Inspection on 08/11/06 for Fairlight & Fallowfield

This inspection was carried out on 8th November 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Fairlight & Fallowfield 02/10/07

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 8th November 2006 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 Fairlight & Fallowfield DS0000010134.V313191.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. Fairlight & Fallowfield DS0000010134.V313191.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 The Mills Family Limited Position Vacant Care Home 68 Category(ies) of Old age, not falling within any other category registration, with number (68) of places Fairlight & Fallowfield DS0000010134.V313191.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. 28th November 2005 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. Initially the home had been two facilities although has had changes 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. Fairlight & Fallowfield DS0000010134.V313191.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 by two inspectors. The acting manager and members of staff on duty assisted with this. During their visit, the inspectors toured the premises, observed care practices, and examined documentation. They spoke with service users, visitors and staff members. The inspectors provided feedback at the end of their visit to the acting manager. What the service does well: What has improved since the last inspection? The home had met most requirements from the random inspection carried out by the commission in July 2006. These included ensuring all medicines are within their stated expiry dates, notifying the commission promptly of accidents to service users, and ensuring the safe use of portable fans. The home was working towards meeting a requirement that care plans address service users’ health and welfare needs in sufficient detail, in this instance, social and psychological needs. Fairlight & Fallowfield DS0000010134.V313191.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. Fairlight & Fallowfield DS0000010134.V313191.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 Fairlight & Fallowfield DS0000010134.V313191.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users are assessed to ensure the home can meet their needs. Service users can make an informed choice about whether to move into the home, though it should be made evident that information is provided before admission and that trial visits take place. Service users are provided with a contract. The home does not offer intermediate care, thus standard 6 does not apply in this instance. EVIDENCE: Service user guides were seen in bedrooms during the inspection visit. Of the twelve service users who provided written comments to the CSCI, ten confirmed they had received enough information about the home before moving in so they could decide if it was the right place for them. One stated s/he did not receive any information and one that s/he was admitted as an emergency placement. Fairlight & Fallowfield DS0000010134.V313191.R01.S.doc Version 5.2 Page 9 Of the twelve service users who provided written comments to the CSCI, eleven stated they had received a contract. One respondent did not answer this question. The inspectors saw examples of pre-admission assessments for service users. Within the care plan documentation for individual service users there was evidence of assessment information. The staff use a standard form for assessing prospective service users. The team leader on Fairlight outlined the process of assessment, confirming that she visits referred service users to carry out the assessments. There was also information such as hospital discharge letters and other information from members of the multidisciplinary team. It was said that trial visits are offered but the inspectors were unable to find evidence in the home that these had taken place or that information about the home had been provided prior to admission. This was raised with the acting manager and a recommendation is made. The statement of purpose and service users’ guide were available in the home. Fairlight & Fallowfield DS0000010134.V313191.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 at least once during a 12 month period. 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 service users have a care plan, based on assessment of their needs. Their physical needs are subject to more detailed assessment than their social or psychological ones, and supporting assessment information for care plans could be improved. Service users health care needs are met. Service users are treated with respect and their privacy upheld. Medicine administration is generally satisfactory. EVIDENCE: The inspectors selected six care plans and supporting assessments to view, noting there had been general improvement in the documentation. In addition, food and fluid charts were also inspected. Every service user was on a fluid chart, though the reason for this was unclear. The fluid charts seen for the day of the inspection were up to date. Those for previous days were of a variable standard, with some fully completed but others not. Care plans throughout the home contained photographs of service users as well as personal information and next of kin contact details. Fairlight & Fallowfield DS0000010134.V313191.R01.S.doc Version 5.2 Page 11 Care plans reflected the physical health needs of the service users and the interventions to address these were appropriate to achieve the end goal. In some cases the service user’s or advocate’s signature was omitted, although in all cases the staff member producing the care plan had signed the document. Review dates were in place although some reviews were limited in content. In one service user’s file, the assessment referred to aggression and shortterm memory loss. This was referenced twice and community psychiatric nursing involvement had been arranged. There was no specific care plan in respect of the service user’s aggression and short-term memory. In all care plans seen there was a lack of information relating to social and psychological aspects of care, thus a previous requirement in this respect had not been fully met. The daily records focused on physical health issues and only occasionally addressed other areas. More information is required to address the totality of