Inspection on 02/10/07 for Fairlight & Fallowfield

This inspection was carried out on 2nd October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

Fairlight & Fallowfield 08/11/06

Fairlight & Fallowfield 28/11/05

Fairlight & Fallowfield 11/08/05

Fairlight & Fallowfield 20/04/05

Fairlight & Fallowfield 04/01/05

Fairlight & Fallowfield 20/07/04

Fairlight & Fallowfield 27/02/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Fairlight & Fallowfield Ashfield Lane Chislehurst Kent BR7 6LQ Lead Inspector David Lacey Unannounced Inspection 10:00 2 October 2007 nd 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 DS0000010134.V344409.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. DS0000010134.V344409.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fairlight & Fallowfield Address Ashfield Lane Chislehurst Kent BR7 6LQ 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) 020 8467 2781 020 8468 7028 admin2@millsgroup.fsnet.co.uk The Mills Family Limited Patrick Sena Care Home 68 Category(ies) of Old age, not falling within any other category registration, with number (68) of places DS0000010134.V344409.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Staffing Notice issued 29 September 1998 Morning: 1 RGN and 1 EN and 4 Care Assistants Evening: 1 RGN and 1 EN and 4 Care Assistants Night: 1 RGN and 2 Care Assistants Fairlight and Fallowfield is to be registered for 68 places in total, of which 33 places can have a category of Nursing. 8th November 2006 2. Date of last inspection 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 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. Previously, Fairlight and Fallowfield have been two separate care homes but are now connected by a walkway and has one registration with the commission. However, it is often referred to as two homes and staff tend to maintain it as such, for example, the staffing for the home is organised separately and the provider supplies separate reports of monitoring visits. The fees for this home (as at October 2007) are £550 - £900 per week. DS0000010134.V344409.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection included an unannounced visit to the care home, which took place over two days. Responses from a survey we carried out have also been taken into account. During the visit, I toured the premises, observed care practices, and examined documentation. I spoke with residents, visitors and staff members. I enquired about progress in meeting previous requirements and recommendations. The registered manager and members of staff on duty assisted with the inspection visit. I gave feedback to the manager at the end of my visit. What the service does well: What has improved since the last inspection? The home has met requirements from the last key inspection carried out by the commission in November 2006. We have registered the manager, following a process of assessment. The home has installed a new communal bathroom and new perimeter fencing. DS0000010134.V344409.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. DS0000010134.V344409.R01.S.doc Version 5.2 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 DS0000010134.V344409.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can make an informed choice about whether to move into the home and are assessed to ensure the home can meet their needs. Residents are provided with a contract/statement of terms and conditions. EVIDENCE: The home’s statement of purpose and its service user guide were readily accessible to residents, relatives and other visitors to the home. The content of the statement of purpose and the service user guide have been examined previously, and I did not re-assess them on this occasion. The manager confirmed a previous recommendation about providing information to prospective residents had been addressed. Eighty-eight per cent of the residents who returned survey questionnaires to us stated they had received enough information about the home before moving in so they could decide if it was the right place for them. One resident stated that her family viewed the home on her behalf as she was in hospital at the time. DS0000010134.V344409.R01.S.doc Version 5.2 Page 9 Senior staff visit prospective residents to carry out these assessments. I saw examples of residents’ pre-admission assessments on their files. There was also information from health and social care professionals, for example, hospital discharge letters. All the residents who provided us with written comments stated they had received a contract, and examples were seen on files viewed during the inspection visit. The home does not offer intermediate care, thus standard 6 does not apply in this instance. DS0000010134.V344409.