Medication is administered by trained staff and stored securely. The staff at the home builds positive relationships with residents that are based upon the residents dignity and privacy. EVIDENCE: A previous requirement to develop care plans has been complied with. It is now evident from discussion with residents, staff and inspection of documentation that individual care needs are identified appropriately and that residents are encouraged to express their views in the formation of their care plans. Care plans clearly identify service users abilities and care needs and from this specify what actions staff should take to ensure that the care need is approached in a consistent manner. The inspectors reminded the management team that care plans must be updated regularly to ensure that they reflect current care needs and specify what actions staff must take to address the need. Fairholme DS0000008893.V258511.R01.S.doc Version 5.0 Page 12 Residents and their representative’s participation in the implementation and subsequent review of their care plans were in the majority of cases recorded as occurring. From discussion with residents they commented that they felt that they received satisfactory care. A previous requirement to audit the number of falls / incidents involving residents has been complied with. The manager has implemented a monitoring system assessed for each resident on his or her individual needs. From this a plan of monitoring has been identified. The consequence of this system is that the number of incidents/ falls has reduced significantly. If an individual does experience a number of incidents this is risk assessed and a plan of action to prevent further falls is implemented. The inspectors were encouraged to see that falls has reduced so significantly in the home. Residents 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. 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. Fairholme has a detailed policy in the ordering, administration, storage and disposal of medication-dated 21.9.05. Designated staff attended refresher training in this area of care. Medication sheets were completed correctly. Medication kept in the fridge was inspected. Daily temperatures of the fridge are monitored. No residents self-administer medication at Fairholme. All residents spoken with stated that staffs display a high standard of respect in their daily interactions. Residents stated that staffs ensure that their privacy and dignity is maintained and could not see how this area of care could be improved. The inspector noted that the atmosphere of the home and residents appeared to be relaxed. Residents commented staff ’ were ‘kind’. Residents confirmed that 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. In addition the inspector observed staff interacting with residents in a professional manner at all times, alongside a sense of humour when appropriate. Fairholme has appropriate policies in the event of a resident’s health deteriorating, or their death. Some residents wishes have been gained in this event, it is acknowledged that this area needs to be discussed and timed with great sensitivity to the individual. The inspectors reminded the managers that palliative care needs must be updated on individuals care plan when needed. Fairholme DS0000008893.V258511.R01.S.doc Version 5.0 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): 12,13,15 Fairholme provides a programme of activities to promote and encourage the pursuit of residents social, educational and leisure needs. Flexible visiting arrangements are in place and visitors are welcomed at the home. A varied and nutritious diet is provided to all residents. The dining area is being reviewed. EVIDENCE: From discussions with residents the majority commented that there is ‘enough to do’ during the day at Fairholme. Residents recalled a variety of activities that are provided: i.e. film club, entertainers, celebrations, games and pastoral services. 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 residents attend clubs, societies in the community i.e. Parkinson group, Dysphasia Society and local churches. There is a flexible visiting policy and residents determine where they meet with their guests. Residents felt their visitors were welcomed to the home positively and could not think of improvements in this area. Visitors echoed this. Fairholme DS0000008893.V258511.R01.S.doc Version 5.0 Page 14 Mealtimes were not inspected in detail on this occasion. However residents commented that the quality of meals was ‘good’ and a recent written compliment by a resident about the quality of food was seen. The majority of residents acknowledged that it is difficult for the catering staff to accommodate for all individual tastes and felt that on the whole the food was ‘satisfactory’. Menu cards promote a choice in meals for residents. Residents 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. Residents can also choose where to have their meals, either in their room or in the dining area. The registered providers are in the process of redecorating and furnishing the dining room facilities. This statutory requirement remains within timescale for compliance. Fairholme DS0000008893.V258511.R01.S.doc Version 5.0 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): 16,18 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 last inspection in May 2005, the number of complaints received by the home and to CSCI has reduced significantly. There have been staffing and organisational changes in the home. From discussion with residents, 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, and now the manager if they had any concerns. With the implementation of residents and their representatives meetings, regular staff meetings and supervision 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 residents and their relatives are receiving. Fairholme DS0000008893.V258511.R01.S.doc Version 5.0 Page 16 Fairholme has amended its adult protection policy since the last inspection. However further amendments to this policy are needed and these were discussed with the management team e.g. reference to Cornwall Mutli Agency adult protection procedure and DOH ‘No Secrets’ guidance and what process must be followed when a allegation of abuse has been made. 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 and training in this area of care has occurred. Fairholme DS0000008893.V258511.R01.S.doc Version 5.0 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): 19,20,22,25,26 The registered providers 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 continue to invest in the homes maintenance, upgrading of facilities and 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. Residents and their representatives remained positive about the changes to the home. The registered providers have an ongoing refurbishment programme. 