Inspection on 22/04/05 for Fairlight Manor

This inspection was carried out on 22nd April 2005.

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 10/09/07

Fairlight Manor 04/12/06

Fairlight Manor 18/11/05

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 Kev Whatley Unannounced 22 April 2005 10:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Fairlight Manor H59-H10 S62060 Fairlight Manor V218591 220405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Fairlight Manor Address 48 Fairlight Avenue Telscombe Cliffs East Sussex BN10 7BS 01273 582786 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Fairlight Manor Ltd Mr Ashraf Patel Care Home only 15 Category(ies) of Old age, not falling within any other category registration, with number (OP) 15 of places Fairlight Manor H59-H10 S62060 Fairlight Manor V218591 220405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 1. The number of service users accommodated must not exceed fifteen (15). 2. The people accommodated will be aged sixty-five (65) years and over on admission. Date of last inspection 25 November 2004 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. Fairlight Manor H59-H10 S62060 Fairlight Manor V218591 220405 Stage 4.doc Version 1.20 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 May and lasted for approximately five hours. At the time of the inspection the home was accommodating fourteen 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 several others commented on their care during lunchtime after the Inspector had been invited to join them for the meal. The provider/manager, and two members of care staff were spoken with during the visit; whilst care staff were also observed carrying out their duties. Two friends and a relative, who were all visiting residents, were also spoken to during the inspection, as was a visiting District Nurse. Records and documentation inspected included: The homes statement of purpose and care staff induction and training plan 2005/06, residents files, residents care plans, the homes complaints and accident books, whilst various policies and procedures were also viewed. What the service does well: Fairlight Manor offers residents a caring, homely, and relaxed atmosphere. The home ensures that no resident is admitted without first confirming that they can meet their needs. The home maintains good levels of communication with prospective residents, relatives and carers. The home meets the dietary needs of residents with a balanced, varied, and nutritious menu. The home have a high standard of care planning and review, that clearly describes how the residents needs are to be best met. Care staff encourage residents to participate in the homes routines and activities and take a positive approach toward stimulating residents. Care staff at the home are competent, caring, and committed to providing a high level of care. The management approach of the home is positive, inclusive, and supportive. Fairlight Manor H59-H10 S62060 Fairlight Manor V218591 220405 Stage 4.doc Version 1.20 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Fairlight Manor H59-H10 S62060 Fairlight Manor V218591 220405 Stage 4.doc Version 1.20 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Fairlight Manor H59-H10 S62060 Fairlight Manor V218591 220405 Stage 4.doc Version 1.20 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3, and 4. The homes statement of purpose and service user guide needs to offer prospective residents, their relatives, and carers, more detailed information about Fairlight Manor and the services it offers. The home ensures that residents needs can be met prior to being accommodated. EVIDENCE: The homes statement of purpose and service user guide was viewed and was seen to set out the homes philosophy of care in a clear, concise, and easy to understand manner. They also contained general information about the home and the services it offers. However these documents did not contain all the required information such as details of staff numbers and qualifications, the homes actual environmental layout, and the contact details of the Commission for Social Care inspection (CSCI). Residents files confirmed that the home carry out full needs assessments of prospective residents prior to them being offered a place at Fairlight Manor. This includes the proprietor/manager visiting residents at their homes or in hospital to assess their physical, emotional, social, and health care needs prior to being admitted. Evidence was found that the home also complete a preadmission questionnaire which includes sections for relevant social care and Fairlight Manor H59-H10 S62060 Fairlight Manor V218591 220405 Stage 4.doc Version 1.20 Page 9 emotional well being; several of these had been completed by relatives and carers. Pre-admission documentation also contained relevant information from G.P’s, Social Services departments, and hospitals. A relative spoken with confirmed that the home had kept them informed throughout the referral and admission process, and stated that the proprietor/manager had visited their relative in hospital to undertake a needs assessment. The relative also confirmed that they were made fully aware that admission to the home was initially on an eight week trial basis, stating that the home had been ‘excellent’ and ‘very supportive’. Fairlight Manor H59-H10 S62060 Fairlight Manor V218591 220405 Stage 4.doc Version 1.20 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, and 10. Since the last inspection the home have improved it’s system of care planning to ensure the care needs of residents are properly met. The home must ensure that the recording of medicine administration is accurate. Residents are treated with respect, dignity, and care. EVIDENCE: A number of residents care plans were viewed, these were seen to have been improved since the last inspection with a new format being used that clearly identifies the assessed needs of residents whilst clarifying how such needs are to be met by care staff. These included day to day personal care needs such as bathing, dressing, mobility, health care, and emotional and social needs. All care plans viewed were legible, relevant, and well prepared, with evidence of daily log recordings and monthly reviews. Files also contained completed risk assessments regarding residents mobility, health care, and mental comprehension and awareness. The homes medicine administration records were also viewed and a suitable system of recording is in place including details of the type of medicines that are prescribed to each resident, when these have to be given, and when medicines are administered by care staff. However there were several entries that had either not been completed correctly, or were not up to date. Fairlight Manor H59-H10 S62060 Fairlight Manor V218591 220405 Stage 4.doc Version 1.20 Page 11 Care staff were observed to interact in a caring, respectful, and considerate manner with residents, and it appeared care staff have very good relationships with residents in their care. Residents stated that care staff were ‘lovely’ and ‘very helpful’. Fairlight Manor H59-H10 S62060 Fairlight Manor V218591 220405 Stage 4.doc Version 1.20 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 standard(s) 12, 13, 14, and 15. Care staff at Fairlight Manor actively seek to involve residents in the daily routines