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All residents have a care plan, with supporting assessment information. Plans address the totality of residents’ needs. Residents may be assured their health care needs will be met. Medicine administration is carried out safely and effectively. EVIDENCE: The general improvement in care plan documentation noted at the last inspection had been maintained, though the content still tends to focus on tasks, rather than setting clear goals for care and what will be needed to achieve them. Staff told me they had received training in care plan documentation and it was apparent this training had had positive outcomes for residents’ care. In the care plans I examined, there was good information about physical health issues and more attention given to social and psychological aspects. A visitor told me her relative’s mental health needs, as well as her physical ones, were being met very well since she had moved into this home. DS0000010134.V344409.R01.S.doc Version 5.2 Page 11 Residents’ life histories were more detailed, and I met with a visitor who was writing such a history in her relative’s care plan to give staff information about her life before she moved into the home. The visitor was pleased to be invited to do this, and felt it would be beneficial for her relative’s care. However, I noticed the practical difficulty staff had in arranging for her to do this. The home uses a ‘Standex’ system, in which care plans for different residents are grouped together in a metal-framed holder. To enable the visitor to write the life history without being able to see other residents’ care plans, the relevant section was removed from the Standex and given to her as a loose-leaf page. We have suggested before that the provider considers introducing a system whereby each resident has an individual file. This would make it easier for residents and their representatives to read and review their plans, would promote confidentiality and would lessen the risk of pages going missing. I raised this again but was advised that staff are comfortable with this system, which has been in use in the home for some years. Since the previous inspection, the home has implemented a new system of ‘care reviews’ that I was told has been introduced across the provider’s care homes. The manager explained these are to be undertaken every six months for each resident. He told me they are intended to replace relatives’ meetings and they allow for broad discussion, including about issues such as fees. Reviews are recorded on a form designed for the purpose and a copy is given to the next of kin. Residents and their representatives are invited to the review meeting, which will focus on the goals for care and whether they need to change, and also whether there are any issues to resolve. The resident’s, relatives’ and home’s views of care and comments are recorded, and the form is signed by the manager and the next of kin. It was not made clear why the resident does not sign or be given a copy, and the home may need to consider this in relation to residents’ capacities to act for themselves and make decisions. I spoke with a resident and relatives who had attended a review, and their comments about the process were positive. The manager was able to state that previous requirements about risk assessments had been met. We had required the home to ensure that in all cases there is a care plan and supporting risk assessment for the use of bedrails, specific to the individual resident, and to ensure assessments are completed for risks identified in respect of falls. I saw an example of each of these in care documentation I sampled. Of the residents who provided us with written comments, 88 stated they always receive the medical care they needed and 12 that this was usually the case. A local GP practice provides medical support to the home, with visits as required. There was documentation relating to the GP visits and those made by the multidisciplinary team. Care staff assist residents with personal care as needed, and document provision of care needs such as bathing and hair washing. Residents are DS0000010134.V344409.R01.S.doc Version 5.2 Page 12 encouraged to retain their mobility, and are assessed for risk of falls and any equipment needed, such as walking frames. Nursing staff work proactively to prevent the development of pressure ulcers, and I saw there was pressurerelieving equipment in use. The manager said that at the time of my visit one resident had a hospital-acquired pressure ulcer, which was healing and at grade 1. Residents were well groomed and dressed in suitable clothing for the time of year. Residents said they were cared for well. Of the residents who returned completed questionnaires to us, 75 stated they always receive the care and support they need and 25 that this is usually the case. Observation and discussions with residents confirmed they are treated with respect and their right to privacy and dignity maintained. Staff were seen to address residents respectfully and by their preferred names. A resident with visual impairment said that staff were kind and caring but did not always make themselves known, for example, when coming into her room and sometimes she had to try guessing from their voices who they are. The manager agreed to remind staff about the importance of effective communication with people with sensory impairment (requirement 1). Practice with regard to medication administration was seen to be safe. Two previous recommendations about medicine administration had been met, and it was understood from the manager that the recommended update of the home’s medication policy and its associated documentation is in progress. On the nursing unit, the nurses give medicines and on the residential side carers who have completed medication training carry out the medicine rounds. There were no residents administering their own medicines at the time of my visit. Medicine charts had been completed well, and included information about any allergies and a photograph of the individual resident. One resident had been consistently refusing her medication. This had been recorded and her doctor had been informed. The doctor was reviewing her progress