Inspection on 17/12/07 for Fairmead Lodge

This inspection was carried out on 17th December 2007.

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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fairmead Lodge 24/01/07

Fairmead Lodge 10/02/06

Fairmead Lodge 21/03/05

Fairmead Lodge 23/11/04

Fairmead Lodge 11/03/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Fairmead Lodge 45 Fairmead Avenue Westcliff On Sea Essex SS0 9RY Lead Inspector Ann Davey Unannounced Inspection 17th December 2007 3pm Fairmead Lodge DS0000015496.V353987.R01.S.doc Version 5.2 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 Fairmead Lodge DS0000015496.V353987.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 Adults 18-65. 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. Fairmead Lodge DS0000015496.V353987.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fairmead Lodge Address 45 Fairmead Avenue Westcliff On Sea Essex SS0 9RY 01702 308197 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) Mr Mehmood Hassan Mrs Nusrat Hassan Mrs Nusrat Hassan Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Fairmead Lodge DS0000015496.V353987.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th January 2007 Brief Description of the Service: Fairmead Lodge is registered to provide care and accommodation for three residents with a learning disability. Accommodation is a family style house in keeping with other houses in the locality. There are two bedrooms, bathroom, toilet and office on the first floor. On the ground floor there is a third bedroom, small laundry, toilet, kitchen and lounge/diner. There is a small paved parking area to the front of the home. The rear garden and patio area is well kept, functional and well used by residents. The fees range from £420 - £1700.00 per week depending on the assessed care needs and source of funding. Additional charges should be discussed directly with the home. A copy of the home’s Statement of Purpose and Service User’s Guide is available from the home upon request. The home is currently developing both documents to make them more ‘user friendly’. They will be available early in 2008. Fairmead Lodge DS0000015496.V353987.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced site visit that started at 3pm and finished at 8.30pm. The last key inspection took place on 24th January 2007. The home had completed and returned their Annual Quality Assurance Assessment (AQAA) to us prior to the inspection. This document gives homes’ the opportunity of recording what they do well, what they could do better, what has improved in the previous twelve months as well as their future plans for improving the service. The outcome of this inspection reflected the information and detail within the AQAA. The home’s manager is also the owner. For the purposes of this inspection, Mrs Hassan has been referred to as the manager throughout the report The manager, two members of staff and all three residents were spoken with during the inspection. The manager telephoned two relatives to say that an inspection was taking place and asked if they would like to visit the home and speak with us. Both relatives told the manager that their views had been expressed within their submitted surveys and did not feel the need to make a special journey. We (CSCI) received three completed surveys from staff, three completed surveys from residents and two completed surveys from relatives. Comments from staff and relatives surveys have been included within the report. We would acknowledge the completed residents surveys, but as all residents were spoken with during the inspection, comments from these surveys have not been specifically included on this occasion. The views and opinions expressed by the residents to us during the day were the same as within the surveys. The afternoon and evening spent in the home was pleasant and staff members on duty were co-operative and helpful. The inspection process was undertaken with ease and was ‘resident led’ from beginning to end. Residents clearly wanted to be involved as much as possible and their ‘first hand’ opinions and thoughts about the home was invaluable and appreciated. One resident showed us around the home in the afternoon and another resident showed us some other aspects of the home during the evening. Throughout the inspection, care practices were observed and a random selection of records viewed. A notice advising any visitors to the home that an inspection was taking place is normally displayed, but on this occasion this practice was not thought necessary as no visitors were expected. All matters relating to the outcome of the inspection were discussed with the manager. The manager or member of staff took notes so that development Fairmead Lodge DS0000015496.V353987.R01.S.doc Version 5.2 Page 6 work could be started. Full opportunity was given for discussion and/or clarification both during and at the end of the inspection. What the service does well: What has improved since the last inspection? What they could do better: The manager should ensure that staff recruitment processes are robust. This is to ensure that residents are not placed at potential risk of being cared for by unsuitable members of staff. A suitable complaints procedure should be available so that anybody who wishes to raise a concern knows how to do it. The manager understands the importance of ensuring that residents care needs are assessed on a regular basis and any changes are documented. Existing staff may know of residents’ ongoing needs, but if a new member of staff comes into the home they will need to refer to current information. Safe working practices and environmental risk assessment need to be developed so that staff know of any potential risks and the measures they need to take to prevent accidents. The manager should ensure that the home’s policies and procedures are reviewed to ensure that the information and guidance used by staff is current. Fairmead Lodge DS0000015496.V353987.R01.S.doc Version 5.2 Page 7 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. Fairmead Lodge DS0000015496.V353987.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fairmead Lodge DS0000015496.V353987.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to receive a comprehensive pre admission assessment to ensure their needs are identified. EVIDENCE: No new residents have been admitted to the home since the last inspection. The home has a comprehensive admissions policy that would be used if a vacancy occurred and a new resident considered. There are no plans to change the current living arrangements. Within completed surveys relatives stated that they had received sufficient information about the services provided the home. Fairmead Lodge DS0000015496.V353987.