Inspection on 18/11/05 for Fairlight Manor

This inspection was carried out on 18th November 2005.

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

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

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 10/09/07

Fairlight Manor 04/12/06

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 Fairlight Manor 48 Fairlight Avenue Telscombe Cliffs East Sussex BN10 7BS Lead Inspector Kevin Whatley Unannounced Inspection 08:00 18 November 2005 th 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.V249115.R01.S.doc Version 5.0 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.V249115.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Fairlight Manor Address Fairlight Manor 48 Fairlight Avenue Telscombe Cliffs East Sussex BN10 7BS 01273 582786 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) Fairlight Manor Ltd Ashraf Patel Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Fairlight Manor DS0000062060.V249115.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The number of people accommodated must not exceed 15 The people accommodated will be aged 65 years or over on admission Date of last inspection 22nd April 2005 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 ammenities. The property comprises of two large semi detached houses, which have been made into a single building and extended. Residents accommodation is presented over two floors; a lift is available to all floors. There are nine single and three double rooms, although none of the double rooms are being used to accommodate more than one resident. There are currently no en suite facilities. The home have a large lounge area with TV and stereo, with a smaller dining room situated near by. Residents have easy access to the garden at the rear of the premises. Building work has recently begun to add three aditional bedrooms to the second floor of the home. Fairlight Manor DS0000062060.V249115.R01.S.doc Version 5.0 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 will be referred to as ‘residents’. The unannounced inspection took place on a weekday in November beginning at 8am and lasting for approximately five hours. At the time of the inspection the home was accommodating thirteen residents. The inspection included a tour of the premises and it’s facilities, with many residents also consenting for their bedrooms to be viewed. Approximately four residents were spoken with individually, whilst others commented on their care during the visit. The provider/manager, his deputy manager and two members of care staff were spoken with during the visit; whilst care staff were also observed carrying out their duties. A relative who visiting a resident at the time was also spoken with during the inspection as were the builders undertaking the extension work on the second floor of the home. A number of records and documentation as required by registration were also inspected. What the service does well: Fairlight Manor continues to offer residents a caring, homely, and relaxed environment that places their needs first. The home ensures that no resident is admitted without first fully assessing their care needs, such needs are incorporated into a robust system of care planning. Residents have the opportunity to participate in activities and events. Residents are protected from the risk of harm by suitable adult protection procedures, whilst the views of residents are listened to and acted upon. Residents have input into the decoration of their home. Care staff at the home are competent, caring, and committed to providing a high level of care, whilst the management approach of the home remains positive, inclusive and supportive. Fairlight Manor DS0000062060.V249115.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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 Manor DS0000062060.V249115.R01.S.doc Version 5.0 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 Manor DS0000062060.V249115.R01.S.doc Version 5.0 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 and 4. The homes statement of purpose and service user guide need to be reviewed and amended to ensure prospective residents, their relatives/carers and others have access to suitable information regarding the home. Fairlight Manor ensures that no resident is admitted to the home without first having their care needs fully assessed. EVIDENCE: The previous report made a requirement that the homes statement of purpose and service user guide needed to be updated to include all the necessary information as required by legislation. The proprietor/manager acknowledged that this is still an outstanding matter but wished the three new bedrooms, currently being built, to be completed so that all new rooms and facilities can be included in a ‘revised’ statement of purpose and service user guide. A number of residents files were viewed, notably those residents most recently admitted to the home. All documentation seen confirmed that the home carry out full needs assessments of prospective residents prior to them being offered a place at Fairlight Manor with either the proprietor/manager or his deputy visiting prospective residents prior to admission to carry out assessments. Fairlight Manor DS0000062060.V249115.R01.S.doc Version 5.0 Page 9 Such assessments address the resident’s physical, emotional, social, and health care needs prior to being admitted. Evidence was found that the home also complete a pre-admission questionnaire which includes sections for relevant social care and emotional well being. Pre-admission documentation also contained relevant information from G.P’s, Social Services departments, and hospitals. One of the most recently admitted residents stated that they had been visited by the proprietor/manager ‘a week or two’ before being admitted. Resident’s files also contained contracts of residency including the terms and conditions of their stay, all of these had been signed and in some cases counter signed by their relative or next of kin. Fairlight Manor DS0000062060.V249115.R01.S.doc Version 5.0 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, 9 and 10. The home ensures that the assessed needs of each individual resident are incorporated into appropriate plans of care. The home have a suitable medicine storage and administration system and have implemented a monitoring format to ensure residents benefit from consistent medicine care. Residents are treated with respect, dignity, and care. EVIDENCE: A number of residents care plans were viewed, these were found to contain up to date and accurate information regarding the assessed needs of residents. Several newly admitted residents care plans clearly identified their physical needs such as medical history and current issues with clear guidance on how these needs will be met, they also contained details of the residents mobility and emotional needs including issues associated with dementia type illness. All care plans contained risk assessments