Inspection on 10/09/07 for Fairlight Manor

This inspection was carried out on 10th September 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 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 Manor 13/05/09

Fairlight Manor 18/12/08

Fairlight Manor 14/10/08

Fairlight Manor 30/06/08

Fairlight Manor 04/12/06

Fairlight Manor 18/11/05

Fairlight Manor 22/04/05

Fairlight Manor 25/11/04

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

CARE HOMES FOR OLDER PEOPLE Fairlight Manor 48 Fairlight Avenue Telscombe Cliffs East Sussex BN10 7BS Lead Inspector Melanie Freeman Key Unannounced Inspection 10th September 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Fairlight Manor DS0000062060.V347238.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 Manor DS0000062060.V347238.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fairlight Manor Address 48 Fairlight Avenue Telscombe Cliffs East Sussex BN10 7BS 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) 01273 582786 01273 582786 ashrazpatel@btinternet.com Fairlight Manor Ltd Ashraf Patel Care Home 19 Category(ies) of Dementia - over 65 years of age (0) registration, with number of places Fairlight Manor DS0000062060.V347238.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th December 2006 Brief Description of the Service: Fairlight Manor is located in a quiet residential area of Telscombe Cliffs, near to the seafront and local shops and amenities. The property comprises of two large semi detached houses, which have been made into a single building and extended. Residents’ accommodation is presented over three floors; a passenger lift is available to all floors. The home has a large sitting room with television and stereo, with a smaller dining room situated just off, between the sitting room and the kitchen. Residents have easy access to the garden at the rear of the premises that is equipped with garden furniture and umbrellas in the summer for them to use during the fine weather. The home provides personal care and support to residents who are both privately funded and those who are funded by Social Services. The home’s fees as from 01 April 2007 range from £410.72 to £475.00 per person per week. Additional costs are charged for hairdressing; chiropody, newspapers, toiletries and contributions are requested for outside activities. The homes literature states that ‘the home is committed to working with these individuals, and believe that however impaired they are, they still deserve to be treated with respect and dignity’. Fairlight Manor DS0000062060.V347238.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Fairlight Manor care home will be referred to as ‘residents’. Fairlight Manor applied to vary its registration to accommodate residents with a dementia type illness with the Commission for Social Care Inspection last year. This was granted in March 07 and in accordance with agreed improvements with the registration team, the home has ensured that staff receive training in dementia care, and an activities co-ordinator has also been supplied although suitable training needs to be undertaken by this individual. In addition the communal areas have been improved and the garden area secured. However the bathing facilities have not been improved to provide a shower and the garden area has not been upgraded for improved resident use. All residents apart from one have a dementia type illness. The one resident who does not wishes to remain at Fairlight Manor and this choice has been respected. This was a key inspection that included an unannounced visit to the home and follow up contact with resident’s representatives and visiting social/health care professionals. The deputy manager was working in the home on the day of this visit and facilitated the inspection Mr Patel the registered manager/provider also attended and received the inspection feedback directly at the end of the day. The deputy manager has been responsible for the day to day running of the home for several months with Mr Patel overseeing management matters through him. It is unclear how much time Mr Patel is spending in the home in order to fulfil his responsibilities as the registered manager. On the day of the home assessment the inspector was able to spend much of her time meeting with residents and their visitors, talking to staff and observing practice, and noting how residents needs were being met. A tour of the premises was undertaken and a range of documentation was reviewed including the homes statement of purpose/service users guide, the assessments completed prior to admission, medication records, training records and recruitment files. In addition the care documentation pertaining to two residents were reviewed in depth. The inspector was able to eat a midday meal with the residents in the communal living area and review the arrangements for providing suitable diets. Fairlight Manor DS0000062060.V347238.R01.S.doc Version 5.2 Page 6 During the inspection visit three visitors and one visiting professional were spoken to and able to provide their views on the home and how their relatives were being cared for. Following the visit one resident’s representatives was contacted by telephone along with three social/health care professionals. In addition surveys were sent to the home to circulate none of these were returned to the inspector before the report was written. An Annual Quality Assurance Assessment completed by the home was not received before this inspection was undertaken. What the service does well: What has improved since the last inspection? What they could do better: The management of the home needs to ensure that all prospective residents are suitably assessed and that the home confirms in writing to the prospective resident or their representative