service users’ problems. Care plans contained supporting assessment information in relation to manual handling, nutrition and skin integrity. Several of these assessments fell in to the ‘high’ or ‘very high’ risk category but evidence of close monitoring by way of more frequent reviews was lacking. This was raised in discussion with the acting manager. It was recorded in one care plan that the service user required bedrails. In such cases there must be a care plan and supporting risk assessment for the use of bedrails, which must be specific to the service user. In another care plan there was reference to three episodes of falls or slips, however there was no falls risk assessment in place. A requirement has been made. In addition, this service user had a ‘very high’ risk identified in both her nutrition status and skin integrity. In another care plan there was specific information in relation to a wound dressing. This had been written by the Community Liaison Team as an instruction to the qualified staff in the home. The inspector met with one of the qualified staff to discuss her knowledge of this procedure. She was able to repeat the instructions in detail, as they had been written. There was documentation relating to the GP visits and those made by the multidisciplinary team. Service users confirmed that access to a doctor was available to them when they needed it. Of the twelve service users who provided written comments to the CSCI, eight stated they ‘always’ and four that they ‘usually’ received the medical care they needed. A local GP practice provides medical support to the home, with visits as required. Newly admitted service users may retain their own GP, providing that GP agrees. Fairlight & Fallowfield DS0000010134.V313191.R01.S.doc Version 5.2 Page 12 It was evident from discussions with service users and relatives that they are treated with respect and their right to privacy and dignity maintained. Staff were seen to address service users respectfully and by their preferred names. Of the twelve service users who provided written comments to the CSCI, eight stated they always received the care and support they needed. Three stated they usually received this care and support, and one service user that s/he sometimes received it. Of the nine relatives/visitors providing written comments to the CSCI, all stated they were satisfied with the overall care provided. Seven stated they were consulted about their relative/friend’s care if s/he was not able to make decisions. The other two respondents indicated their relatives/friends were able to make their own decisions. The CSCI also received written feedback from a visiting health care professional about the standard of care provided to the home’s service users. This feedback was positive, and included comment about staff members’ understanding of service users’ care needs and the home’s management of medication. The practice of administering medications was observed to be safe and the staff were patient with service users, some of whom took a long time to take their medications. The medication charts were generally well completed. Allergies had been recorded and charts included clear photographs of the individual service user. There was a list of initials and signatures of those staff administering medications. Those medications received into the home were recorded. On a couple of occasions, changes had been made to the instructions for administration. In such cases two staff should sign to agree the record is accurate. There were a lot of medications in stock, as the delivery had just arrived. This made the clinical room very cramped. Those medications with a short shelf life, including Calogen, had been dated on opening. Records of the drugs fridge temperature were in place. The medications disposed of had supporting records in place. There was one resident on Temazepam, which the home was recording and storing as a Controlled Drug. Records relating to this were accurate as was the stock balance. Stocks of Fortisip were being rotated and those with the shortest shelf life were at the front. This met a requirement from the previous inspection. The homely remedies sheet was dated 10/3/2005 and signed by the GP. The acting manager was recommended to ask the GP to review this at least annually. It was a generic listing of homely remedies, and did not refer to named service users. The acting manager was reminded that the homely remedies listed must be assessed as suitable and safe for all service users, including those newly admitted to the home. Fairlight & Fallowfield DS0000010134.V313191.R01.S.doc Version 5.2 Page 13 It was recommended that the home’s medication policy (dated July 2002) be reviewed. For example, the section on ‘disguising medication’ needs updating as it refers to outdated references from former local authority inspection units and the former UKCC. There were other pieces of documentation filed with the home’s medication policy that would also benefit from review. These were: Medication Administration (July 2000), Medicines (Night) (July 2000), Medicines (Giving) (July 2001), and Medicines (New Stock and Audits) (June 2001). Fairlight & Fallowfield DS0000010134.V313191.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Planned activities are available to service users, to engage in as they choose. Service users choose how they spend their time and are supported to maintain contact with their families and friends. The content of menus was balanced and nutritious. Service users’ are mainly satisfied with the food, though the meat served is not always tender enough for some. EVIDENCE: There was a calm, relaxed atmosphere in the home when the inspectors arrived in the morning. Service users were either in the lounge or their rooms. The home appeared well organised, and staff were going about their care duties in an unhurried manner. The inspector observed the morning routines in one of the lounge areas. Tea was served as the inspectors arrived. There were fluids available in the lounge and individual bedrooms. Two service users had cold drinks on the table beside them although other service users were not offered fluids except when the tea came. Music was playing in the background. Fairlight & Fallowfield DS0000010134.V313191.R01.S.doc Version 5.2 Page 15 Service users 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. A