every two weeks. On the residential unit, handwritten amendments had been signed by two staff who have had medication training, and two nurses sign on the nursing side. There were records of medications received into the home and no overstocking noted in the medication trolley. There was a list of initials and signatures of those staff administering medications. Medication on Fallowfield is stored in a locked trolley in a locked room. The room had enough cupboards to allow separate storage for internal and external medication. On Fairlight, a locked trolley is chained to a solid wall outside the unit manager’s office. There is also a locked cupboard on this unit, which contains a controlled drugs cabinet. The one controlled drug being stored was checked and the stock tallied with the records in the register. The controlled drugs stored on the nursing unit were also being stored and recorded correctly. The drugs fridges on each unit were being used for the correct medicines and the temperature is recorded daily. Those medications with a short shelf life had been dated on opening. DS0000010134.V344409.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents choose how they spend their time and are supported to maintain contact with their families and friends. The content of menus is balanced and nutritious, and the majority of residents are satisfied with the food provided. Planned activities are available for residents to join in with as they choose. EVIDENCE: The home had a relaxed atmosphere, whilst being at the same time well organised. I saw examples throughout the day of positive, relaxed interactions between residents and staff. The activities coordinator and the hairdresser were working well with residents, and we heard positive comments from residents about their work. Each of them knows most of the residents and their preferences, which is an advantage to residents. The home offers a programme of planned activities, both in and out of the home. The coordinator was seen facilitating activities, which residents seemed to enjoy. Two residents said that outside entertainers come in and perform shows, which is something they enjoy. Of the residents who returned completed questionnaires to us, 63 stated the home always arranges activities that they could take part in and 37 that this is sometimes the case. DS0000010134.V344409.R01.S.doc Version 5.2 Page 14 Residents are encouraged and supported to make their bedrooms as personal as possible, by bringing their own personal items, family photographs and small pieces of furniture. Some residents had chosen to remain in their rooms, rather then go to the communal areas. They had televisions, music and newspapers available. Residents said they were able to have visitors at any reasonable time. A relative visiting the home during my visit said he was always made to feel welcome. Residents are offered a choice of menu at each meal, and can ask for an alternative if they do not want what is on the planned menu. At lunch on the day of my visit, choice was evident both in the food and fluids provided. It was less evident in the use of bibs, which every resident was wearing. It was not clear that this was due to individual need or preference and I later raised this with the manager as an issue to address (requirement 2). The use of plate guards and adapted feeding mugs was helpful to less able residents. The chef came in to ask residents if they were enjoying their meal. At most of the tables, a carer sat with residents to assist them where necessary, engage them in conversation and provide general supervision. There was always a member of staff in the lounge to encourage residents to take their drinks. The residents using wheelchairs at lunchtime were mostly on one table, which helped to allow easier movement around the dining room. These residents were positioned so they were comfortable and were given assistance with feeding as required. We had previously recommended, following comments received, that meat served with meals should be sufficiently tender that residents can easily chew it. Residents had no complaints about the meat on the day I visited. Of the residents who returned completed questionnaires to us, 37 stated they always like the meals at the home and 25 that they usually like them. Thirtyseven per cent stated they sometimes like the meals. DS0000010134.V344409.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home displays and provides information about how to make a complaint but should try to make sure all residents know about this. Full records of complaints received and investigated need to be kept. Residents will now have access to information about local independent advocacy services. The home has procedures to ensure residents are protected from abuse. Staff receive relevant training but the home needs to make sure the outcomes from this training are effective. EVIDENCE: The homes complaints procedure is displayed prominently. Seventy-two per cent of the residents who returned completed questionnaires to us stated they always know who to speak to if they are not happy. Fourteen per cent stated this is usually the case, and 14 that they sometimes know who to speak to if they are not happy. Seventy-five per cent of the residents stated they knew how to make a complaint and 25 that they did not know how to do this. The home should ensure that, as far as possible, all residents know how to complain and who to speak to if they are worried or not