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Inspection on 11/08/05 for Fairlight & Fallowfield

Also see our care home review for Fairlight & Fallowfield for more information

This inspection was carried out on 11th August 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Staff were positive about the work that they undertake and felt that things had improved in the home. The reason that they attributed to the improvement was recruitment of staff, giving a full staff complement on all shifts. Staffing levels now allow the qualified staff to support the care staff and work alongside them to monitor the care practices. The appointment of a new manager has brought leadership and experience to the staff team. Positive comments were also received form the residents and visitors with whom the inspectors met, again relating to the staff attitudes and care provided.

What has improved since the last inspection?

It was evident that record keeping had improved. This was particularly apparent on the Fallowfield (Nursing) side. Care plan documentation was better completed with reviews and supporting risk assessments in place. The records relating to medication administration, receipt and disposal had also improved.

What the care home could do better:

The staff are provided with opportunities to participate in training including mandatory topics and those specifically related to care of the elderly. Some staff felt that although training was available the limited amount of places, or the fact that they work part-time ,meant that they missed out on training which would equip them with skills to undertake their work. This is something, which the manger needs to address to ensure an equality of training throughout the staff team.

CARE HOMES FOR OLDER PEOPLE Fairlight & Fallowfield Ashfield Lane Chislehurst Kent BR7 6LQ Lead Inspector Rosemary Blenkinsopp Announced 11 August 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Fairlight & Fallowfield G51-G01 s10134 Fairlight Fallowfield AI v230700 110805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Fairlight & Fallowfield Address Ashfield Lane, Chislehurst, Kent, BR7 6LQ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8467 2781 The Mills Family Limited Post Vacant Care Home with Nursing 68 Category(ies) of Old age, not falling within any other category registration, with number (68) of places Fairlight & Fallowfield G51-G01 s10134 Fairlight Fallowfield AI v230700 110805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 Staffing Notice issued 29 September 1998 Morning: 1 RGN & 1 EN & 4 Care Assistants Evening: 1 RGN & 1 EN & 4 Care Assistants Night: 1 RGN & 2 Care Assistants 2 Fairlight & Fallowfield is to be registered for 68 places in total, of which 33 places can have the category of Nursing Date of last inspection 20/04/05 Brief Description of the Service: The home is located in a residential area of Chislehurst. It is an older style building with new bedroom and communal facilities having recently been added. Bedroom accommodation is located on all floors. The main communal area is on the ground floor of the home with additional quiet rooms. The home provides care for up to 68 service users in the category of old age. The home is in two separate sections and provides nursing and residential care. Initially the home had been two facilities although some two years ago had revisions made to the building including an adjoining walkway. The home has one registration and is managed as one facility. However, it is often referred to as two homes and staff tend to maintain it as such. The staffing for the home is organised in two separate sections i.e. Fairlight and Fallowfield. The newly appointed manager started in February 2005. Staffing levels for Fallowfield should be maintained as per the staffing notice issued under the previous regulating authority. Fairlight & Fallowfield G51-G01 s10134 Fairlight Fallowfield AI v230700 110805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted as an announced of which the home was notified in advance. In preparation for the inspection the pre-inspection documentation had been received by the CSCI. Eight relatives/visitors comment cards were received prior to the inspection. Comments relating to food and staff were noted in the comment cards; these were related to the manager on the day of the inspection. The inspector sat in on part of the staff shift handover on the Fallowfield side. Two inspectors spent six and half-hours in the home meeting with residents, interviewing staff and sampling records. The inspectors toured the premises and sampled care plans on the individual units. Some relatives, who were in visiting, met with the inspectors. The findings in some areas varied and these will be identified throughout the report. What the service does well: What has improved since the last inspection? What they could do better: The staff are provided with opportunities to participate in training including mandatory topics and those specifically related to care of the elderly. Some staff felt that although training was available the limited amount of places, or the fact that they work part-time ,meant that they missed out on training which would equip them with skills to undertake their work. This is something, which the manger needs to address to ensure an equality of training throughout the staff team. Fairlight & Fallowfield G51-G01 s10134 Fairlight Fallowfield AI v230700 110805 Stage 4.doc Version 1.40 Page 6 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. Fairlight & Fallowfield G51-G01 s10134 Fairlight Fallowfield AI v230700 110805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Fairlight & Fallowfield