that with regard to the needs assessment completed the home can meet the needs of the prospective resident. This Fairlight Manor DS0000062060.V347238.R01.S.doc Version 5.2 Page 7 ensures that decisions around admission to the home are informed and evidenced. Further attention needs to be paid to ensuring all residents care needs are fully documented and responded to in consultation with either the resident or their representative. All possible risks need to be assessed with appropriate documentation that records the interventions made to minimise these risks. Resident’s privacy and dignity must be promoted at all times with individual choices and preferences being recorded. Staff providing therapeutic activities for residents need to be appropriately trained and resourced to ensure all residents have the opportunity for appropriate social interaction. All complaints received must be recorded along with the action taken in response. The home needs to be cleaned thoroughly to ensure a good standard of cleanliness is maintained. The staffing arrangements need to be reviewed to ensure suitable staff are employed in such numbers to make sure that all residents care needs can be met. The recruitment practice needs to be improved to ensure all the necessary checks are completed by the home before staff start to work in the home. This will ensure robust recruitment practice is followed and safe guard residents. The management arrangements need to be improved to promote strong and effective management. Systems for quality auditing need to be developed with the questionnaires received being reported on and responded to and for interested parties being made aware of the findings and action taken. Robust Health and Safety systems need to be adopted and recorded to ensure staff and residents safety. 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. Fairlight Manor DS0000062060.V347238.R01.S.doc Version 5.2 Page 8 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 Manor DS0000062060.V347238.R01.S.doc Version 5.2 Page 9 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 and 6 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives have access to full and accurate information about the home to inform their choice of home. The admission procedures ensure residents are assessed prior to their admission although this is not clearly recorded by the home. Consultation with other health/social care professionals ensures that the home admits only those residents whose needs can be met. However the home does not confirm in writing to prospective residents or their representatives that the home is able to meet their needs. Intermediate care is not provided at Fairlight Manor. EVIDENCE: Fairlight Manor DS0000062060.V347238.R01.S.doc Version 5.2 Page 10 A statement of purpose and service users guide was available in the lounge area, however when Mr Patel the registered manager/proprietor arrived he advised that these documents were to be replaced and provided copies of the new documents. These were found to be informative and Mr Patel said that a copy of the service users guide would be provided to all residents and given to prospective residents at the time of their pre-admission assessment. Both these documents refer to Fairlight Manor as Nursing Home and Mr Patel said that he was aware of this and would be addressing this before they were circulated and also agreed to include a copy of the homes terms and conditions within the service users guide. A relative and Social Worker spoken to said that they had enough information about the home and services it provides and were able to visit the home on the prospective residents behalf. They also indicated that the admission procedure was smooth and well managed. When the inspector asked to see the contract arrangements for two residents these were not available and the registered manager/proprietor assured that these were in place and was reminded that these should be available in the home for inspection purposes. An assessment of the admission process followed included the review of the documentation relating to the last two admissions to the home. The assessments completed by the registered manager or deputy manager were found to be poor they did not include any evidence relating to the prospective residents needs. The documentation used was also not dated, signed and did not record where the assessment was completed or who was present. It was however noted that a comprehensive assessment had been completed by the care manager, which clearly identified the specific care needs of the prospective resident. It was also noted that the home does not provide a letter to the prospective resident or their representatives confirming that the home having taken into account the assessment of need can meet their needs and that it would be a suitable admission. These shortfalls were identified to the deputy manager and Mr Patel. Mr Patel confirmed that intermediate and rehabilitative care is not provided at Fairlight Manor. Fairlight Manor DS0000062060.V347238.R01.S.doc Version 5.2 Page 11 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 and 10 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Whilst the care documentation provides a framework for the provision of care it needs to be extended to cover individual choices preferences and risks. Resident’s health and care needs are met with evidence of regular input from health care professionals as necessary. The homes practice ensures resident’s medicines are administered safely and residents are treated with respect and usually have their privacy and dignity maintained. EVIDENCE: The care documentation pertaining to two residents were reviewed as part of the inspection process and each of these residents were met with during the