happy (recommendation 1). I saw the home’s complaints file, in which there were two entries since the previous inspection. Records had been kept of these complaints but the evidence that they had been managed in accordance with procedure was not sufficient. Statements and correspondence relating to one of the complaints were not on file and could not be located by the manager (requirement 3). DS0000010134.V344409.R01.S.doc Version 5.2 Page 16 The manager responded to my query about the availability of independent advocacy services by locating information that had been provided to the home by a local (Bromley) service. He agreed to make sure this is displayed prominently where residents and visitors can see it. The manager confirmed that the home completes the electoral roll form, including the names of all in residence at that time. The provider has safeguarding and whistle blowing policies and procedures, and the home had a copy of ‘No Secrets’ and a copy of the local authority adult protection guidelines on file. The home’s abuse policy was poorly formatted, making the document difficult to read and use as a working tool, but its content was detailed and comprehensive, and made an explicit link to local (Bromley) multi-agency guidance. The whistle blowing policy makes reference to relevant legislation (Public Interest Disclosure Act). It was understood from the manager that all the company’s policies and procedures are presently being updated and that this process is nearing completion. Staff receive relevant training in the protection of vulnerable adults. There was differing awareness of safeguarding issues. Staff were clear about their responsibilities with regard to reporting any abuse but less clear about the procedures to be followed. For example, staff members I spoke with said that we and sometimes the police need to know about an abuse allegation but they did not say that social services must be informed promptly. This is important as social services hold the lead responsibility in such matters (recommendation 2). In the week following the inspection visit, the manager informed us about an allegation made by the ambulance service with regard to a resident they had taken to hospital. The manager was following safeguarding procedure, and had liaised with Bromley social services. At the time of writing, the outcome was not yet known. DS0000010134.V344409.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a clean and homely environment. The broken down lift on Fairlight unit is awaiting repair, but in the meantime residents, staff and visitors are inconvenienced. The home has infection control procedures, which staff are trained to follow. EVIDENCE: The home was maintained at a pleasant temperature. It was clean, tidy and free from odour. Eighty-seven per cent of the residents who returned completed questionnaires to us stated the home is always fresh and clean, and 13 stated this is usually the case. I saw several bedrooms, which were well decorated and had good quality furnishings. They are cleaned and dusted, and en-suites are cleaned and mopped. Domestic staff clean the bedroom carpets as required. Since the previous inspection, a new bathroom has been installed on the ground floor. This appeared to be a good facility, as it is a spacious room that DS0000010134.V344409.R01.S.doc Version 5.2 Page 18 has a new Malibu assisted bath and recessed ceiling lights. I suggested it could be made more inviting by putting some pictures on the walls and the manager said he would invite ideas for brightening the room. The home has also installed some new perimeter fencing, to improve the security of the building as some garden furniture was stolen. The home normally employs a maintenance technician to whom the staff report items needing attention. However, this was not the case at the time of inspection and a technician from another of the company’s homes was providing support. The previously exposed pipe work in the link corridor between Fairlight and Fallowfield had received attention, following a requirement from the last inspection. All floors can be accessed by a passenger lift but the lift on Fairlight was not working. This lift had been out of action for some weeks, which was causing inconvenience to residents, staff and visitors. Residents were using the stairs or, if necessary, the stair-lift. It was understood from the manager that the delay was because a replacement part needed to be specially made, as due to the age of the lift it was no longer available from stock. The manager gave assurance that the repair would be completed shortly. Grab rails are fitted in all corridors and toilets. The emergency call system is readily accessible and operates throughout the home. I saw that call bells had been placed within reach of residents with restricted mobility. There was one standing hoist on each floor and I was told people have to wait sometimes. I raised this with the manager, as it is important to residents that there are enough hoists to meet their needs. He agreed there were about ten people on each floor who needed to use a standing hoist, and I have suggested the hoist provision be reviewed to make sure the home has enough to meet the dependency needs of its residents (recommendation 3). Infection control procedures are in place, and staff are offered relevant training. A laundry person is employed to launder bed linen, towels and personal laundry. Red alginate bags are used to launder soiled items. The home has two sluices, which are fitted with disinfectors for the effective cleaning of commode buckets. I discussed infection control with the manager who, when questioned, told me about the measures being taken for a resident with MRSA. He showed me there was a yellow bin in the en-suite, confirmed clothes were being washed in an alginate bag, and that staff use gloves and aprons, and carry out hand-washing according to procedure. The manager said there were no residents with clostridium difficile infection. DS0000010134.V344409.