CARE HOMES FOR OLDER PEOPLE
Fairholme Roskear Camborne Cornwall TR14 8DN Lead Inspector
Stephen Baber Key Unannounced Inspection 8th Aug 2007 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 DS0000008893.V340443.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Fairholme DS0000008893.V340443.R01.S.doc Version 5.2 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 fairholmeuk@tiscali.co.uk 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.V340443.R01.S.doc Version 5.2 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 June 2006 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 residents 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 with doors that open onto the garden and paved pathways that lead to the greenhouse where some residents like to grow tomatoes and other produce. 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. Information about the home is available in the form of a service users’ guide, which can be supplied to enquirers on request. A copy of most recent inspection report is available in the main entrance hall. Fees range from £300 to £560.00 per week. Additional charges are made in respect of private healthcare provision, escort services and personal items such as newspapers, confectionary and toiletries. Fairholme DS0000008893.V340443.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) have made changes to the way we inspect services, known as Inspecting for Better Lives (IBL). We are now more proportionate when reporting our findings, and more focused on the experience of people using services. The purpose of the inspection was to ensure that resident’s needs are appropriately met with good outcomes. One inspector conducted the Key Inspection following analysis of the self-audit tool submitted by the manager. All key and some core standards were inspected. I talked with residents and their families who visited and their views were sought about the care they receive. Information received from and about the home since the previous inspection has also been taken into consideration in making judgements about the quality of outcomes for the residents living there. I spoke and met with the registered providers Mr and Mrs Mangat, manager, deputy manager, senior nurses care assistants, chef and handy man. The last inspection in June 2006 identified several requirements and recommendations. Since that time, the providers and new manager have turned the business around complied with all requirements and recommendations and increased her quality rating from level two to level three. This was a very positive inspection and reflects the hard work put in by the providers, manager and staff. Other activities included an inspection of the premises, examination of care, safety and employment records and discussion with the nurse in charge of the home, who is going to be interviewed by the Commission on the 29th August to be registered as the manager. The principle method of inspection was “case tracking”. This involves interviews with a select number of residents; staff caring for them and/or their representatives, and examination of records relating to their care. This provides a useful impression of how the home is working overall. At this inspection four residents were case-tracked, with particular reference to their needs relating to their age, culture and ethnicity, religion, gender, sexual orientation and disabilities. What the service does well: Fairholme DS0000008893.V340443.R01.S.doc Version 5.2 Page 6 Most of the people who were interviewed during the inspection said that they had made an active decision to be admitted to the home and that they had been provided with good information about it before they moved into it. Some gave detailed accounts of how the relatives had visited the home if they were unable to and discussed their needs before they were admitted to the home or visited the home. They were not formally admitted as residents until they and the home were assured it would be suitable for them. Most of the residents are admitted on a long-term basis, although the home does provide short-stay admissions occasionally, depending on vacancies. Information about this can be supplied, by the home upon request. Residents’ individual health, personal and social care needs are set out in detailed care plans, so that staff are aware of how they should be cared for. These are regularly reviewed and updated as their needs change. Some of the residents who were interviewed said that they are aware of the contents of their care plans and all of them agreed that the staff were kind and caring to them. Comments like” very good staff” “ Girls are excellent and no complaints”” The nurses are very responsive to my needs” “ I wouldn’t stay here if I didn’t like it” were made There are qualified nurses on duty at all times and residents have good access to external healthcare providers, such as general practitioners when they need them. There are safe and sound systems in place to ensure that residents’ medicines are properly managed so that they are kept safe and as comfortable as possible. All of the residents who were interviewed said that staff look after them well. During the inspection staff were seen to treat residents with kindness and respect at all times. An activity coordinator is employed and residents are offered a wide range of activities on offer. There is also a private Chapel where people can receive religious services of their choosing according to their faith or visit there for quiet contemplation. All of the residents who were interviewed indicated that they are satisfied with what is on offer to them. Visitors are made to feel welcome in the home and were observed coming and going from the home throughout the inspection, so that residents maintain valued contacts. Residents who were interviewed said that they are able to make decisions about things that are important to them and gave examples of this, such as choosing whether to join in with communal activities or enjoy the privacy of their own rooms. Management have improved the dining experience for the residents by the attention to detail in the dining room. Tables were nicely laid with table clothes, paper napkins and condiments sets. New round tables have been purchased and this will allow the people in wheelchairs to access the tables more easily. All of the residents who were interviewed said that they enjoy
