Inspection on 04/12/06 for Fairlight Manor

This inspection was carried out on 4th December 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Fairlight 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 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 Fairlight Manor 48 Fairlight Avenue Telscombe Cliffs East Sussex BN10 7BS Lead Inspector Linda Boereboom Key Unannounced Inspection 4th December 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Fairlight Manor DS0000062060.V304021.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.V304021.R01.S.doc Version 5.2 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 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Fairlight Manor DS0000062060.V304021.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is nineteen (19). Service users must be older people aged sixty-five (65) years or over on admission. 18th November 2005 Date of last inspection 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 two 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. Building work to the home has recently been completed on the second floor providing additional bedroom space with ensuite facilities and a quiet area. Fairlight Manor DS0000062060.V304021.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 will be referred to as ‘residents’. This unannounced inspection took place over a period of two weekdays at the beginning of December 2006 and lasted approximately 9 hours. At the time of inspection the home was accommodating seventeen residents, three of whom had been admitted to hospital. During the inspection, the Inspector was able to speak to three residents individually, whilst others commented on their care during the visit. In addition the Inspector spoke with three visitors, toured the premises and looked at the home’s administrative procedures including a number of staff and residents record as required by registration. The inspection was facilitated by both the Registered Provider/Manager Mr Ashraf Patel and the Deputy Manager Mr Paul Gonda. Three staff were also interviewed and others observed and chatted with whilst working in the home. The Commission for Social Care Inspection sent out at random ten residents surveys and ten care staff surveys and at the time of writing this report one had been received back by the Inspector. The Inspector would like to thank all the care staff and residents in the home for helping to make the inspection both positive and enjoyable. What the service does well: Fairlight Manor continues to offer residents a caring, homely and relaxed environment that places their needs first. Each resident is properly assessed prior to being offered a place in the home. Residents are offered the opportunity to take part in organised activities and are protected from the risk of harm by suitable adult protection and health and safety procedures. Residents’ views are respected and the care staff are competent, caring and committed to their wellbeing. The management approach of the home is positive and supportive, taking into account the wishes and feelings of both residents and staff. Two residents spoken with by the Inspector said: ‘The staff here have made me very welcome’ and ‘I’m quite happy here’ whilst another remarked ‘I don’t think I’d find a better place’. Fairlight Manor DS0000062060.V304021.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Fairlight Manor DS0000062060.V304021.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fairlight Manor DS0000062060.V304021.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has reviewed its statement of purpose and service user guide that is available in the home but residents and relatives need to be informed they are able to have a copy if they so wish. Fairlight Manor ensures that no resident is admitted to the home without a full care needs assessment taking place. EVIDENCE: Whilst in the home the Inspector found through conversation with care staff that the statement of purpose, service user guide and any information leaflets that were usually available had been moved from the sitting room to accommodate the Christmas decorations. This prompted conversation with the Registered Provider/Manager on the availability of information and he confirmed that although he took it with him when undertaking pre-admission assessments, he didn’t always leave the information with the prospective resident. When speaking with residents and relatives it was unclear if they had received any information therefore it was agreed between the Inspector, Fairlight Manor DS0000062060.V304021.R01.S.doc Version 5.2 Page 9 Registered Provider/Manager and the Deputy Manager that all residents would have a copy of the information in their individual rooms. In addition all prospective residents would be left information following assessment. It was also noted that the most recent quality questionnaire sent to each resident did have a question asking if they were satisfied with the amount of information provided by the home. It was confirmed that the latest inspection report is generally also available in the main sitting room of the home. The registration certificate and insurance policy for the home were seen to be on view in the main entrance hall. The Registered Provider/Manager and/or the Deputy Manager undertake all pre-admission assessments and prospective residents are given the opportunity to visit the home for a meal to meet the care staff and other residents before making the decision to move in. This was confirmed during conversations the Inspector had with relatives and residents in the home. Once admission has taken place there is an eight-week settling in period. The Inspector did not see contracts of residency, although the Inspector at the last inspection reported doing so. The Registered Provider/Manager explained that these were with the person who managed the home’s administration. It was agreed that these would in future be housed in the home for review during inspection. The Registered Provider/Manager is a qualified registered nurse who also has a teaching and assessment qualification and therefore is able to provide specific training for care staff to enable them to meet residents individual needs. All three residents spoken with by the Inspector said they thought the care staff did everything possible to meet their care needs. The home is not registered for intermediate care. Fairlight Manor DS0000062060.V304021.