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has enough staff members to meet the needs of the people in residence. The home’s recruitment procedures provide protection for residents. Staff members have access to training opportunities that are relevant to their work in the home. EVIDENCE: Eighty-eight per cent of the residents who returned completed questionnaires to us stated that staff listened and acted on what they [the residents] said, and 12 stated that staff did not do this. Fifty per cent of these respondents stated staff are always available when they needed them, 38 that this is usually the case, and 12 that staff are sometimes available. On the day of my visit, the nursing unit (Fallowfield) had two qualified nurses, two senior carers and six carers on duty. The manager confirmed the home is fully staffed at the present time, in respect of care and ancillary staff. He was well aware that he must make sure staffing levels and mix always meets the dependency of the residents, as dependency levels in the home may fluctuate from time to time. The worked staff rotas for recent weeks showed that staffing levels throughout the 24 hours had been consistent. Observation and discussions showed that residents’ needs were being met, generally without hurry, and that staff had time to talk with residents. I looked at a sample of staff recruitment files. As far as possible, I selected files of staff members who I had seen working in the home and had spoken DS0000010134.V344409.R01.S.doc Version 5.2 Page 20 with. The files showed that residents are supported and protected by the operation of sound recruitment procedures. In the sample I saw, all the required information had been obtained about the staff members before they started work in the home. Staff I spoke with confirmed they receive statutory training and carers are supported to undertake NVQ awards in care. Nurses are supported to undertake continuing professional development in line with Nursing and Midwifery Council requirements for maintaining their nursing registration. Staff files contained details of training completed. DS0000010134.V344409.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. We have assessed the manager as fit to be the manager of this care home. The home operates strategies to assure the quality of its services. We have been supplied regularly and promptly with reports of the provider’s monthly visits to the home but we must be informed promptly of significant events that may affect residents’ welfare. In general, the home promotes the health and safety of its residents, staff and visitors well, although there are some areas in this respect that need improvement. EVIDENCE: Since the previous inspection, we have assessed the manager as fit to be the manager of Fairlight and Fallowfield. The manager is qualified and experienced, and has previously managed a care home. DS0000010134.V344409.R01.S.doc Version 5.2 Page 22 Relatives who were visiting the home were complimentary about service provision and the open style of management. Staff members I spoke with were also positive about the way the home is being managed. Most recent staff meetings had been in March for Fallowfield and in June for Fairlight. Minutes of these meetings were available for my inspection, as evidence that staff are able to give their views about the running of the home. The home has strategies to assure the quality of its services, and the manager has supplied us with an annual quality assurance assessment. I saw the reports of quality assurance surveys and staff quality assurance surveys that had been carried out in 2006. The results of staff surveys carried out in the first half of 2007 have been obtained but not yet collated into a final report, as this will be made available at the end of the year. The manager told me that relatives’ survey questionnaires had been sent out and responses were awaited. We have been supplied regularly and promptly with reports of the provider’s monthly visits to the home. These reports cover main areas of the services provided and give useful information. Copies of the reports were also on file in the home. Each of the two units has a ‘communication book’ for staff to write messages for the manager. The manager signs when he has read a message. Issues raised in the books included some regarding quality of service, for example, if a meal was not well presented or cooked or if a piece of equipment needs repair or replacement. The home safeguards residents’ financial interests by following appropriate procedures. No money is held on residents’ behalf by the home, and they or their families are invoiced for any extra charges, such as hairdressing and newspapers. It was understood some residents keep small amounts of money, which allows for more dignity and independence in buying small items without always relying on others to assist them. Some staff were receiving regular supervision but it was