Fairholme DS0000008893.V340443.R01.S.doc Version 5.2 Page 7 mealtimes and were complementary of the food and choices provided to them. They said that they are offered a choice of food and their preferences are taken into account. One said that they appreciate being given meals that suit them because they have a medical condition. Most of the residents and relatives who were interviewed were aware of what they should do if they wish to make a formal complaint and one described the manager as very approachable in this respect. All were satisfied with the care and services provided to them and said that they had not had any reason to complain about the care or services provided to them. All of the residents who were interviewed said that they feel safe in the home and staff are trained on what to do if they suspect a resident is being abused. Most importantly, the home is part of the local community with plenty of visitors coming and going from it so that residents are not isolated there. All of the residents who were interviewed expressed satisfaction with the accommodation provided to them at the home. Several remarked that they were pleased to stay in the area where they lived all their lives. The home have improved the decoration and are currently purchasing new recliner armchairs. It was clean and tidy and staff are aware of the importance of good hygiene to prevent risks of infection spreading in the home. There are always qualified staff on duty, including qualified nurses. They are recruited fairly and on the basis that they are suitable to work in a care setting and undertake regular training so that they keep their knowledge and skills updated. What has improved since the last inspection?
The new manager and providers have worked very closely together since the last inspection to improve the quality of experience for people who come to live at the home and the fabric of the building. There were some noted improvements in the way prospective residents are assessed, so that their individual needs, wishes and circumstances are accounted for better. This means that their subsequent care plans can be much more personal to them as individuals. There is improved consideration of their cultural backgrounds and religion, for example, so that they can be made as comfortable as possible in the home. Fairholme DS0000008893.V340443.R01.S.doc Version 5.2 Page 8 The manager described how she in agreement with the providers have created heads of departments and has set up systems to cover all areas of the home. She meets regularly with them to discuss future improvements and carries out internal quality audits to ensure that everything is up to date. There was improved evidence at this inspection, that the home has safe systems to protect residents from abuse. This includes checks made on new staff, by law, to demonstrate that they are suitable to work with vulnerable people. What they could do better:
The new manager and providers were given comprehensive feedback on the findings of the inspection. Whilst it is acknowledged that there have been improvements further work should be undertaken in the following areas: Service user care plans. When resident information was reviewed staff were not detailing any changes to guide and inform the staff but were squeezing review dates on the current sheet and recording No Change. All information reviewed should have its own review sheet with outcomes recorded for residents. Medication and health related activities. I will discuss with the link inspector for home the current arrangements for the recording of an analgesic in the controlled drugs book. All nurses must sign the MARS sheets and refer to the index when medication is not given. Policies and Procedures Policies and procedures should be reviewed and amended E.g. complaints procedure should have the contact details and telephone number of the Adult Social Care department who have a statutory responsibility to investigate complaints on behalf of people it commissions care for. Statement of Purpose should be amended to have the name of the new manager and contact details of CSCI Ashburton should be recorded. Resident and Staff files. It is agreed that how files are maintained is a decision that rests with the manager. However resident and staff files could be more professionally presented to make the retrieval of information easier. Various standards and regulations inform good practice and there will be times when residents will want to access their files. Snooker room The seams on the windows have gone. This means that parts of the windows are misted up and residents cannot see out of the windows to the garden. As