inspection visit to the home. Fairlight Manor DS0000062060.V347238.R01.S.doc Version 5.2 Page 12 Each resident has a care assessment and from this care plans are developed. The care assessments are comprehensive however these need to be completed more thoroughly. The care plans are pre written and adapted to individual residents. These provide a good rationale for the identified care to be provided however the guidelines for the provision of care are not specific and record more of what needs to be assessed or taken into account before individual plans of care are written. In addition there was no clear record of residents preferences and choices or that the resident or their representative had been involved in the planning of care. It was also noted that the use of individual risk assessment was minimal for example there are no nutritional screening moving and handling assessments and although information on assessing the risk of falls is available this is not followed up with individual assessments. The care documentation recorded regular contact with health and social care professionals and a visiting community nurse confirmed that they are involved as necessary with the residents care and a relative said that they and social services were involved with ensuring appropriate care for their relative. On the whole feedback received from residents and relatives was positive about the standard of care delivered at Fairlight Manor and during the inspection visit it was clear that staff responded to residents needs in a friendly manner. Visiting professional also indicated that the care provided was appropriate and comments included ‘her care needs are being well attended to and she receives a very acceptable level of care’ ‘ the home is providing good care taking into account the residents needs’. The home has a designated locked cupboard for the storage of medication and although there are no facilities for the safe storage of Controlled Drugs Mr Patel gave his assurances that this would be provided if needed. Records on the whole were found to be accurate and meaningful and the deputy manager confirmed that he completed an audit on medicines and when some gaps on the administration charts were noted he said that he was aware and following this matter up with the appropriate staff. Some residents are on medicines on an ‘as required’ basis and the need to provide individual guidance to staff on when to give this medication was discussed with Mr Patel and the deputy manager it was also recommended that staff record the medicines received from the pharmacy. During the inspection visit it was noted that medicines were awaiting return to the pharmacy and these were being stored in the activities room, this was identified as a risk. The deputy manager was reminded that all medicines must be stored securely at all times even when awaiting collection and arrangements must be put into place to ensure this. This medicine was removed later that day. Staff were seen to be respectful to residents and visitors and care records were seen to record residents preferred term of address and staff were heard Fairlight Manor DS0000062060.V347238.R01.S.doc Version 5.2 Page 13 to use this. It was however noted that the community nurse was completing a dressing on a residents leg in a communal area when asked why she said that she would ask staff to move the resident but they did not seem to have time to do this. This matter was discussed with Mr Patel and the deputy manager along with the importance of promoting privacy and dignity of residents at all times. In addition it was noted that net curtains are not in place in residents rooms. The deputy manager said that people were offered the choice of having net curtains however the care records did not record that this choice was given. When a family member was asked if she was asked if they would like net curtaining they said that they had not been asked and they would of liked these if they had been offered. As mentioned previously residents choices and preferences are not well documented. Fairlight Manor DS0000062060.V347238.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The daily routines and activities provided meet most residents’ needs and are flexible. Residents are encouraged to keep in contact with their family and friends. Residents receive a wholesome and appealing diet. EVIDENCE: The home now provides specific time for the promotion of individual activities two hours every week day afternoon. A dedicated carer has been given this extra role and on speaking to her it was clear that she is well motivated although she has not received any training to facilitate her in this important role. During the inspection it was noted that this staff member was trying to stimulate residents with some colouring and this was not well received by residents. She is developing life histories for residents, which will help her, Fairlight Manor DS0000062060.V347238.R01.S.doc Version 5.2 Page 15 develop appropriate individual meaningful activity. She is aware that residents enjoy walks to the sea and shopping and time for these trips should be made available. Mr Patel said that some outside entertainment is also provided and a visitor to the home came to the home with her dog that the residents loved to see and touch. The home has a garden and an area separate to the home that is to be used more for the promotion of activities. Mr Patel said that the garden is to be improved for resident use and it was noted that on the day of this visit despite it being a warm day the garden was not well used. Visiting is well promoted and encouraged with no restrictions and it was noted that visitors are well received and always offered a drink. Residents are able to bring in personal possessions in the home. The