service user whose care plan had been inspected had no complaints and was quite positive about the home. She had breakfast at 12.00 and was still in her pyjamas at 14.00 hours. She was clear that this is what she wanted and staff supported her choice. There were several residents who were in their bedrooms and indicated that this is where they preferred to stay. They had televisions, music and newspapers available. Service users said they were able to have visitors at any time. Relatives were in visiting and offered positive comments about the home and the open style of management. The inspector saw a visiting relative on Fairlight being welcomed by a carer and offered a drink on arrival at the home. Another relative visiting Fallowfield was also offered a drink on arrival, by three separate staff in close succession! He said he was always made to feel welcome in the home. Of the nine relatives/visitors providing written comments to the CSCI, eight stated they were welcome to visit the home at any time and that they could visit their relative/friend in private. The home offers a programme of planned activities, both in and out of the home. Staff members on Fairlight were planning a trip out from the home for the following day, at which four service users were to be taken out for lunch. The activities coordinator works five days a week, seven hours a day. She was seen facilitating activities, firstly reading the daily newspaper, then gentle exercises and then a game of skittles. The service users seemed to enjoy this. The activities coordinator demonstrated a good attitude with the service users, engaging them in the activity and encouraging their participation. Service users in both units offered positive comments about the activities coordinator. In the afternoon, a group of service users on Fairlight took part in a keep-fit session. A service user said that outside entertainers come in and perform shows in the lounge, which is something that she enjoys. Of the twelve service users giving their written comments to the CSCI, seven stated there were always activities arranged by the home that they could take part in. One service user stated this was usually the case and three stated that there were sometimes activities they could join in. Service users could choose whether to take part. One of the respondents commented, “Prefer to listen to own music, so only join in some activities”. A relative said that “my [relative] has never wished to take part in activities”. Service users 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. The lunch was observed during the inspection visit and it was a relaxed affair. At each of the tables, care staff sat with service users assisting them to eat and engaging them in conversation whilst providing general supervision to other service users. The lunch was spread over an hour period. Choice was evident both in the fluids provided, as well as food choices. The use of plate guards and Fairlight & Fallowfield DS0000010134.V313191.R01.S.doc Version 5.2 Page 16 adapted feeding mugs assisted less able service users. The chef came in during the meal to see how service users were enjoying the food. Generally, the food was felt to be satisfactory, though one comment regarding the food was that the meat was always tough. This was a comment also received from the CSCI survey of service users at the home. It was said this made it difficult to chew the meat, thus sometimes service users did not eat it. This issue was brought to the acting manager’s attention and action is recommended. Of the twelve service users who provided written comments to the CSCI, nine stated they either ‘always’ or ‘usually’ liked the meals at the home. One stated s/he ‘sometimes’ liked the meals and two did not answer this question. Fairlight & Fallowfield DS0000010134.V313191.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users have information they need to make a complaint. The care provider follows its procedures when responding to complaints. Service users are protected from abuse. Staff receive appropriate training about protecting vulnerable adults. EVIDENCE: A copy of the homes complaints procedure is displayed in the home and a copy is also provided in the guide given to each service user. The timescales for response to complainants were appropriate and the procedure includes the CSCI’s contact details. Awareness by service users and their relatives of the home’s complaints procedure was good. Of the twelve service users who provided written comments to the CSCI, nine stated they knew who to speak to if they were not happy and ten that they knew how to make a complaint. Of the nine relatives/visitors providing written comments to the CSCI, seven stated they were aware of the home’s complaints procedure. Two of the relatives stated they had made a complaint to the home. During the inspection visit, service users said they would speak to a staff member or the person in charge if they were not happy about something. The home’s complaints file was seen and records had been kept of any complaints received, and the action taken in respect of complaints. Monthly Fairlight & Fallowfield DS0000010134.V313191.R01.S.doc Version 5.2 Page 18 analysis sheets are compiled for complaints received both in Fairlight and Fallowfield. The inspectors saw examples throughout the day of positive, relaxed interactions between service users and staff. The home had a copy of ‘No Secrets’ and a copy of the local authority adult protection guidelines on file. The acting manager was not able to locate copies of the home’s site-specific adult protection and whistle blowing policies and procedures during the visit but forwarded these to the CSCI subsequently. It is important that these documents are readily available to staff in the home. Staff receive relevant training in the protection of vulnerable adults. Fairlight & Fallowfield DS0000010134.V313191.