Fairholme DS0000008893.V340443.R01.S.doc Version 5.2 Page 9 the conservatory is new the windows may still be under guarantee and repair will not cost the providers anything. Repair is essential to allow people to look out of the windows to the gardens. 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. The summary of this inspection report can be made available in other formats on request. Fairholme DS0000008893.V340443.R01.S.doc Version 5.2 Page 10 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.V340443.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,3 and 6 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are given information on the home so that they can make a decision on where they wish to live. Admission to the home is on the basis of an assessment so that prospective residents can be confident it will be suitable to meet their needs. The home does not provide intermediate care but will accept people for short-term admissions and has suitable facilities for this. EVIDENCE: The Statement Of Purpose and Service User Guide are available to prospective residents and their representatives. The range of services and facilities detailed in the documents enables the people to make a decision on whether they wish to live at the home. The residents I spoke with said they received information about the home which enabled them to make a decision. Most of the residents
Fairholme DS0000008893.V340443.R01.S.doc Version 5.2 Page 12 who were interviewed confirmed that they had made an active decision to be admitted to the home and said that the admission process included an assessment of their needs so that they could be assured it would be suitable for them. The manager and staff who were interviewed confirmed that admission is on the basis of an assessment and prospective residents and their relatives are encouraged to provide as much information about themselves as possible, so that the home has a “background information” on which they can personalise subsequent care planning. This was evident in the records inspected. The manager demonstrated a good knowledge of the diverse backgrounds and needs of the residents who were case-tracked, which was confirmed in interviews with them and their records. There is consideration of peoples’ religion and cultural background during the assessment process, for example and information is sought about their disabilities so that care plans can be appropriately tailored for them. Needs relating to their age, gender and sexual orientation are also taken into account, with appropriate sensitivity. The manager also takes risks relating to any history of falls and specific behavioural problems into account and monitors it closely. The home’s statement of purpose clearly states that the home does not provide specialist rehabilitation or intermediate care services although it will accept people for short-term and respite care. Facilities available in this respect are clearly set out in the information provided to prospective residents Fairholme DS0000008893.V340443.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 and 10 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents health, personal and social care needs are clearly set out in individual care plans so that they and staff working with them are aware of how their needs should be met. There are good systems in place to ensure that their healthcare needs are met and safe and sound systems to manage their medicines but residents should be protected from the effects of medication errors. Residents are treated with respect and due regard for their dignity so that they enjoy a good quality of life in the home . EVIDENCE: Some of the residents who were interviewed were aware of their care plans and all had detailed written records of their needs and how they should be met on their personal files. There was documentary evidence that care plans are regularly reviewed but when reviews take place good practice would dictate that the resident files it would look more professional if they had their own review sheet and outcomes of the reviews recorded compared to comments such as “ No Change”. Residents who were interviewed indicated that their
Fairholme DS0000008893.V340443.R01.S.doc Version 5.2 Page 14 healthcare needs are met well. The manager said that there are qualified nurses on duty at all times and the home has good links with local external health providers. Records on residents’ personal files verified this. All the residents and visitors who were interviewed confirmed that they staff care for them well. Staff were observed to treat residents with kindness and respect at all times There are clear written guidelines for staff on the safe handling of residents’ medicines. Only the qualified nurses manage residents’ medicines. Records of administration appeared to be up-to-date but there were some omissions on the MARS sheets. This was discussed and will be put right. I will discuss the recording of analgesia in the controlled book with the link inspector and she will contact the home regarding its continued recording. Fairholme DS0000008893.V340443.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 and 15 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ social, cultural, religious and recreational interests are accounted for and their needs met so that they enjoy a good quality of life in the home. Relatives and visitors are made to feel welcome in the home so that residents maintain valued contacts and do not feel isolated in the home. Residents are encouraged and supported to make decisions so that they maintain control over aspects of their lives that are important to them. Choices are provided to residents who are provided with wholesome, home prepared meals so that their nutritional needs are met and they enjoy their food. EVIDENCE: Residents’ assessment and care planning information demonstrates that their social, cultural, religious and recreational interests are taken into consideration. The activities coordinator records all group and individual activities. Residents who were interviewed expressed satisfaction with the programme of activities available to them and gave examples of the things they enjoy. The newly created chapel provides an area for residents or their relatives for quiet contemplation. The chapel is multi denominational.