meals were well complimented and there is strong emphasis on quality home cooking with fresh produce. The meal eaten with residents was served in the communal dining area and was attractive and well enjoyed by the residents. It included roast beef, roast potatoes, Yorkshire pudding, and fresh vegetables. The inspector was told that the home is recruiting a new chef and meantime a carer with catering qualifications achieved abroad is working as a cook. It is unclear if these qualifications are transferable and the arrangements for pest control in the kitchen were also unclear and Mr Patel was asked to contact the Environmental Health Department about these issues. Fairlight Manor DS0000062060.V347238.R01.S.doc Version 5.2 Page 16 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 and 17 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has suitable arrangements to deal with complaints made to it however the records relating to complaints need to be full and demonstrate action taken when concerns are raised. Procedures available in the home ensure that adult protection issues when raised would be responded to appropriately. EVIDENCE: The home has a suitable complaints policy and procedure, which is made available to residents and their representatives. Mr Patel was reminded to ensure the correct address for the CSCI is recorded. Following discussions with relatives and the deputy manager it was identified although concerns around the conduct of some staff were raised and dealt with by the home there were no records to confirm the concern or the action taken in response to the concern. The deputy manager who has been working in the capacity of the home manager needs to ensure appropriate record keeping is maintained. Fairlight Manor DS0000062060.V347238.R01.S.doc Version 5.2 Page 17 Complaint records did demonstrate that there had been one formal written complaint that was sent on to the home from the CSCI. This complaint had been investigated and the complainant had been responded to. Staff, residents and relatives spoken to said that they would feel happy to raise any issue and thought that this would be dealt with in a satisfactory way. The home has an in depth adult protection procedure to facilitate prompt reporting if an allegation or suspicion of abuse if it occurred. The new local Safeguarding Adults procedures were discussed and Mr Patel who agreed to get a copy of this document. Staff spoken to had a good understanding of the possible abuses and felt confident with the leadership that would be provided by the deputy manager and registered manager. Fairlight Manor DS0000062060.V347238.R01.S.doc Version 5.2 Page 18 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, 21, 25 and 26 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Fairlight Manor provides residents with a homely and pleasant environment. The standard of cleanliness needs to be improved to ensure a high standard at all times in all areas. EVIDENCE: The home was found to be maintained to a satisfactory level and it was confirmed that one bathroom is to be upgraded before the end of the year to provide a fully assisted shower facility. The home has a light and airy feel to it and provides a pleasant environment for residents. All rooms are single apart from one used as a shared room. Fairlight Manor DS0000062060.V347238.R01.S.doc Version 5.2 Page 19 The garden has been made secured since the last inspection and the change of the homes registration to accommodate those residents with a dementia type illness. Mr Patel said that he intends to improve the garden area further to make it more suitable for the residents in the home. This is to be progressed by the end of the year. The communal area is attractive and allows for flexible use and provides a lounge area and dining room area. During the visit it was noted that one radiator in a bedroom was unguarded and the deputy manager arranged to have this guarded immediately. He also confirmed that all radiators on the top floor are low surface temperature radiators and are therefore safe for residents. It was later noted that there was unguarded radiators in the communal bathroom and toilet areas; this was identified to Mr Patel and the deputy manager. Mr Patel agreed to risk assess all radiators the next day. Contact from Mr Patel the day following this inspection visit confirmed that he had completed risk assessment and that all radiators that could be a risk had been turned off and would be guarded in the near future. During the inspection it was noted that two floor carpets were particularly badly stained one with faeces and one with blood. The deputy manager explained that the homes shampooer had broken down and a new one had been ordered and was expected to arrive on the previous Saturday. He later confirmed that it had arrived and would be used to ensure the all stains are dealt with as a priority. The standard of cleanliness in the home was seen to be generally satisfactory however there were some areas that clearly needed deep cleaning. When this was discussed it was identified that the home does not have a cleaner. The care staff do all the cleaning and laundry duties in the home. The laundry room is very small and Mr Patel said he was thinking about moving the laundry into the garage area. The staff said that there was a lot of laundry to complete and this made things difficult in the mornings, as they tended to be busy. All laundry was seen to be dealt with appropriately and residents were well dressed. Fairlight Manor DS0000062060.V347238.R01.S.doc Version 5.2 Page 20 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 and 30 People who use the service experience poor outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staffing arrangements allow for staff to be