and activities of the home. Residents are supported and encouraged to maintain contact with others outside of the home. The home meets the dietary needs of residents. EVIDENCE: Meal times are clearly displayed around the home and are set at reasonable periods of the day. The home have recently implemented a programme of regular 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. Care staff were seen to encourage and engage residents to participate and it was clear that those residents taking part enjoyed the stimulation and attention. Other regular events include weekly services, which are held at the home. The home have also implemented resident meetings. Visitors to the home stated that they always ‘felt welcome’ when they visit and noted that visiting times are ‘relaxed’ allowing residents flexibility and choice of when they can have visits from family and friends. The visitors book confirmed that residents are visited regularly and at reasonable times of the day. Fairlight Manor H59-H10 S62060 Fairlight Manor V218591 220405 Stage 4.doc Version 1.20 Page 13 The Inspector was invited to have lunch with the residents, this took place in a small yet suitable dining room setting. The lunch was well prepared, nutritious, and tasty. The menu was viewed and this confirmed that the home offer a varied and balanced diet to residents, including a daily meal alternative. Fairlight Manor H59-H10 S62060 Fairlight Manor V218591 220405 Stage 4.doc Version 1.20 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 standard(s) 16 and 18. The home must ensure that sufficient information is provided for residents to express any concerns or complaints. The home must have procedures in place to protect residents from the risk of harm, neglect, or abuse. EVIDENCE: The homes complaints procedure was viewed, this was found to lack the necessary details of the manner in which any complaint must be addressed, including 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. Since the last inspection the home have implemented a staff induction programme that includes Care Management and the Protection of Vulnerable Adults (POVA), however not all care staff have yet undertaken such formal training. Staff spoken to all had a clear and knowledgeable understanding of adult protection maters and displayed a competent approach to adult protection procedures. Fairlight Manor H59-H10 S62060 Fairlight Manor V218591 220405 Stage 4.doc Version 1.20 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 24, 25, and 26. The homes offers residents a homely, clean, and pleasant environment. The home must ensure that the premises are assessed to meet the needs of residents. EVIDENCE: Fairlight Manor has been maintained to a good structural order both inside and out and has been decorated to a standard that is both homely and relaxed. 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. The home was found to be clean, tidy, hygienic and free from any odours or smells. Fairlight Manor H59-H10 S62060 Fairlight Manor V218591 220405 Stage 4.doc Version 1.20 Page 16 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. It would appear that it has been several years since an environment assessment had been carried out by an Occupational Therapist. Fairlight Manor H59-H10 S62060 Fairlight Manor V218591 220405 Stage 4.doc Version 1.20 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 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. The home must develop it’s induction and training programme to ensure that residents are protected from any risk of harm, neglect, or abuse. 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. Residents stated that care staff were ‘extremely caring’ and ‘brilliant’ at their jobs and none spoken to had any complaints as to the level or quality of care they receive at the home. 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 recently 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. However no evidence could be found of staff undertaking compulsory adult protection training as part of their induction. Fairlight Manor H59-H10 S62060 Fairlight Manor V218591 220405 Stage 4.doc Version 1.20 Page 18 The home currently employ five members of care staff who have achieved a National Vocational Qualification (NVQ) level 2 in Care, whilst six others are currently undertaking the award. Fairlight Manor H59-H10 S62060 Fairlight Manor V218591 220405 Stage 4.doc Version 1.20 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36, and 38. The management approach of the home creates a homely, caring, and relaxed atmosphere. The management team need to implement a system of formal staff supervision. EVIDENCE: The current ownership and management of Fairlight Manor was taken on by Mr Patel in October 2004. The atmosphere within the home was relaxed, caring, and thoughtful with existing and new members of staff stating that they felt the takeover of the home had taken place without causing undue concern or distress to the lives of residents. Staff spoke positively about the management of the home and the changes implemented so far, noting that they felt supported by the proprietor/manager. No residents spoken to had any negative comments to make in regard the manner in which the home is managed, and indeed stated that the levels of care within the home have been maintained and ‘improved’ since the takeover. Fairlight Manor H59-H10 S62060 Fairlight Manor V218591 220405 Stage 4.doc Version 1.20 Page 20 A draft system for the formal supervision and appraisal of staff was seen which appeared to be suitable, however there was no evidence of any formal staff supervision having taken place since the last inspection. 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. Fairlight Manor H59-H10 S62060 Fairlight Manor V218591 220405 Stage 4.doc Version 1.20 Page 21 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 x 3 3 x 3 STAFFING Standard No Score 27 3 28 3 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 3 x 3 x x 2 x 3 Fairlight Manor H59-H10 S62060 Fairlight Manor V218591 220405 Stage 4.doc Version 1.20 Page 22 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. That the recording of medicine administration must be maintained accurately at all times (outstanding from the previous inspection). That the homes complaints procedure be amended to include the contact details of CSCI and displayed accordingly (outstanding from the previous inspection). That the home must ensure that all staff undertake adult protection awareness and training. That the home implements a system for the formal supervision of staff. Timescale for action 13th November 2005 Immediate 2. OP9 13(2) 3. OP16 22 13th November 2005 4. OP18 & OP30 OP36 13(6) 13th November 2005 13th November 2005 5. 18(2) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Fairlight Manor H59-H10 S62060 Fairlight Manor V218591 220405 Stage 4.doc Version 1.20 Page 23 No. 1. 2. Refer to Standard OP15 OP22 Good Practice Recommendations That the home should display the menu in a communal area. That the home should have an assessment of the premisses completed by an Occupational Therapist. Fairlight Manor H59-H10 S62060 Fairlight Manor V218591 220405 Stage 4.doc Version 1.20 Page 24 Commission for Social Care Inspection 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. 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