G51-G01 s10134 Fairlight Fallowfield AI v230700 110805 Stage 4.doc Version 1.40 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 standard(s) 1,3,4,5. Prospective residents are provided with sufficient information on which to base their decision regarding placement in to his home. Pre-admission information and assessments enable the home to ensure that residents’ needs can be met. EVIDENCE: The notice of inspection was available in several locations throughout the home. Service User Guides were available in those bedrooms inspected. The Statement of Purpose was available in the hall. Fallowfield The manager assesses all prospective residents. Assessment information is received from the care manager and, where applicable, the hospital. In the care plans, there was documentation relating to the assessments conducted and supporting information from other members of the multi disciplinary team. Pre-admission visits are encouraged although these are usually undertaken by family members, as residents are generally too frail to do so. A letter confirming the home’s ability to meet residents’ needs confirms the suitability of the home. Fairlight & Fallowfield G51-G01 s10134 Fairlight Fallowfield AI v230700 110805 Stage 4.doc Version 1.40 Page 9 Fairlight Residents are given the opportunity to visit the home prior to admission and are offered a trial period to enable both parties time to ascertain if a permanent admission is appropriate. Senior staff stated that all residents are written to prior to admission, confirming that following assessment, the home will be able to meet their needs. Senior staff would conduct the initial assessment of residents either in hospital or at home prior to admission. Assessments included key information on next of kin, general health, mobility, personal care manual handling etc. Following the assessment a short-term care plan is completed. The inspector identified two registration issues on the Fairlight side of the home, detailed as follows: One resident who is in the home, is under 65 and has a learning disability. This resident had been in the home for some time prior to the appointment of the current manager. A number of residents were described as having Dementia; staff were unclear if the residents had been assessed by the Psycho Geriatrician. In addition, two residents are receiving support from the CPN. Discussion took place around applying for a variation if these people are to remain in Fairlight. Please see requirement 1. Fairlight & Fallowfield G51-G01 s10134 Fairlight Fallowfield AI v230700 110805 Stage 4.doc Version 1.40 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 standard(s) 7,8,9,10 Health care is well addressed in this home. Medication procedures and supporting documentation promote safety in the daily administration practices. EVIDENCE: Fallowfield A selection of four care plans were randomly selected. All contained photographs of the resident and documentation relating to the assessment process. The problems identified in the care plans were inline with those identified at the assessment, although the interventions section was limited, and the actions to be taken by staff would not sufficiently address the identified problem. In one care plan, the detail on the progress of a wound was not recorded. Supporting risk assessments relating to manual handling, nutrition, and skin integrity were in place. These are routinely reviewed on a monthly basis even when high risk was identified. This was evident for several of the care areas identified. In the event that the assessment process indicates a level of risk then the frequency and content of reviews should be increased to ensure the situation is closely monitored. Supporting, comprehensive information must be maintained to ensure continuity of care and early detection should the situation change. Fairlight & Fallowfield G51-G01 s10134 Fairlight Fallowfield AI v230700 110805 Stage 4.doc Version 1.40 Page 11 The inspector noted “ turn charts” and fluid balance charts were in use for those who required closer monitoring in these areas. Residents’ care plans were discussed with the key workers. Staff displayed a reasonable knowledge of the residents for whom they were the key worker. Equipment was available, observed to be used appropriately and in working order. A new assisted bath has been installed. Medication The medications were inspected. Storage was satisfactory. Sharps bins were dated on opening. Medication charts were satisfactorily completed with allergies recorded and medications received, documented. The Controlled Drugs were checked and found to be correct with supporting records accurately completed. The date of opening needed to be recorded on some items of medication. Discrepancies were identified in some of the medications, which were audited. The amounts of medications were checked against the supporting records and these did not correlate in respect of the amounts. Staff must accurately record all medications. In the event that PRN medication is required, where a variable amount is indicated, then staff must record the actual amount administered to the resident. Ongoing and random auditing should be introduced to monitor this situation. Fairlight Senior staff would conduct the initial assessment of residents either in hospital or at home prior to admission. Assessments included key information on next of kin, general health, mobility, personal care manual handling etc. Following the assessment a short-term care plan is completed; this is until a fuller assessment can take place in the home. Care plans also detailed residents’ wishes in respect of action to be taken following death. The care plan is signed