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users have a safe, clean and homely environment. Some attention to décor in parts of the home where there has been general wear and tear is needed. Procedures are in place to prevent infection and staff members have good understanding of basic infection control practices. EVIDENCE: The home appeared generally well maintained. It was clean, tidy and mainly free from hazards. The heating was kept at a comfortable temperature. Of the twelve service users who provided written comments to the CSCI, nine stated the home was always fresh and clean. The remaining three service users stated this was usually the case. The home employs a maintenance technician to whom the staff report items needing attention. Some attention to decor in communal areas of the home was needed. For example, there was evidence of wear and tear in the corridors. There was exposed pipe work in the link corridor between Fairlight Fairlight & Fallowfield DS0000010134.V313191.R01.S.doc Version 5.2 Page 20 and Fallowfield, which was pointed out to the acting manager as needing attention. There is a programme of refurbishment, and the acting manager said that bedrooms are decorated as they become vacant. There was evidence of personal belongings, such as photographs and ornaments, in many bedrooms. Specialised equipment was in use, including pressure relieving mattresses and hoists. Equipment is stored on the ground floor although some items were located in bathrooms. The home has a passenger lift to access upper floors. Grab rails are fitted in all corridors and toilets. The emergency call system is readily accessible to service users and operates throughout the home. The hot water outlets tested during the inspection visit were at a satisfactory temperature. Infection control procedures are in place. Infection control was discussed with all staff interviewed during the inspection visit, and their knowledge and understanding was appropriate. Fairlight & Fallowfield DS0000010134.V313191.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 at least once during a 12 month period. 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. Suitably qualified staff members were working in the home in sufficient numbers to enable effective care delivery to service users. The home’s recruitment procedures provide protection for its service users. Staff members have access to training opportunities that are relevant to their work in the home. EVIDENCE: On the day of the inspection visit, the number of staff working in the home and the skill mix of the staff members was appropriate to meet the needs of the service users in residence. Fallowfield had two qualified nurses, seven care staff and three domestics on duty. All staff felt that having two qualified nurses on duty throughout the daytime was beneficial. They stated they felt that there was someone to advise, support and give guidance when needed. The two qualified staff themselves felt this allowed time for completion of documentation and records, as well as providing on going support. Staff members confirmed there were always enough staff on duty and that agency staff were rarely used. Staffing rotas seen showed that staffing levels and mix had been maintained. Information supplied by the home in September 2006 did not include assessment of the service users’ dependency needs but it was noted during the inspection visit that there were some service users with high dependency needs in the nursing unit. The acting manager assured the inspectors that staffing levels and skill mix are kept under review to ensure that service users’ needs continue to be met. Fairlight & Fallowfield DS0000010134.V313191.R01.S.doc Version 5.2 Page 22 Of the twelve service users giving their written comments to the CSCI, three stated that staff were always available when they needed them and nine stated this was usually the case. Of the nine relatives/visitors providing written comments to the CSCI, five were of the opinion that there were always enough staff on duty. One stated there were enough staff most of the time. Three relatives/visitors did not think there were always enough staff on duty in the home. Information supplied by the home in September 2006 showed that 72 staff had left since the November 2005 CSCI inspection, indicating a high turnover of staff. The commission also received a written comment that there seemed to be a high turnover of staff and that this could be unsettling to service users. This was discussed with the acting manager who explained that, following a successful recruitment drive earlier this year, a number of staff had been removed from the home’s staff ‘bank’ as they were no longer required. This had led to a short-term increase in the numbers of staff recorded as leaving the home whereas, in the six months since the acting manager had been in post, only five staff had left. The inspector selected a sample of staff recruitment files for examination. As far as possible, these were files of staff members who met with the inspectors. The files showed that sound recruitment procedures were in operation and that all required information was obtained about applicants before they started work in the home. The authenticity of references would be enhanced by ensuring referees use either their company-headed paper or add their company stamp to the reference; this was not evident for all references in the files seen. CRB disclosures are stored separately within the home; each of the staff files had a corresponding disclosure on file. The home supplied a matrix showing training completed by individual staff members. Staff confirmed they receive statutory training and carers are supported to undertake NVQ awards in care. Nurses undertake continuing professional development in line with NMC requirements for maintaining their nursing registration. Feedback during the inspection visit from four staff members about the work they did and the on going support they received was positive. When interviewing staff, the inspector focused on specific areas, including service users’ care, staff training and supervision. Infection control, mandatory training and adult protection were discussed with all staff interviewed. The qualified staff were also asked about wound care and demonstrated a good knowledge. One staff member had limited English and was unable to understand terms such as whistle blowing and COSHH, hence it was difficult to establish her level of knowledge about particular topics. Other staff demonstrated a reasonable knowledge in respect of whistle blowing abuse and infection control. Staff confirmed that training was provided both in house and Fairlight & Fallowfield DS0000010134.V313191.R01.S.doc Version 5.2 Page 23 externally. One staff was a key worker to a service user whose care plan had been inspected and she was aware of the service user’s needs and on going support required. Of the twelve service users giving their written comments to the CSCI, eleven confirmed that staff listened and acted on what they said. A relative commented “I find the staff caring, friendly and professional towards my [relative] and friendly and helpful to me”. Fairlight & Fallowfield DS0000010134.V313191.