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. Fairholme DS0000008893.V258511.R01.S.doc Version 5.0 Page 18 Progress on the redesign of the dining are is near completion and therefore has been left as a requirement for compliance at this time. The inspectors advised that a reviewing of the lighting in rooms is undertaken to ensure that it meets required standards. In addition lighting in the stairwells must be covered. The home has installed a call bell system. Residents commented they felt that the response time to the call bells have improved significantly. Staff stated that they felt the new system was better in that you could easily identify the area the call was made and ask for assistance if needed in a more prompt manner. The management team continue to monitor the new system. The home was clean throughout. Residents commented positively about the cleanliness at the home. Fairholme DS0000008893.V258511.R01.S.doc Version 5.0 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): 27,28,30 Suitable trained and experienced staff are employed in sufficient numbers at all times to meet residents care needs. Fairholme ensures that staff have access to appropriate training to undertake their work. EVIDENCE: On the day of inspection seven carers, 2 qualified nurses, plus domestics, handyperson, kitchen staffs, laundress, administrator, manager and registered providers were on duty. Staffing ratio during waking hours is aimed to be 1:5. 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. A manager has been appointed and has applied to CSCI for registration. From the inspectors observations of staff they interacted with residents in a positive manner and demonstrated good communication skills in working with and caring for them and their representatives. From discussion with staff it was evident that the staff team had a variety of experience, skills and qualifications. Residents spoke positively about the staff team. Fairholme has prioritised staff training and from discussion with staff and inspection of staff files this demonstrated a commitment to staff updating their training. Fairholme DS0000008893.V258511.R01.S.doc Version 5.0 Page 20 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): 31,32,34,35,36,38 A suitably qualified manager has been appointed and must apply to be registered in this post. The registered providers have promoted a management structure, which creates an open, positive and inclusive atmosphere. The home is financially viable. The administration and auditing of service users monies ensures their finances are protected. Supervision of staff is commencing in order to review their care practice on a regular bases. The home is maintained to a safe standard for all who live, work or visit the home. EVIDENCE: The registered providers undertake 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 Fairholme DS0000008893.V258511.R01.S.doc Version 5.0 Page 21 been positive as residents, 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. The inspectors noted that the changes made have led to consistent practices in care. Regular residents and relatives meetings plus individual discussions between them and the registered providers evidence that view on the services that Fairholme provides are sought. Residents stated that the registered providers are keen to rectify any concerns/issues that they raised. Although stated that they had none at this time. Staff also meets regularly with the management team. Staff were positive about the differing management style and changes within the home. With the appointment of the manager staff and residents felt that the changes have not been affected negatively by his appointment. Residents and staff felt that these meetings were beneficial The registered manager has completed a quality assurance survey with residents, and relatives, and stakeholders. The results were overall satisfaction with the care provided. Fairholme has a policy in the administration of service users monies. This explains the philosophy of service users rights in managing their own money. The inspectors devised that a process in how to receive, deposit and reimburse monies to residents must be implemented. The care plan includes if the home will manger a persons monies or not. The registered provider stated that he audits the records with the administrator. The registered provided confirmed that supervision with staff is commencing. She is aware that all staff should receive at least six supervision sessions per year. Fairholme undertakes regular health and safety checks in the home i.e. fire drills, Legionella, emergency lighting, training of staff in the areas of COSHH, moving and handling and first aid. In addition inspections from other authorities occur and no issues have arisen form these inspections. Fairholme DS0000008893.V258511.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 X 3 X X 2 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 3 2 2 X 3 Fairholme DS0000008893.V258511.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 OP1 Regulation 4, Sch 1 Requirement The registered provider must ensure that the statement of purpose is updated to accurately reflect the services that Fairholme provides. The registered provider must send to CSCI plans in respect of the redesign of the dining areas. The adult protection process must be amended and this cascaded to all staff. The registered provider must audit the lighting in the home and ensure it is of sufficient wattage and has suitable coverings. The registered provider must ensure that the registered manager application is processed in line with the requirements of with CSCI. The policy on the administration of service users money must be amended to specify the process of the scheme. This is re notified to you. Timescale for action 30/01/06 2. 3. 4 OP20OP15 OP18 OP25 16(2)(i) 23(2)(h) 13 (6) 23 28/02/06 30/01/06 28/02/06 5. OP31 8(1)(a)(b) (ii) (iii) 30/01/06 6. OP35 20, 17, Sch 4(9) 30/01/06 Fairholme DS0000008893.V258511.R01.S.doc Version 5.0 Page 24 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 OP9 OP36 Good Practice Recommendations The planned installation of radiator covers on surfaces that service users have access to should continue. Oxygen signage should be visible on service users bedrooms doors for health and safety purposes. All staff should receive a minimum of six supervision sessions per year. These should be recorded. 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