Fairholme DS0000008893.V340443.R01.S.doc Version 5.2 Page 16 The home’s manager and staff who were interviewed said that relatives are welcome in the home, which residents who were interviewed confirmed. Visitors were observed coming and going, unrestricted, from the home during the inspection. They are able to receive visitors in the privacy of their own rooms if they wish. Residents who were interviewed said that they are able to make decisions about things that are important to them, such as whether to take part in social activities in the lounge or remain in their own rooms and when to get up and go to bed for example. A staff member who was interviewed said that care planning improvements enabled the to provide an individualised care programme to the residents. Residents’ assessment, care planning and daily care records indicate that their choices and preferences are well accounted for and respected. All of the residents who were interviewed said that they enjoy the meals provided and said that they are offered a choice. The Chef said that resident’s nutritional needs are assessed. Residents’ assessment and care records note their food likes, dislikes and preferences, so that menus can be planned accordingly. The providers and manger will be taking delivery of new round dining tables, which will enable the residents in wheelchairs to access the tables more easily. Fairholme DS0000008893.V340443.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has good systems in place to enable residents to make complaints so that they can be confident they will be listened to and the issues they raise will be taken seriously. There are systems in place to protect residents from abuse so that they can feel safe in the home. EVIDENCE: The manager said that there was one complaint made since the last inspection. The Commission recived one complaint from another professional, which was investigated at the time of the inspection. New residents are provided with copies of the home’s formal complaints procedure in their information packs upon arrival in the home. All of the residents who were interviewed said that they are satisfied with the care and services provided to them in the home and most knew how to go about making a complaint if necessary. Staff who were interviewed demonstrated a good knowledge of the home’s complaints procedure. The relatives said that they would go straight to the office if they had a complaint to make. There are formal systems in place to protect service users from abuse, including written guidance for staff and access to training internally and
Fairholme DS0000008893.V340443.R01.S.doc Version 5.2 Page 18 externally to the home. The manager said that several staff members have attended the local multi-agency training for the protection of vulnerable adults from abuse. There are records to show that staff are recruited on the basis that they are suitable to work with vulnerable adults in a care setting. All of the residents who were interviewed said that they feel safe in the home. Fairholme DS0000008893.V340443.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The improvements made to the home evidence that the home is pleasant, comfortably furnished, nicely decorated and safe so that residents enjoy a good quality of life in a homely environment. The home is kept clean and hygienic so that residents are protected from the risks of cross-infection. EVIDENCE: There was evidence of substantial financial investment in the decoration and fabric of the home. The home looked nicely decorated and furnished throughout at the time of the inspection. The providers said that they have purchased new reclining chairs for the home and are investing financially to provide a good standard of accommodation. Rooms are decorated for new residents and suitability of rooms for residents is assessed prior to admission.