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans belonging to residents include sufficient information to enable their care and social needs to be met. The home has a suitable medicine storage and administration system and staff that administer medication are appropriately trained. Residents are treated respectfully and their privacy and dignity acknowledged. EVIDENCE: The Inspector looked at six care plans belonging to residents and found them to obtain up to date information, including a photograph. Care plans are based on the initial assessment undertaken when a resident is admitted into the home. The Registered Provider/Manager confirmed that care plans are reviewed monthly and at six monthly reviews relatives are invited to attend. Through conversation with relatives the Inspector found that the home is proactive in sharing information and concerns with them about the health of the resident’s and keep in touch if a resident is admitted to hospital. Care plans include details of medical history and current issues with guidance on how needs are to be met. They also include information on mobility, social and Fairlight Manor DS0000062060.V304021.R01.S.doc Version 5.2 Page 11 emotional needs and any areas that may give rise for concern. Care plans also contained risk assessments however in some cases it was difficult to identify when the last risk assessment took place; this was discussed with the Registered Provider/Manager and the Deputy manager who agreed to address the matter. The home has a designated locked cupboard for the storage of medication. At the time of inspection no resident either self medicated or required controlled medication. The Registered Provider/Manager was aware of the need for suitable storage facilities and recording systems should controlled medication be required by anyone in the home. Unwanted medication is returned to the local pharmacy and the Inspector was informed by the Registered provider/manager that the pharmacist, who has confirmed this is current practice, no longer signs a receipt for unwanted medication. The Deputy Manager audits medication every four weeks and it is checked by the Registered Manager. Staff were very clear on the process of administering medication and confirmed that only trained staff take responsibility for giving medication to residents. The Registered Manager confirmed that in the event of the death of a resident, medication would be kept in the home for 7 days in case a coroner’s inquest took place. Residents spoken with by the Inspector said that staff looked after their medication and that they received it at the right time. The home has a privacy and dignity policy, which is promoted, in the home and the Inspector noted that care staff knocked on doors before entering and were polite and respectful as well as sensitive and friendly in conversation with residents. Residents and relatives praised care staff for their cheerfulness and manner when dealing with them. Residents confirmed being able to wear their own clothes, open their own post and see their visitors in private if they wished. The home has a death and dying policy in place and the Registered Provider/Manager confirmed that the district nursing teams would be involved if necessary and the resident’s condition monitored throughout, he confirmed that the ethos of the home is for families to be as involved as they wish, sharing the home’s facilities as necessary. Fairlight Manor DS0000062060.V304021.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents at Fairlight Manor are involved in daily routines and activities with encouragement from the care staff, they are supported and encouraged to maintain contact with others outside the home and visitors are made welcome. EVIDENCE: Since the last inspection the activities programme in the home has been reviewed and at the time of this inspection the residents and staff were very involved with the planning of the Christmas party to which relatives and other visitors including the Mayor and healthcare professionals, had been invited. Residents were also involved in decorating the home and their own individual areas within the home. The Inspector saw Christmas decorations and Christmas notice boards on bedroom doors made by the residents for their own Christmas cards. Other activities for Christmas included a production of Jack and the Beanstalk from a small acting group, three carol services, one from a local school, another from a local singing group and a third from the Saltdean and District choir. A separate entertainer had also been booked. Activities for Christmas were advertised within the home. Fairlight Manor DS0000062060.V304021.R01.S.doc Version 5.2 Page 13 Other activities included music and movement organised by staff, a residents art and crafts group when decorations are made for festive events. There is also an opportunity for still life painting. There are framed photographs on display in the main hallway of the home showing residents, staff and relatives enjoying activities together. In addition there are aromatherapy sessions. The Deputy Manager told the inspector that the church service within the home has ceased but that the home would look into finding a replacement. In good weather the residents have organised trips outside the home to Eastbourne or Brighton, or for a walk along the seafront however the Deputy Manager said that sometimes it is difficult to get the residents to participate but they are encouraged to join in or go out with relatives. On the day of inspection two residents had gone out and others confirmed