evident this did not apply to all staff members, senior staff in particular. I discussed this with the manager and asked that he ensure all staff members receive formal supervision at least six times each year (recommendation 4). The notification from the home about the passenger lift becoming temporarily inoperable was dated over two weeks following the incident. This was an important matter, affecting the Fairlight unit in particular, which needed to be notified to us without delay (requirement 4). There were satisfactory general standards being maintained in the kitchen but chilled food storage needed to be improved. Some jars had not been labelled DS0000010134.V344409.R01.S.doc Version 5.2 Page 23 with their opening dates, a bowl of prunes was out of date, and there was salad on a shelf below raw meat. The chef took immediate action to rectify these matters but I have made a requirement to ensure good practice is maintained. It was evident that food temperatures are checked in the kitchen but, when questioned, care staff told me they do not check the temperature again before serving from the hot trolley. I raised this with the manager who said he expected that temperatures are checked in the kitchen and again before serving to make sure they are at safe levels. He said he would remind staff to do this. In the kitchen, the door seals for one fridge needed attention and the door of the other fridge was out of alignment. I also raised these matters with the manager for his attention (requirements 5 and 6). The manager was able to confirm that a previous requirement that all staff members attend a fire drill at the appropriate intervals had been met. He also advised that a previous recommendation to review and update the home’s moving and handling policy was being addressed, as part of a general review of all the company’s policies and procedures. I examined a sample of health and safety documentation, nearly all of which were up to date and within the appropriate timeframes. These included certificates for gas safety, fire safety, electrical installation, and servicing of lifting equipment. Water testing was overdue as the certificate on file was dated August 2006 and there was a reminder letter from the contractor about re-testing (requirement 7). The hot water from the outlets I tested during the inspection visit was comfortable to my touch. The home has a policy for the risk assessment of bedrails. This includes the commitment to carry out and document three monthly maintenance assessments and have these available in the home. Documentation I saw confirmed these assessments are being carried out, the last occasion being 30/08/07. DS0000010134.V344409.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 2 3 X X 3 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 3 3 X 3 2 X 2 DS0000010134.V344409.R01.S.doc Version 5.2 Page 25 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. 1 Standard OP10 Regulation 12 Requirement The registered person must ensure staff members always communicate effectively with residents who have sensory impairment, in the way the resident prefers. The registered person must ensure that where a resident has a bib at mealtimes, this is to meet a need or preference identified for that individual. Timescale for action 31/10/07 2 OP14 12 31/10/07 3 OP16 22 The registered person must 31/10/07 ensure it is always evident that any complaint has been fully investigated and the complainant informed of the action (if any) to be taken. The registered person must ensure a passenger lift breakdown that cannot be repaired immediately is notified to the commission without delay. This is because such an event may adversely affect the wellbeing or safety of residents. The registered person must DS0000010134.V344409.R01.S.doc 4 OP38 37 31/10/07 5 OP38 16 31/10/07 Version 5.2 Page 26 ensure good food hygiene practices, specifically, that the opening dates of perishable foods are recorded, that salad is not stored in the fridge beneath meat, and that cooked meat temperatures are always checked before meals are served from the hot trolley. 6 OP38 13 The registered person must ensure the fridge door seals and loose fridge door are repaired or replaced. The registered person must ensure an up to date watertesting certificate is obtained for the home. 31/10/07 7 OP38 13 30/11/07 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 Refer to Standard OP16 Good Practice Recommendations The registered person should ensure that, as far as possible, all residents know how to complain and who to speak to if they are worried or not happy. The registered person should ensure there are effective outcomes from the adult protection training provided to staff. The registered person should keep the home’s equipment under review to ensure there are always enough hoists to meet the assessed needs of the people in residence. The registered person should ensure that all staff members receive formal supervision at least six times each year. 2 OP18 3 OP22 4 OP36 DS0000010134.V344409.R01.S.doc Version 5.2 Page 27 DS0000010134.V344409.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection SE London Area Office River House 1 Maidstone Road Sidcup Kent DA14 5RH 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 © 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 DS0000010134.V344409.R01.S.doc Version 5.2 Page 29 - 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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