suitably trained although the staffing numbers need to be reviewed to ensure staff can meet all the care needs of residents. The recruitment practice was found to be inconsistent with robust procedures not being followed. EVIDENCE: At the time of this inspection visit 18 residents were living at Fairlight Manor. The deputy manager confirmed that the staffing levels provided two care staff and one senior carer during the day and two care staff who are awake at night. The day care staff include the deputy manager in the mornings and the activity person in the afternoon. In addition the care staff are completing all the laundry duties cleaning and evening catering duties. This clearly puts the care staff under some pressure depending on the care needs of the residents and the staffing levels must be kept under review to ensure suitable staffing is maintained and that all residents care needs are met. Fairlight Manor DS0000062060.V347238.R01.S.doc Version 5.2 Page 21 Staff spoken to confirmed that the completion of non caring duties like laundry and cleaning do impact on the care and their comments included ‘The laundry causes extra work which effects time for residents. The mornings are hectic’ ‘the laundry takes up a lot of time and spring cleaning is needed’ ‘some residents are woken up to fit in with the staffing arrangements’. Discussion with staff and residents identified that all residents are up and dressed by 08.00 am apart from one or two. It was unclear if this was due to resident preference or in response to the staffing arrangements, as resident’s preferences on this matter are not recorded. This issue was discussed with Mr Patel who said that he would review the staffing and the time that residents get up in the mornings. The duty rotas seen did not clearly identify what each member of staff was working or in what role and the deputy manager said that he would in future ensure that the records are clearer. Feedback from residents and all visitors to the home was positive about the staff working in the home who on the whole were said to respond to residents in a caring, skilled and respectful manner. Comments received included ‘staff have a nice approach to residents and interaction is good’ ‘I have found the staff well informed regarding the care and specific care needs of residents and they seem appropriately trained’. There was evidence that staff training was being progressed in some areas this needs to be formalised to evidence all relevant training is provided. It was confirmed that most staff are undertaking a distance-learning course on the care of people with dementia along with completing a National Vocational Qualification in care level 2. Mr Patel also confirmed that he was aware of ‘the skills for care’ induction standards and he had training packs to be progressed. The recruitment files pertaining to three staff members were reviewed as part of the inspection process and identified that the recruitment practice was not robust and needs to be improved to ensure robust procedures are followed, the following shortfalls were identified. • None of these staff had any evidence that references were obtained. • Only one of the three staff members had terms and conditions of employment. • Only one staff member had evidence of any staff induction. • There was no evidence that staff had been given a copy of the GSCC. • Not all staff had a photograph. Once Mr Patel was made aware of these shortfalls he confirmed that he would be following up with identifying all employees who had been employed without a reference and sourcing two verbal references to be followed up with written references. Verbal references he assured would be gained on the day following the inspection visit. Written confirmation was received from Mr Patel the next day that he had secured these references. Fairlight Manor DS0000062060.V347238.R01.S.doc Version 5.2 Page 22 Fairlight Manor DS0000062060.V347238.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Fairlight Manor is run in a friendly manner although the current management arrangements are not providing an appropriate management structure. Systems are being developed to monitor the quality of care provided. The health, safety and welfare of residents and staff are not well protected in all areas. Resident’s financial interests are safeguarded. EVIDENCE: Although Mr Patel is the registered manager of the home it was clear from discussion with staff and relatives that he is not in the home very often and Fairlight Manor DS0000062060.V347238.R01.S.doc Version 5.2 Page 24 the responsibility of the day to day management has been allocated to the deputy manager. The deputy manager has worked as a deputy manager for two years and is completing the Registered Mangers Award to develop his care and management skills. He works in the home Monday to Friday but is included in the care staffing numbers each morning. This inspection visit has identified a number of shortfalls in respect of the management for example the recruitment and health and safety practice in the home. Mr Patel needs to ensure the management arrangements are appropriate and that the deputy has the skills and time to manage the home effectively. Observation confirmed that the deputy manager and the registered manager had a good rapport with staff, residents and relatives. Staff spoken too during the inspection visit indicated that although they have staff meetings and supervision they do not think that staff listen to each other and there is no team spirit. The homes management need to look at ways to improving this to get the best out of the staff working in the home. Systems to monitor the quality of services are being developed and the deputy manager explained that he has started an auditing system that looks at