Fairholme DS0000008893.V340443.R01.S.doc Version 5.2 Page 20 I.E. ensuite, large single room or double to be used as single and choice of colour, carpets etc. One of the rooms was being redecorated at the time of the inspection. The manager and staff who were interviewed confirmed that maintenance tasks are undertaken promptly, as and when they become necessary. Residents expressed satisfaction with the accommodation provided to them and confirmed that they can personalise their own bedrooms in accordance with their own tastes. Residents who were interviewed said that the home is kept clean and it appeared clean and tidy throughout at the time of the inspection, which was unannounced. The manager described the systems in place to maintain good hygiene, including written procedures to guide staff, access to training in infection control and provision of suitable equipment to maintain good hygiene. Fairholme DS0000008893.V340443.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 and 30 were assessed. Quality in this outcome area isgood. This judgement has been made using available evidence including a visit to this service. The home is recruiting more staff to provide sufficient staff, in a variety of capacities so that residents’ needs are met. Staff are recruited fairly and on the basis that they are suitable to work with vulnerable adults in a care setting so that residents can feel safe in their care. Staff undergo regular training to update their knowledge and skills so that residents can have confidence in them. EVIDENCE: The manager is going to place an advertisement in the local papers to recruit more staff. Most of the residents who were interviewed said that there are sufficient staff on duty at all times to meet their needs. Staff were observed working in different capacities such as catering and domestic work, care work and nursing so that they are able to work effectively with the resident group. There is a qualified nurse on duty at all times in the home and 90 of the care staff are qualified to NVQ 2 or above, which is in excess of the national minimum standards. Staff records that were inspected verified this. Staff who were interviewed during the inspection confirmed that they had been fairly recruited and that checks had been made of their suitability to work with vulnerable adults in a care setting. Records inspected verified this.
Fairholme DS0000008893.V340443.R01.S.doc Version 5.2 Page 22 The home employs staff from other countries where English is not their first language expressed themselves clearly to residents and communication appeared good apart from one member of staff whose English was improving. It is important that the providers and managers employ staff who can communicate effectively with residents. Staff who were interviewed during the inspection said that they have good access to ongoing training so that they maintain and develop their knowledge and skills. Fairholme DS0000008893.V340443.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,36 and 38 were assessed. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The home is well managed for the benefit of the residents. There are formal systems to ensure that their best interests are taken into account in the planning and development of the service. There are systems in place to ensure that the health, safety and welfare of residents are protected. EVIDENCE: he home’s manager is a qualified nurse and will be having her registered manager’s interview with the Commission on the 29th August 2007. The manager has completed 18 months of a 3-year “End of Life “ project with Warwick University. She was able to describe recent training she has undertaken to update her own knowledge and skills. Staff and residents expressed confidence in her abilities.
Fairholme DS0000008893.V340443.R01.S.doc Version 5.2 Page 24 The supervision takes place at two monthly periods for all staff and systems have been set up to continue to monitor supervision including training in supervision via auditing. The manager described formal systems in place to measure the quality of the services the home provides. This includes questionnaires to residents and people who have an interest in the home and regular formal meetings with residents, when they can express their views and concerns. Evidence was available in the form of the home’s published internal quality development plan. The manger may wish to extend this to other interested stakeholders. Staff who were interviewed said that they have good access to ongoing training to ensure that they know how to keep the home safe for residents. Training records inspected verified this. A selection of health and safety records and policies and procedures were inspected including the home’s fire safety risk assessment and records of equipment tests and checks, which were up-to-date and complete. The heads of department created by the management team ensure that their area of responsibility is kept up to date with regular inspections carried out by the manager. Fairholme DS0000008893.V340443.R01.S.doc Version 5.2 Page 25 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 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 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 3 x X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x x 3 x 3 Fairholme DS0000008893.V340443.R01.S.doc Version 5.2 Page 26 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 OP9 Regulation 13(2) Requirement The registered person must ensure that all staff with a responsibility for medication sign the record sheets and refer to the index to protect residents from medication errors. This is immediate from receipt of this report. Timescale for action 09/09/07 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 Refer to Standard OP1 OP7 Good Practice Recommendations The registered person must update the Statement of Purpose with the correct information. The registered person should review the current system of reviews and establish a professional recording format with outcomes for residents and resident files should be more professional in their presentation. The registered person should include in the complaints procedure the contact details and telephone number of the Adult Social Care department should people wish to make a complaint.
DS0000008893.V340443.R01.S.doc Version 5.2 Page 27 3 OP16 Fairholme 4 5 OP19 OP29 The registered person should make good the windows in the conservatory so that people can look out of the windows. The registered person should ensure that the staff files are more professionally presented which will make the retrieval on information easier. Fairholme DS0000008893.V340443.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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