that activities do take place some of which include exercises and bingo. There is a three monthly newsletter for residents and their relatives, written by staff about activities and events in the home including staff training that has been completed. In the November issue the Inspector saw that reference had been made to an impromptu party that took place on the day the lift was finally repaired. The Registered Provider/Manager also told the inspector he is hoping to set up a Friends of Fairlight Manor group to assist with local outings and events for the home. The kitchen at Fairlight Manor is homely and the cook prepares home cooked food from fresh ingredients each day working between 8am and 3pm. Food shopping is undertaken by the Registered Provider/Manager and the Deputy Manager with additional deliveries of vegetables from local shops and Brighton superstores. Menus are kept in a file and taken to each resident on a daily basis for them to make their choice of meals for the day. Residents mainly eat in the dining room, this was seen by the inspector who was also told that they could eat in their own rooms if they preferred. A record is kept of meals that residents eat each day and fridge and freezer temperatures are regularly recorded. One resident told the Inspector he could always have more food if he wanted, and another said she had put on weight since being in the home because the food was so good. The home has a visitor’s policy and residents said their relatives and friends visited them whenever they wanted. Visiting relatives said they were always made very welcome and were always offered coffee or tea on arrival, another said she has been offered a meal at short notice when visiting her father in the home. There is a visitors signing in sheet at the entrance of the home and the Inspector noted that it confirmed residents are visited regularly. Fairlight Manor DS0000062060.V304021.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Fairlight Manor has policies and procedures in place to ensure that residents’ views, concerns and complaints are listened to and they are protected from risk of harm, neglect and abuse. EVIDENCE: The inspector looked at the complaints records, which confirmed that three had been received since the last inspection and records showed the nature of each complaint, the action taken and the outcome. All were signed. The last one was received on 31/10/06. The Inspector spoke to three visiting relatives and three service users about the complaints procedure and asked if they were aware and would feel able to make a complaint. The relatives all said they felt comfortable enough to speak to the management staff should they have any concerns at all, one resident commented that she had no need to know because her family had all the information, another said he had noticed the information on the notice board and a third felt she would be able to make a complaint but couldn’t remember being given any information. The home is registered for postal voting and the Deputy Manager told the Inspector that this is the preferred way of voting for the residents. The Inspector spoke to staff about the protection of vulnerable adults and gave them a scenario, asking what they would do. They showed a common sense approach and also confirmed they had received training however the Deputy Fairlight Manor DS0000062060.V304021.R01.S.doc Version 5.2 Page 15 Manager told the Inspector that some staff failed to attend the last training course on 5/06/06 and still require a refresher course to support their existing knowledge. The Deputy Manager has been on a train the trainer course with Brighton and Hove Council to enable him to pass information on to staff. It was agreed that this issue would be addressed in the near future. All staff are Criminal Records Bureau checked and the home has a whistle blowing policy in place and a suitable adult protection policy. Fairlight Manor DS0000062060.V304021.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23.24,25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Fairlight Manor provides residents with a homely, clean and pleasant environment. The home must ensure that regular checks are made on fittings to ensure they are safe and meet the residents’ needs. EVIDENCE: The home has undergone a considerable amount of changes and structural alteration since the present Registered Provider/Manager bought the home., this is with a long-term view of applying for a possible change in registration. Since the last inspection, the second floor has been completely refurbished providing five ensuite rooms and a compact quiet area that has skylight window. Plans for this were approved by the local council. The ensuite facilities include ‘wet rooms’ with central floor drainage. All renovations have been designed to be functional and attractive and to fit the purpose; all are wheelchair accessible. All bedroom ensuite facilities are lockable with a safety Fairlight Manor DS0000062060.V304021.R01.S.doc Version 5.2 Page 17 lock that enabling them to be accessed from the outside in the event of an emergency. One of the bathrooms on the first floor has been upgraded and the bath has a raised manual seating system. Four bedrooms have been refurbished and redecorated and currently work is being undertaken on a fifth room. On the ground floor another room has been redecorated. The Deputy Manager told the Inspector that the first floor and ground floor were re-carpeted in March 2006. Residents and relatives confirmed that the home and the grounds are kept tidy saying that the home is vacuumed regularly and that in the summer residents are able to use the garden. The Registered Provider/Manager and Deputy Manager also undertake gardening duties and the Deputy Manager said that in the summer months residents are encouraged to sit out under the umbrellas however for health and safety reasons the BBQ is not used. He said residents are risk assessed to use the garden and are always accompanied by