Inspection on 27/10/05 for Fairholme

This inspection was carried out on 27th October 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

Fairholme 28/10/08

Fairholme 14/11/06

Fairholme 21/06/05

Fairholme 22/11/04

Fairholme 30/06/04

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Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Fairholme Morda Road Oswestry Shropshire SY11 2AP Lead Inspector Pat Scott Unannounced Inspection 27th October 2005 10.00 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 DS0000020664.V253928.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 DS0000020664.V253928.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Fairholme Address Morda Road Oswestry Shropshire SY11 2AP 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) 01691 653499 01691 654247 Coverage Care Shropshire Limited Denise Beryl Morris Care Home 40 Category(ies) of Dementia (14), Old age, not falling within any registration, with number other category (26) of places Fairholme DS0000020664.V253928.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home may accommodate a maximum of 40 persons. The home may accommodate a maximum of 26 Elderly Persons and a maximum of 14 Older Persons with Dementia. Mrs Morris must achieve the Registered Manager Award by 2005. Date of last inspection 21st June 2005 Brief Description of the Service: Fairholme is registered to care for a maximum of forty older people; within this number up to fourteen of the service users may have dementia care needs. The care home provides both long term and respite care, there is a designated respite unit. All of the rooms within the home are single and all meet the National Minimum Standards. The Registered manager Mrs Denise Morris has been at the home since June 2003. The registered provider is Coverage Care (Shropshire) Ltd – a ‘not for profit’ organisation registered with the Register of Industrial and Provident Societies and has a charitable trust status. Fairholme has pleasant gardens and grounds, which are well maintained and provide a safe outside environment for the service users and their visitors. Fairholme DS0000020664.V253928.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 27th October 2005 commencing at 10.00am. The National Minimum Standards for Care Homes for Older People focus on achievable outcomes for service users – that is the impact on the individual of the facilities and services of the home. Evidence was looked for that the standards were being met and a good quality of life enjoyed by service users through: • Discussions with service users, families and friends, staff and managers. • Observation of daily life in the home • Scrutiny of written records. The statement of purpose was used to assess how far the home’s claims to be able to meet service user requirements and expectations were being fulfilled. Reports regarding an overview of the conduct of the home are sent to CSCI on a monthly basis by the Head of Operations for Coverage Care. These, as well as the risk assessment from the last inspection were taken into account to determine the core standards focused on and depth of inspection. The Commission does not currently have any concerns regarding this home. What the service does well: What has improved since the last inspection? There were no requirements made at the last inspection. Fairholme DS0000020664.V253928.R01.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. Fairholme DS0000020664.V253928.R01.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 Fairholme DS0000020664.V253928.R01.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): 1,3, 4 The homes statement of purpose and service user guide is generally good providing service users and prospective users with details of the services the home provides. It does not contain sufficient information regarding emergency admissions, enabling all prospective parties to make an informed decision about admission to the home. Pre-admission detail obtained regarding emergency admission is sometimes poor. This does not ensure that service users who move into the home at a time of crisis are assured that their needs will be met. Once admitted the documentation is good. Emergency admission procedures provide minimal guidance and do not assist the decision making process for staff to admit service users in a crisis. EVIDENCE: The statement of purpose is on display in the foyer. It is considered that it provides good detail about the services provided. However, a recent incident Fairholme DS0000020664.V253928.R01.S.doc Version 5.0 Page 9 has identified the need to have more comprehensive detail regarding emergency admissions to the home. This will enhance information and choice. A recent emergency admission on 11.10.05 into Fairholme for a service user who had a diagnosis of dementia did not go well. Staff did not have any more recent information from the placing authority regarding this person than 9.8.05. The homes procedures regarding emergency admissions are vague and do not clearly define how staff should respond to and question requests for such admissions within each category of registration, i.e. dementia and older people. Fairholme DS0000020664.V253928.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 The medication at this home is well generally well managed promoting good health. EVIDENCE: Medicines are kept safely with full records of their receipt, administration and disposal. Reviews of medication are conducted by the GP on a regular basis. Wherever possible and depending on their capabilities, service users are enabled to take responsibility for their own medicines. Homely remedies (paracetamol) are provided without GP authorisation to administer within stated guidelines. The drug round on the respite unit was observed at 11am. This was to administer the 9am drugs. This was because the home carer on that unit had not received medication training. The deputy manager and the carer reported that this does not frequently happen. The manager needs to be sensitive to this issue, especially as the next medication due at 13.00 hrs may be given too close together. However, the drug round was carried out professionally, unhurried and with courtesy, allowing time for service users to take their medication. However, medication was signed for prior to administering it the service user. Fairholme DS0000020664.V253928.R01.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, 14, 15 Staff have an excellent understanding of the service users support and leisure needs and use this to assist them to exercise choice and control in their lives. Dietary needs of service users are well catered for with a balanced and varied selection of food available that meets service users tastes and choices. EVIDENCE: The way in which service users are informed of activities taking place is good with an emphasis on more meaningful pastimes tailored to individual needs and reviewed at service user meetings. Minutes of the last resident meeting held on 2.10.05 detailed forthcoming entertainment and recent events enjoyed. Many service users were attending a session of bingo today. Service users spoke of the food and mealtimes as being a social event and that they enjoyed good tasty meals. Menus seen demonstrate that the food provided is nutritious, well balanced and appealing. Menus and food were discussed at the resident meeting and service users informed that they can have other options to the main choice. Service user comments are recorded in the minutes. Fairholme DS0000020664.V253928.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The home has a satisfactory complaints system with evidence that service users feel that their views are listened to and acted upon. Staff are provided with induction and on-going training regarding adult protection. This provides staff with the relevant knowledge to safeguard service users from many types of abuse. EVIDENCE: The complaint log was examined. Complaints received in the home have been appropriately dealt with. On the whole, all service users spoken with were very happy with life at Fairholme. They said they knew whom they could speak to if they were worried about anything. Staff training contains information regarding adult protection. A staff file seen demonstrated this. The care manager on duty, who is new in post, confirmed that she had received such training at induction. Regulation 37 incident reports are sent to the CSCI as required by legislation. Fairholme DS0000020664.V253928.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26 The laundry is well organised ensuring that service users clothes and bed linen are always clean and fresh. EVIDENCE: Laundry equipment is in place to meet the standards. Service users confirmed that their clothes are well laundered. Sluice rooms provided are situated away from areas used by service users. Fairholme DS0000020664.V253928.R01.S.doc Version 5.0 Page 14 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): These standards were not assessed at this inspection. EVIDENCE: Fairholme DS0000020664.V253928.R01.S.doc Version 5.0 Page 15 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 Service users personal monies are well managed so that their financial interests are safeguarded. EVIDENCE: The system for keeping and recording service users’ personal allowances was examined. Accurate records are kept with the money of one reconciling with the balance. Fairholme DS0000020664.V253928.R01.S.doc Version 5.0 Page 16 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 3 x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 X X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X X Fairholme DS0000020664.V253928.R01.S.doc Version 5.0 Page 17 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP1 OP9 OP9 Good Practice Recommendations To review the statement of purpose to include details regarding emergency admissions. Obtain GP authorisation for use of homely remedies. The manager must ensure that service users receive their drugs at the stated times at all times. Fairholme DS0000020664.V253928.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Fairholme DS0000020664.V253928.R01.S.doc Version 5.0 Page 19 - 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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