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The provider supplies the CSCI with copies of the monthly visits to the home. The home promotes the health and safety of its service users, staff and visitors. The acting manager’s fitness for registration is being assessed by the CSCI. EVIDENCE: At the time of the inspection visit, the acting manager was undergoing the CSCI’s assessment of his fitness to be the registered manager of the home. The CSCI has 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. Specific audits carried out regularly include accidents, which are recorded monthly for both Fairlight and Fallowfield. The audit format includes recording of the day, date and time of Fairlight & Fallowfield DS0000010134.V313191.R01.S.doc Version 5.2 Page 25 the accident, the person’s name, the cause, and any injuries sustained. This allows monitoring and identification of any trends emerging in accidents within the home. The home has appropriate procedures to safeguard service users’ financial interests. It was understood no service users’ money is held on their behalf by the home. Service users or their families are invoiced for ‘extras’, such as hairdressing and newspapers. A selection of health and safety documentation was examined and found to be up to date and within the appropriate timeframes. These included certificates for gas safety, electrical installation, legionella testing, and servicing of lifting equipment. The home had a ‘clean food award’ from Bromley Council, valid until October 2007. An environmental health inspection of the kitchen on 26/10/06 found “good general standards”. The acting manager has confirmed in writing to the CSCI that the three requirements from the fire authority (LFEPA) following their visit in March 2006 were met. It was apparent from records of fire drills that not all staff had attended a fire drill this year, including night staff, and this must be addressed. The fire alarm is normally tested each week, and had last been serviced on 11/09/06. It is recommended that the home’s “Moving and Handling Policy” be reviewed. The policy is brief and undated. It could incorporate other important factors, for example, reference to specific legislation (i.e. HASAW Act 1974; MHO Regulations 1992, revised 2002) and procedures to follow in dealing with emergencies. Although we saw no evidence during our visit that service users were being transported with hoists, the policy could also make it clear that hoists are lifting devices and not transport aids. The home’s documents “Moving and Handling Techniques” and “Moving and Handling (Blue Slings)” are both dated July 2000 and should also be reviewed to ensure they take account of the 2002 revisions to the Manual Handling Operations Regulations. Generally, the home communicates well with its service users and their families. Of the nine relatives/visitors providing written comments to the CSCI, seven confirmed they were kept informed of important matters affecting their relative/friend. One visitor stated they were not kept informed and one said being kept informed was not applicable to them. Two previous requirements under this group of standards had been addressed and met. Fairlight & Fallowfield DS0000010134.V313191.R01.S.doc Version 5.2 Page 26 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 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 X 3 X 3 X X 3 Fairlight & Fallowfield DS0000010134.V313191.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement The registered person must ensure that care plans address service users’ health and welfare needs in sufficient detail, in this instance, social and psychological needs. Previous requirement partly met – please see comment in report under this standard. Timescale for action 31/12/06 2 OP7 15 The registered person must 31/12/06 ensure that in all cases there is a care plan and supporting risk assessment for the use of bedrails, specific to the individual service user. The registered person must ensure assessments are completed for risks identified in respect of falls. The registered person must ensure the exposed pipe work in the link corridor between Fairlight and Fallowfield is either repaired or removed. The registered person must DS0000010134.V313191.R01.S.doc 3 OP3 15 31/12/06 4 OP19 23 31/12/06 5 OP38 23 31/12/06 Version 5.2 Page 28 Fairlight & Fallowfield ensure that all staff members attend a fire drill at the appropriate intervals. 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 OP5 Good Practice Recommendations The registered person should ensure it is made evident both that information is provided to service users before admission and also that trial visits take place. The registered person should ensure that when changes are made to the instructions for medicine administration, two staff should sign to agree the record is accurate. The registered person should ensure that the GP reviews the homely remedies protocol at least annually. The registered person should ensure the home’s medication policy (July 2002) and its associated documentation are reviewed and updated as necessary. The registered person should ensure that meat served with meals is sufficiently tender that service users can easily chew it. The registered person should ensure referees use either their company-headed paper for references or add the company stamp to their written reference. The registered person should ensure the home’s moving and handling policy and its associated documentation are reviewed and updated as necessary. 2 OP9 3 4 OP9 OP9 5 OP15 6 OP29 7 OP38 Fairlight & Fallowfield DS0000010134.V313191.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Sidcup Local Office 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 DS0000010134.V313191.R01.S.doc Version 5.2 Page 30 - 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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