by the resident or their relative at the time the assessment is completed and the care plan drawn up. The reviews contained limited information except for staff signatures. There was no written evidence that residents or their relatives are involved in the review process. Residents spoken with stated that staff asked them if they were happy with everything or had any complaints but could not recall being asked to participate in the written updating of care plans. The home operates a good key worker system. Key workers spoken wit, described clearly residents’ needs and detailed the additional responsibilities they have to residents in terms of liaising with relatives when necessary, and ensuring rooms are being kept clean and tidy. In addition it is the responsibility of key workers to ensure that residents have adequate supplies of toiletries, and that clothing is appropriately laundered and labelled. The key worker Fairlight & Fallowfield G51-G01 s10134 Fairlight Fallowfield AI v230700 110805 Stage 4.doc Version 1.40 Page 12 meets residents on a one-to-one basis at least once a week. Staff are responsible for conducting these sessions and writing an additional weekly report on the residents’ activities, general demeanour, contact with family/ friends etc. This is in addition to the daily record, which is maintained by the senior care worker on duty for each shift. Fairlight also benefits from some male carers, enabling them to provide residents with the same gender carer. Senior staff stated this worked particularly well and a male resident who had refused assistance from female staff, had accepted help with personal care from a male carer. Senior staff stated that female residents are asked at the time of assessment if they would feel unhappy about receiving assistance with personal care from a male carer. Medication Medication is stored in an appropriate metal trolley secured to the wall in the corridor outside of the office. A smaller locked metal cupboard secured directly to the wall, is used to house Controlled Drug medication. Both storage facilities were clean and appropriately organised. The lunchtime medication round was observed. The senior member of staff conducted this. She administered medication ensuring the cupboard was locked each time she removed an individual residents medication and then signed the Medication Administration Record (MAR) sheet when returning to take out the next persons medication. Discussion took place regarding the need for two members of staff to date and sign handwritten entries to the MAR sheet. Confusion arose in relation to one of the medications in use, namely Temezepam. The medication administration sheet had been signed by one person, and in one instance not signed at all. This was brought to the staff’s attention, who produced the Controlled Drug book which was being signed by two members of staff. Discussion also took place in relation to the difference between medications not required/refused. Clarification was given that as required namely PRN medication, which is declined by a resident, does not constitute refused. Please see requirements 2 and 3. Fairlight & Fallowfield G51-G01 s10134 Fairlight Fallowfield AI v230700 110805 Stage 4.doc Version 1.40 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 standard(s) 12,13,14,15. Daily life is as individual as possible within the restrictions of communal living. Individual and group activities are provided. EVIDENCE: Fallowfield During the course of the morning those residents who were in the lounge spoke to the inspector. The comments were generally favourable as one resident said: “As happy as you can be in a place like this”. Residents were seen to spend time either in the communal areas or their own bedrooms. Bedrooms had radios, TVs, books, magazines and other items for recreation and in the main were personalised. Two relatives were in visiting. They visit weekly. They related positive comments regarding the care of their mother and her appearance. They felt well informed about their mothers on going care, with staff displaying a caring attitude. They expressed their satisfaction with the home. Other relatives were taking a resident out for lunch. Visiting is open. The lunch was observed. Staff were assisting residents with eating, and prompting them as needed. Choices were available. The food received variable comments such as “ Homely,” “Good” and “Monotonous”. One resident felt that Fairlight & Fallowfield G51-G01 s10134 Fairlight Fallowfield AI v230700 110805 Stage 4.doc Version 1.40 Page 14 the period between the evening meal and the breakfast was too long. She was unable to recall being offered supper. This was referred to the manager for action. Group activities are available including outside entertainment. Fairlight The home has been without an activities coordinator for some time, however, staff stated that a new person was due to commence the following Monday. It is proposed that this person will spend two afternoons a week on the Fairlight side and two afternoons on the Fallowfield side. One resident spoken to, who is registered blind, receives the RNIB talking book and the local audio paper. She stated that staff help her with ordering tapes and operating the equipment. All residents were appropriately dressed in clean and well-laundered clothing. Male residents were appropriately shaved, and female residents’ hair was cut and styled. Good interaction was seen between staff and residents; those requiring assistance were helped by staff in a calm unrushed manner. One resident refused to go to the dining room for lunch, and her meal was brought to her in the lounge on a tray. A member of staff assisted