medicines, care documentation and facilities. In addition the home is using residents and relative questionnaires, which now need to be audited and reported on. Discussion took place around extending the use of questionnaires to staff and other visitors to the home and the feeding back of information to all interested parties. Mr Patel confirmed that the home has no dealings with resident’s monies and that any extras costs incurred are paid by the home and then individually invoiced on a 3 monthly basis. Records relating to Health and Safety in the home were reviewed and it was noted that a fire risk assessment had been completed and the electrical safety certificates were available along with the passenger lift thorough examination. A number of health and safety shortfalls were also noted; • • • • • • • No environmental risk assessments were available. The stairs do not have a safety gate at the top to stop residents falling down them. A number of unguarded radiators were noted. The hot water supplied to areas accessible to residents is not being checked. The home does not have a safe bathing policy The home does not have a prevention of Legionnaires disease procedure The home does not have a health and safety policy. Fairlight Manor DS0000062060.V347238.R01.S.doc Version 5.2 Page 25 Mr Patel was made aware of these shortfalls and confirmed that he would check all hot water accessible to residents, ensure appropriate risk assessments in relation to the stairs, radiators and any hot water identified the very next day to ensure resident safety. Contact with Mr Patel and the deputy manager following the inspection visit confirmed that action had been taken to address the health and safety risks in the home. Following the inspection visit the inspector contacted the Environmental Health Department to advise them of the concerns identified in respect to the Kitchen and hygiene and health and safety. Fairlight Manor DS0000062060.V347238.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 2 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X 2 2 STAFFING Standard No Score 27 2 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 1 Fairlight Manor DS0000062060.V347238.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 OP2 Regulation 17(2) Requirement That a record of the terms and conditions of residency agreed with each resident or their representative is held in the home. That a full needs assessment is completed by a competent person for each perspective resident and following this if an admission is thought to be appropriate the home confirms in writing that having regard to the assessment made that the home can meet those needs. That individual care plans providing specific guidance for staff to follow is devised for each resident in consultation with the resident or their representative. That individual risk assessments that cover all residents risk are recorded and responded to. These should include risk of falls, nutritional screening, moving residents and pressure sore development. That staff ensure that the privacy and dignity of residents is promoted at all times and that DS0000062060.V347238.R01.S.doc Timescale for action 01/10/07 2. OP3 14(1) 01/10/07 3. OP7 15 01/12/07 4. OP8 13 01/11/07 5. OP10 12(4) 01/11/07 Fairlight Manor Version 5.2 Page 28 privacy curtains (net curtains) are provided to all windows if wanted. 6. OP12 16 That staff providing activities are suitably trained and resourced to provide meaningful individual activity and entertainment. That all complaints are recorded and clearly record the action taken in response. The radiators identified as requiring replacement covers or repair to covers to be addressed. (outstanding from last inspection with a completion date of 22/12/06) That the standard of cleanliness in the home is improved to ensure all areas in the home are maintained at a high standard and that any accidents are dealt with quickly. That the staffing numbers and skills are reviewed to ensure appropriate to meet the assessed needs of residents in the home. Staff files to show all relevant information relating to recruitment, qualifications and training. (outstanding from last inspection with date of 15/01/07 not met) That appropriate references are sourced for all employees before employment. 12. OP31 10 That the management 01/10/07 arrangements ensure the home is run in an effective manner and ensures the aims and objectives of the home are met. That the information gathered 01/12/07 for quality monitoring is reported on made available to interested parties with recorded evidence of DS0000062060.V347238.R01.S.doc Version 5.2 Page 29 01/12/07 7. 8. OP16 OP25 22 13(4)abc 01/10/07 01/11/07 9. OP26 13 01/10/07 10. OP27 18 01/10/07 11. OP29 17(3)b 01/10/07 13. OP33 24 Fairlight Manor 14. OP38 12 (1) 13 (5) action taken in response to demonstrate ongoing review and improvement to the quality of care and services in the home. That robust health and safety practice is adopted to include clear polices and procedures and thorough environmental risk assessment that are actioned as necessary. 01/10/07 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 OP9 Good Practice Recommendations That suitable storage facilities are provided for medicines at all times to include controlled drugs. That clear criteria guidelines for medicine prescribed on a ‘when require’ basis are provided. All information relating to individual residents to be kept in the home and available for inspection e.g. resident contracts of tenancy. 2. OP37 Fairlight Manor DS0000062060.V347238.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Fairlight Manor DS0000062060.V347238.R01.S.doc Version 5.2 Page 31 - 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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