regarding the homes environment and the individual issues residents have such as the risk of falls and poor comprehension. All care plans viewed were legible, relevant, and well prepared, with evidence of daily log recordings and monthly reviews. The homes medicine administration records were viewed, this confirmed that the home have a suitable system of recording in place including details of the Fairlight Manor DS0000062060.V249115.R01.S.doc Version 5.0 Page 11 type of medicines that are prescribed to each resident, when these have to be given, and when medicines are administered by care staff. Since the last inspection the management team have started to carry out regular monitoring of the homes system of medicine storage and administration. Evidence was found of an error previously being found by the deputy manager with the member of care staff in question subsequently being given advice and guidance regarding the importance of accurate records etc. All records viewed were up to date and accurate. Observations of the level of interactions between care staff and residents found that care staff respond in a caring and sensitive manner to residents needs. It was clear that care staff have known many of the residents for sometime and subsequently know their individual care needs very well. All residents spoken with commented positively on the care they receive from staff and stated that ‘care staff are lovely’ and ‘caring’. Fairlight Manor DS0000062060.V249115.R01.S.doc Version 5.0 Page 12 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 and 13. Care staff at Fairlight Manor actively seek to involve residents in daily routines and activities, though the programme of regular activities should be reviewed. Residents are supported and encouraged to maintain contact with others outside of the home. EVIDENCE: Meal times are clearly displayed around the home and are set at appropriate periods of the day. Residents noted that the times of meals are ‘reasonable’ whilst the mealtimes are ‘relaxed and unhurried’. The home have a programme of activities with events taking place every day including bingo and quizzes. The activities programme also includes physical stimulation during the afternoon including hand massage, foot spas, and static/seating aerobics. Several residents commented that some of the planned activities do not take place, whilst others stated that the events are ‘somewhat boring’. The proprietor/manager acknowledged that he is the process of reviewing the programme. Nevertheless residents still enjoy monthly visits by a qualified aroma-therapist and a monthly church service. During the summer the home arranged trips out to Eastbourne and Brighton with many residents being assisted with wheelchairs to allow them to move around better. The proprietor/manager Fairlight Manor DS0000062060.V249115.R01.S.doc Version 5.0 Page 13 stated that he had arranged for a suitably equipped minibus to ensure the comfort of residents on both days. A photo album of the trips has now been completed by a member of care staff and is available for all to view. A number of events have also been planned to take place at the home during the Christmas period including a resident’s party, a carol service by local school children, a visiting pantomime and a local singer. The home has a relaxed visitors policy and many residents commented that friends and relatives can visit them whenever they wish within reason. One visiting relative stated that she is always made to feel ‘very welcome’ by the home. The visitor’s book confirmed that residents are visited regularly and at reasonable times of the day. Fairlight Manor DS0000062060.V249115.R01.S.doc Version 5.0 Page 14 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 and 18. Fairlight Manor has a robust system in place to ensure residents views, concerns or complaints are listened to, whilst adequate information is available for those outside of the home. The home have improved their procedures to ensure residents are protected from the risk of harm, neglect, or abuse. EVIDENCE: The homes complaints procedure was viewed, this confirmed that since the last inspection the details of the policy have been amended and now includes comprehensive information regarding the manner in which any complaint will be addressed, the length of timescale that any complaint must be dealt with and the contact details of CSCI. Residents stated that should they have any concerns or complaint that they felt able to inform a member of care staff or the proprietor/manager. The homes complaint book confirmed that a couple of concerns had been expressed from residents since the last inspection, however these were all of a minor level and were seen to have been appropriately addressed by the management team. The CSCI have not received any complaints regarding the service since the last inspection. The home have a suitable policy on adult protection, which includes a ‘whistle blowing’ approach. A copy of the East Sussex Area Adult Protection Protocol is kept in a communal area. The previous report made a requirement that all care staff must undertake adult protection training. Since this time both the proprietor/manager and his deputy have recently undertaken adult protection ‘train the trainer’ training; this now entitles the home to carryout their own in-house adult protection Fairlight Manor DS0000062060.V249115.R01.S.doc Version 5.0 Page 15 training. The proprietor/manager stated that all care staff will now work through the adult protection course being assessed by him and his deputy. All care staff spoken with displayed a clear understanding of relevant adult protection concerns and the manner in which these must be addressed. Fairlight Manor DS0000062060.V249115.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 25 and 26. The home continues to offer residents a homely, clean, and pleasant environment. The home must ensure that the premises are assessed to meet the needs of residents. EVIDENCE: As previously mentioned Fairlight Manor is currently having building work carried out on the second floor of the premises to incorporate three new bedrooms. The builders were spoken to and displayed a sensitivity toward carrying out such work above the existing residents home and confirmed that a majority of the work involves utilising roof access and therefore the need to transport building materials through the main building is greatly reduced. Several residents noted that they had been informed by the proprietor/manager ‘well in advance’ of the building works beginning that there may be some disruption, though confirmed that to date they had not been ‘bothered’ by any noise or distraction caused by the builders. Where concerns had been expressed it appears these have been adequately responded to by the management team. It is planned that most existing areas of the home will remain un-altered by the construction. Fairlight Manor DS0000062060.V249115.R01.S.doc Version 5.0 Page 17 A number of residents