the care staff. The home has eighteen single rooms and one double. Five rooms have ensuite facilities and in addition there are three other bathrooms and four separate toilets for residents to use. All bathrooms and ensuites have a toilet. The home has a passenger lift to all floors. It was out of use for a period of time earlier in the autumn of 2006 and repaired fully in November 2006. The Deputy Manager told the Inspector that the delay was due to the manufacture of a new control panel for the lift. The Inspector found it to be in use on the day of inspection. The home has been assessed by an occupational therapist, this was a recommendation in the last report. The home has a standing and lifting hoist, grab rails and raised toilet seats as appropriate. The Registered Provider manager said that if a resident has specific needs then guidance is sought from a physiotherapist or occupational therapist from the local healthcare trust. It was confirmed that residents are able to bring their own belongings into the home; in addition each room has a lockable facility. All residents spoken with said their rooms were warm and comfortable and two said they had comfortable beds. All rooms are centrally heated and naturally lit. The new radiators in the home are all low surface temperature. On a tour of the premises the Inspector found some radiator covers (installed by the past owners) either required replacement or repair. The Registered Provider/Manager said he would address the matter as soon as possible and would inform the Inspector within Fairlight Manor DS0000062060.V304021.R01.S.doc Version 5.2 Page 18 a week of the outcome, it was also agreed that requirement would be made in this report as covering of radiators is a health and safety issue. The home has emergency lighting, which the Deputy Manager said had been upgraded in February 2006 along with the heating and water system. The Deputy Manager confirmed that the water is tested for safety through a contract the home has with a safe water laboratory. The home was very clean, tidy and homely and there was evidence of maintenance work still being undertaken resulting in some areas that still require ‘cheering up’. Everyone spoken with by the Inspector said the home is kept clean and one resident remarked jokingly ’if anything they overdo it!’. Care of the residents’ clothes for the most part is a duty undertaken by care staff in a small area designated for the purpose with a hand washbasin in the toilet next door. Gloves and aprons are supplied for staff when cleaning or undertaking personal care and a recommendation will be made in this report that waterproof shoe covers are obtained for use by staff when showering residents in the wet rooms. One resident told the Inspector ‘they are very fussy about wearing gloves here!’. Conversation with staff revealed they require a refresher course in hygiene and infection control however they are given information and training during the induction process. This was discussed with the Deputy Manager who agreed to look into the matter. Fairlight Manor DS0000062060.V304021.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care staff are experienced, competent and caring and are able to meet the needs of the residents. The selection of staff using the recruitment policy and procedures is good. EVIDENCE: The Inspector looked at the staff rotas in the home and found that there were sufficient members of care staff on duty with a minimum of two care staff supported by either the Registered Provider/Manager or Deputy Manager. The home operates a system of having one waking member of night staff on duty and one sleeping in. There is also a full time cook and care staff undertake personal care of residents as well as housekeeping duties and laundry. The Deputy Manager told the Inspector that in the locality it is not easy to find suitable care staff. The home has a thorough recruitment procedure and focuses on staff attending training in all relevant areas of care including, moving and handling, fire safety, health and safety, protection of vulnerable adults, administration of medication and first aid. The Inspector enquired about staff taking NVQ 2 and 3 and was told that 3 care staff are expected to start their training in January 2007, and 3 care staff already have NVQ2. The home has a personal development policy that highlights all staff training and each course attended includes an evaluation. Training is offered either through Brighton and Hove Fairlight Manor DS0000062060.V304021.R01.S.doc Version 5.2 Page 20 Council or with the Registered Provider Manager who has a training certificate. Care staff told the Inspector that they have commenced training in care of residents with dementia to help them in their work. During a conversation with care staff the Inspector was told that they thought training in the home to be very good. Staff files all had a checklist of stages of the recruitment and induction procedure, however they did not show all the information required for inspection and this was discussed with the Deputy Manager. A recommendation will be made in this report that for good practice staff files include all the information relating to each individual member of staff. Care staff confirmed that the recruitment procedure is thorough although some members of staff had been in post for many years and therefore not all information was available. The Registered Provider/Manager told the Inspector that the ethos of the home is ‘collective teamwork’. This was backed up during conversation with staff that said that they tried very hard to make Fairlight Manor a home for the residents and that residents did not have to wait for anything. They also said that since the Registered Provider/Manager had taken over the home things had improved overall and having younger people on the care staff was a good thing for the residents. One member of staff praised two of her colleagues for their hard work in helping create a pleasant atmosphere in the home. Fairlight Manor DS0000062060.V304021.