her with eating the meal in an appropriate manner. The lunch was chicken, served on the bone, which many residents were unable to manage and much of the food was wasted. This was brought to the attention of the manager who was surprised as sliced chicken is usually on the menu, and would investigate the matter. Fairlight & Fallowfield G51-G01 s10134 Fairlight Fallowfield AI v230700 110805 Stage 4.doc Version 1.40 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 standard(s) EVIDENCE: No standards were assessed in this section. Fairlight & Fallowfield G51-G01 s10134 Fairlight Fallowfield AI v230700 110805 Stage 4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,2,0,21,22,23,24,25,26. The environment is well maintained in a domestic manner. Items of equipment are available to maximise residents’ mobility and assist staff in their daily work. EVIDENCE: Fallowfield The home was clean tidy and hazard free. Communal areas are located on the ground floor; these were maintained in a domestic manner. The large dining room was nicely presented with all items of cutlery, condiments and serviettes. Bedrooms were personalised, with fluids available and call bells at hand. A quiet area is available on the top floor. There is a lift facility between the different floors. The kitchen and laundry are located on the ground floor. The kitchen was inspected. It was well organised and clean. Good quality foods were observed with fresh fruit and vegetables. Fairlight & Fallowfield G51-G01 s10134 Fairlight Fallowfield AI v230700 110805 Stage 4.doc Version 1.40 Page 17 Supporting documentation and records were all in place. The newly appointed chef is undertaking a review of menus with the manager. Fairlight This side of the home was clean, appropriately furnished with attractive furnishing. The house is set in a large well-maintained garden there are a number of seating area and benches positioned around the grounds. The garden is accessible to wheelchair users. Residents’ bedrooms were individually personalised. Residents stated they had been able to bring small pieces of furniture, pictures and small personal mementos from home. Residents with whom the inspector met, who had bedrooms with ensuite facilities, stated they couldnt be without these. The home also benefits from a large, appropriately furnished library, which is also used as a quiet/visitors room. Baths seen have been provided with appropriate hoists. Dining-room tables were attractively presented with clean pressed linen and napkins; residents had the choice of condiments and three alternative fruit juices. Fairlight & Fallowfield G51-G01 s10134 Fairlight Fallowfield AI v230700 110805 Stage 4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30. Staff recruitment procedures are addressed, although some items needed to be actioned. There was conflicting information to confirm that sufficient training is provided to all staff relevant to the work that they do. EVIDENCE: Fallowfield The home works to the staffing notice issued under the Registered Homes Act, by the previous regulatory authority. It has only recently achieved this in respect of the two qualified nurses during the afternoon period. Staff with whom the inspector met felt that the afternoon period had significantly improved with increased staff supervision and support from qualified staff. The second qualified nurse was able to work alongside care staff to monitor care practices, which was not the case previously. The afternoon handover was observed between staff shifts. The main focus was on physical health issues with little reference to other issues such as mental health issues leisure or visitors. In the event that staff vacancies occur there is a bank staff system in operation including five qualified staff. The off duty indicated some staff do long days. This comment had been raised within the comment cards received. The manager confirmed that staff are monitored closely for evidence of fatigue or poor performance and that hours would be reviewed should these come to light. Fairlight & Fallowfield G51-G01 s10134 Fairlight Fallowfield AI v230700 110805 Stage 4.doc Version 1.40 Page 19 Staff with whom the inspector met confirmed that they had received TOPPS induction and that some training was provided inhouse, whilst external training covered other topics. The main training staff referred to was manual handling. Induction had included health and safety practices, dealing with abuse, orientation into the home and routines. Six staff have completed NVQ 2 which is approximately nine percent. The standard refers to 50 of staff having achieved this by 2005. All qualified nurses have their PIN number confirmed through the NMC. The nursing staff have a requirement to maintain their professional registration with updated training. A selection of five staff personnel files were inspected. The majority of the items required under Schedule 2, Care Standards Act 2000, were in place although not all. In addition, there was no terms and conditions for those staff who had been recruited through an overseas agency. The terms and conditions were those for their recruitment agency, although it is the home that employs them currently. Fairlight The senior staff stated that generally she was in charge of the residential side on a day-to-day basis. In addition, a team leader and senior carer were also available. The home operates with five care assistants in the morning and three care assistants in the afternoon/evening until 8:15 p.m. The staff rota indicated that for the previous week it had only been possible to provide four members of care staff on duty in the morning. The senior carer works on the floor with the care staff