agreed for their rooms to be viewed and these were seen to be in good order having been personalised with photo’s, pictures and ornaments. The home have adequate numbers of communal toilets and bathrooms on both levels of the home. The home have reasonable communal area space including a large lounge with TV and stereo, and a smaller dining area; whilst there is a large garden to the rear of the property with easy access for all residents. Since the last inspection the dining area has been re-painted, with residents choosing the colours. The home was found to be clean, tidy, hygienic and free from any odours or smells. Records viewed confirmed that fire safety checks had been carried out though it was unclear how regularly fire drills had taken place. Records also indicated that the necessary fire safety equipment had been maintained in a suitable condition by a certified engineer. The last inspection report made a recommendation that the premises should be assessed by an Occupational Therapist to ensure that all areas offer residents suitable movement and accessibility. The proprietor/manager stated that this will be completed when the current building works are completed to enable the whole building to be assessed. Fairlight Manor DS0000062060.V249115.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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 and 30. The assessed needs of residents are met by the numbers and skills of care staff deployed at the home. Care staff are experienced, competent, and caring. EVIDENCE: The rota was viewed and this indicated that there were three members of care staff on duty during the day, with additional support from the proprietor/manager, whilst the home operates a system of having one ‘waking night’ and one ‘sleep in’ member of care staff on duty during the night. Since the last inspection the home have employed another cook, this now affords residents the benefit of having a full time cook on duty every day of the week, and subsequently allows care staff the opportunity to focus on care tasks. Residents stated that care staff were ‘caring’ and ‘patient’ at their jobs and ‘most kind’ when assisting them. No residents spoke negatively about care staff and indeed it was clear that there is a high level of mutual respect. All staff observed were seen to be competent, knowledgeable, and caring. Many of the care staff employed at the home have worked at Fairlight Manor for a number of years and are subsequently experienced in providing care to older people. The home have implemented an induction and training programme that focuses on care staff attending training in all relevant areas of care including Health and Safety and Fire Safety, Care Planning, Personal Care, Medicine Administration, and Communicating with Residents. Fairlight Manor DS0000062060.V249115.R01.S.doc Version 5.0 Page 19 Fairlight Manor DS0000062060.V249115.R01.S.doc Version 5.0 Page 20 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, 32, 33, 36 and 38. The approach taken toward running the home ensures that the atmosphere is homely, caring and relaxed. Residents benefit from a home that is run with their interests put first, whilst care staff are themselves supported to carry out their duties. EVIDENCE: The proprietor/manager took over ownership of Fairlight Manor just over a year ago. Residents and staff alike stated that the home is ‘well run’ and that the standard of care has been maintained since the takeover, and in many respects has ‘improved’. Residents commented positively on the manner that the home is managed and noted that should they have any problems that they feel able to speak to the proprietor/manager or senior staff. One relative stated that the home is ‘really good’ and felt that the management team have been ‘brilliant’ in caring for their relative and keeping them informed of any issues ‘big or small’. Fairlight Manor DS0000062060.V249115.R01.S.doc Version 5.0 Page 21 The home now has a clear staffing structure in place from the proprietor/manager to his deputy and senior carer and care staff. Some tasks are delegated and care staff, many of whom had worked at the home for a number of years, stated that they felt the changes that have been made have generally been ‘very positive’. The atmosphere in the home throughout the inspection was found to be relaxed, open and supportive with committed care staff obviously seeming at ease in the environment. Since the last inspection the management team have begun to implement a suitable system of formal supervision for care staff. The proprietor/manager has delegated formal supervision to his deputy and senior carer, both of whom have recently completed supervisory training. Care staff noted that they felt ‘extremely supported’ by the management team and stated they were encouraged to utilise their own skills and experience for the benefits of residents. Staff also commented that they are supported to undertake ‘as much training as possible’ to ensure they meet the needs of residents and their particular care related interests. All records relating to residents and staff are kept securely in the office, whilst the homes policies and procedures are suitably stored in the same area. All records viewed were legible, up to date, and accurate. Documentation seen in regard health and safety within the home, including the fire log and accident book contained necessary and up to date information. Some confidential information has been removed from the home whilst the building works take place and stored at the proprietor/manager’s home for safe keeping. Fairlight Manor DS0000062060.V249115.R01.S.doc Version 5.0 Page 22 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 2 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 2 3 X 3 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 X 3 Fairlight Manor DS0000062060.V249115.R01.S.doc Version 5.0 Page 23 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4(c) Requirement That the homes statement of purpose and service user guide must include all information as required in schedule 1 of the Care Homes Regulations 2001 (outstanding from the previous inspection). That the home must ensure that all staff undertake the adult protection awareness training (outstanding from the previous inspection). That the home must have the environment assessed by an Occupational Therapist. Timescale for action 18/05/06 2 OP18 13(6) 18/05/06 3 OP22 23(2)(a) 18/05/06 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 OP12 Good Practice Recommendations That the homes activities programme be reviewed to ensure residents benefit from choice and opportunities to participate in activities and events on a regular basis. DS0000062060.V249115.R01.S.doc Version 5.0 Page 24 Fairlight Manor Fairlight Manor DS0000062060.V249115.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Manor DS0000062060.V249115.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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