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Fairlight Manor is well run and managed by competent management and care staff all of whom are pro-active in ensuring that residents live in a homely, caring and relaxed environment that is safe. Staff are well supported; there is a clear management structure throughout. EVIDENCE: The registered Provider/Manager took over the home just over two years ago and care staff have stated that it has improved in that time and is well run. The Registered Provider/Manager is a Registered Nurse for Adults and a Specialist Practitioner; he is also a District Nurse and has a Nurse Prescriber certificate. He also has three degrees that are healthcare and management associated as well as relevant to the elderly. He is also a trainer and has the ENB 998 certificate. Fairlight Manor DS0000062060.V304021.R01.S.doc Version 5.2 Page 22 The Deputy Manager has over two years experience in care of the elderly and one years experience in his present post. He has undertaken courses with Brighton and Hove council in supervision and appraisal, performance appraisal, budget management, recruitment and employment law, marketing skills, developing care plans for quality assurance, train the trainers awareness in adult protection and change management. He is also undertaking NVQ 3 to underpin his knowledge. The home undertakes management and staff meetings and now produces a newsletter for residents and their relatives, to which they and care staff are able to contribute if they wish. The Registered Provider/Manager told the Inspector that informal meetings take place with relatives; those spoken with by the Inspector said that staff communicated well with them and the residents. The home is hoping that a Friends of Fairlight Manor forum will soon be formed to give assistance with outings and activities and enable more chance for people to give their views on the running of the home. A quality questionnaire was sent out to residents in November 2006 and is currently being collated by the Deputy manager. It is intended that this will take place twice yearly and will be used towards quality improvement within the home. The Registered Provider/Manager told the Inspector that there is an annual development plan for the home and that he is committed to the care staff being well trained for their roles. Policies and procedures are formed in-house using a larger legal organisation to provide the basic formats. Each one has an expiry date; the Registered Provider/Manager and Deputy Manager take responsibility for ensuring each one is renewed. The home also has a business plan and works to budgets for different aspects of running the home i.e. training, food, furnishings and upgrades, and provision of care. This information was given by the Registered Provider/Manager; the Inspector did not see evidence. Residents control their own finances or enlist the help of relatives or advocates, this was confirmed during conversation. Staff confirmed they have no involvement in residents’ finances, making of wills or shopping. Care staff confirmed they receive supervision and the Inspector was able to look at their individual records. Both the care staff and Registered Provider/Manager and Deputy Manager confirmed that care staff are observed unannounced whilst working in the home, this is to identify any poor practices that might crop up. Records are kept locked in the office of the home although all residents personal files are kept in their individual rooms allowing them access at any time. All records are in hard – copy and to date no information is kept on a Fairlight Manor DS0000062060.V304021.R01.S.doc Version 5.2 Page 23 database. The Inspector found that staff records require reviewing and organising to include all relevant information. The home’s administrator was keeping some resident’s records i.e. contracts of residency and the Inspector requested they be returned to the home for future inspection purposes. The Registered Provider/Manager and Deputy Manager confirmed training takes place in all health and safety issues. Residents confirmed that fire drills take place and one told the Inspector that the fire drills are quite good. The cook works within the guidelines of the food standards agency in relation to cross contamination i.e. cleaning, chilling and cooking and management of the kitchen. He has a diary for recording any areas of concern. Fridge and freezer temperatures are kept and an additional record of daily kitchen cleaning which is taken from a specific rota. Records are kept of what each resident eats for a main meal and all food is tested for temperature before serving. Checks to electrical and gas installations take place and the Register Provider/Manager showed the Inspector a new portable appliance testing piece of equipment he had recently purchased for use in the home. Fairlight Manor DS0000062060.V304021.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Fairlight Manor DS0000062060.V304021.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP25 OP29 Regulation 13(4)abc 17(3)b Requirement The radiators identified as requiring replacement covers or repair to covers to be addressed. Staff files to show all relevant information relating to recruitment, qualifications and training. Timescale for action 22/12/06 15/01/07 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 2 Refer to Standard OP26 OP37 Good Practice Recommendations Staff to be supplied with waterproof over shoes for working in the wet rooms assisting residents to shower. All information relating to individual residents to be kept in the home and available for inspection e.g. resident contracts of tenancy. Fairlight Manor DS0000062060.V304021.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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.V304021.R01.S.doc Version 5.2 Page 27 - 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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