and is included in the hours. The inspector noted that the staffing levels seemed low taking into account the dependency of residents and additional tasks such as evening meal and preparation for bed etc. The manager stated that using the Department of Health staffing formula the home was providing an excess of a hundred care hours above the national minimum. Staffing levels should be kept under review particularly in light of increased dependency. Both members of staff were interviewed privately, and indicated that references had been sought before their appointment. Staff stated that when they had commenced work it was in a supernumerary capacity for the first month working alongside a senior carer. Senior staff stated that new members of staff would follow the TOPPS induction programme. Fairlight & Fallowfield G51-G01 s10134 Fairlight Fallowfield AI v230700 110805 Stage 4.doc Version 1.40 Page 20 Both staff stated the only training they could recollect receiving was moving and handling. The inspector specifically asked regarding fire training, they recalled receiving training in relation to this approximately 2 weeks ago. Neither of the two members of staff had undertaken first aid training. Neither staff knew the term “whistle blowing” or if the home had a policy in relation to this. However, both stated they felt confident they could go to a senior member of staff if they had any concerns regarding a colleague’s practices. There was information regarding a half-day adult protection training course being run by Bromley Social Services. One member of staff stated that he intended to undertake NVQ 2 & 3. The other member of staff, who is part-time, stated she had been told it would not be possible for her to undertake this qualification. These issues were raised with the manager who felt that systems were in place to evenly distribute training, however she would review this to ensure all staff had training made available to them, which was updated as necessary. Please see requirement 4 and 5. Fairlight & Fallowfield G51-G01 s10134 Fairlight Fallowfield AI v230700 110805 Stage 4.doc Version 1.40 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,37,38. The home is managed by an experienced manager within a company who has relevant experience in the care industry. Health and safety issues are addressed with ongoing maintenance to provide a safe environment. EVIDENCE: The manager has been in post for approximately six months and has recently completed the CSCI registered managers process. The manager is a Registered General Nurse. Ms Bright has had previous experience in the independent sector with this category of residents. Staff felt Ms bright was approachable and knowledgeable in this area of work. Throughout the inspection heath and safety practices were addressed. COSHH products were stored appropriately in locked cupboards. Equipment was stored under the stairs, although storage remains and issue. First aid boxes were appropriately stocked. First aid training is provided both by way of the four day and one day courses, although not all staff have undertaken this. Fairlight & Fallowfield G51-G01 s10134 Fairlight Fallowfield AI v230700 110805 Stage 4.doc Version 1.40 Page 22 Equipment was being used and staff confirmed training in the use of items used. A copy of the companys health and safety policy was seen “The Responsible Person for ensuring its implementation is one of the company directors who had signed the documentation. The current employees liability insurance was seen displayed in the home. Records indicate that the home has received an inspection by both the Fire and Environmental Health departments. Records indicate that regular maintenance and safety checks have been undertaken in relation to the gas and electrical appliances and to all equipment used by service users and staff working in the home. Fairlight & Fallowfield G51-G01 s10134 Fairlight Fallowfield AI v230700 110805 Stage 4.doc Version 1.40 Page 23 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 3 3 x x x x 3 3 Fairlight & Fallowfield G51-G01 s10134 Fairlight Fallowfield AI v230700 110805 Stage 4.doc Version 1.40 Page 24 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard 3 7 Regulation Requirement Timescale for action 30/8/05 30/9/05 3. 9 4. 29 5. 28 & 30 CSA 2000 The Registered Manager must Section 24 only admit those who are within the category of registration. 15 The Registered Manager must ensure that all care plan documentation is comprehensive in content with supporting risk assessments in place which are kept under review as appropriate. Previous time frame for action 30/9/05 13 The Registered Manager must ensure that medication systems are safe with robust supporting documentation in place. Previous time frame for action 30/6/05 19 The Registered Person must ensure that recruitment procedures are sufficiently robust to safeguard residents. 18 The Registered Person must ensure that staff are provided with training appropriate to the work that they do. 30/9/05 30/9/05 30/12/05 Fairlight & Fallowfield G51-G01 s10134 Fairlight Fallowfield AI v230700 110805 Stage 4.doc Version 1.40 Page 25 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 Good Practice Recommendations Fairlight & Fallowfield G51-G01 s10134 Fairlight Fallowfield AI v230700 110805 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection River House 1 Maidstone Road Sidcup DA14 5RH 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 Fairlight & Fallowfield G51-G01 s10134 Fairlight Fallowfield AI v230700 110805 Stage 4.doc Version 1.40 Page 27 - 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. 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