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to have a plan of care drawn up by the home that reflects their assessed needs. EVIDENCE: When we requested care plans to look at, one of the resident’s asked a member of staff if they could get the folders for us. The resident told us that it was ‘stuff about me’. The resident had a relatively good understanding of what a care plan was all about. Information in all three care plans was current and risk assessments were in place. Information within the documentation was in the main written in the ‘1st person’ and signed by the respective resident. Residents said that staff had told them what had been written in the care plans. Residents told us about what they like to do and their daily routines. This information corresponded with what had been written in care plans and risk assessment documentation. One resident said ‘I go and come where I like’ and ‘they ask me about what I like and I tell them’. Another resident told us about their key worker and what their role is. Fairmead Lodge DS0000015496.V353987.R01.S.doc Version 5.2 Page 11 Care plans and risk assessments broadly reflected current practice but there was no evidence that a formal review of residents’ care needs had been undertaken by the home since March 2007. The manager acknowledges this. The explanation was that the home is introducing a more ‘user friendly’ style of care plan recording system and there had been a delay in obtaining the IT software. The manager assured us that all care plan documentation would be reviewed and updated by the end of January 2008. Staff on duty had a good understanding of residents assessed care needs. Confidential information about residents is kept within the office on the 1st floor. Interaction and rapport between staff and residents during the inspection was warm, natural and friendly. There was a lot of good humour in the home. Residents and staff were often overheard laughing about something that had been said or about an activity they were engaged in. Conversations with staff and residents around the dining table and in the lounge area during the inspection were ‘resident led’. Staff actively encouraged residents to express their personal thoughts and opinions about daily routines and activities within the home. Residents expressed confidence and freedom in their discussions with staff and us. Fairmead Lodge DS0000015496.V353987.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents can expect to receive a varied balanced diet and to be supported in enjoying a fulfilling lifestyle. EVIDENCE: One of the continuing main strengths of the home is that all residents are encouraged and supported to live a social and recreational lifestyle of their own choice. Each resident has a printed scheduled weekly programme of lifestyle activities and events. Residents have access to a wide and varied range of educational, occupational, social and leisure activities. There include day centres, social skills education, work experience, paid employment, swimming, art classes and bowling. In the evening, residents have a wide variety of activities to choose from. These include evening organised social clubs, ‘eating out’ and local community activities and events. Residents spoke excitedly and enthusiastically about their personal interests and hobbies. Fairmead Lodge DS0000015496.V353987.R01.S.doc Version 5.2 Page 13 The inspection took place the week before Christmas and residents told us about the planned events in store for them over the holiday period. In discussing this aspect of care with staff, they too were equally enthusiastic about the various activities residents attend and demonstrated pleasure in being able to support residents. Residents told us about their holiday to Alton Towers earlier in the year. They all clearly enjoyed this. Within the home’s AQAA, it is acknowledged that sometimes the home is unable to deliver all individual residents wishes, as the home would like to because of local authority funding restrictions. All residents have active family involvement. Family members play an active part in residents’ individual lives. Residents told us about the opportunities they have to pursue personal relationships and understood that ‘Mrs Hassan (manager) needs to know where I am’…….’I talk to Mrs Hassan about this and she helps me sort things out’. Residents told us about how menus are planned and who does the shopping. The manager confirmed that their account was accurate. Menu planning is carried out in consultation with residents and shopping is undertaken by who ever would like to accompany staff. One resident in particular enjoys this activity and spoke of the pleasure that going with a member of staff gives them. Residents enjoy ‘eating out’ and told us about the different venues that had been visited. When asked if we could see the ‘menu recording book’, one resident was eager to get it and show us. The record was clear and demonstrated that residents are provided with a healthy balanced diet. Fairmead Lodge DS0000015496.V353987.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to receive good health and personal care support. EVIDENCE: Residents assessed personal, emotional, physical and health care needs are recorded in their individual files. Support is provided and given to residents according to individual assessed ability and taking into account appropriate assessed risk factors. Staff members reported that the home has a good working relationship with all community health care professionals. One resident spoke of their positive experience when they last visited the local GP. Residents indicated that they happy with the support they receive from staff. One resident said ‘I like it here’ and another said ‘all the staff are nice and I like the food’. We overheard one conversation a member of staff was having with a resident about ‘going out alone’ somewhere. The member of staff was sensitively explaining to the resident why it was not safe for them to go out at night on their own. The outcome was that the resident could still go where they wished, but a member of staff would escort them to the entrance and them walk with them back to the home later. Fairmead Lodge DS0000015496.V353987.R01.S.doc Version 5.2 Page 15 Residents are provided with mobile phones so that they can telephone the home at any time and remain in contact with a member of staff when they are out. The use of these phones is sensitively supervised and monitored by staff. Staff reported that they had received medication administration training. Storage facilities for medication were appropriate and medication administration recording sheets (MAR) were available. The manager was reminded that when a member of staff handwrites medication dosages and administration instructions, it is good practice for the entry to be checked and signed as being correct by a second member of staff. Should the first member of staff have made an error, it would be picked up on by the second member of staff. The manager said that all staff members who have responsibility for medication administration would now adopt this practice. Fairmead Lodge DS0000015496.V353987.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to have any concern or complaint dealt with appropriately and to be protected by the home’s ‘safeguarding adults from harm’ procedures. EVIDENCE: Staff members on duty said that they had attended a ‘safeguarding adults from harm’ training course. Both were able to discuss the process they would follow should an incident be suspected. They said that they would immediately inform the manager. Since the last inspection, there has been a potential ‘safeguarding adults from harm’ incident in the home. The local authority investigated and due to the circumstances, the matter was dealt with ‘in house’. The significance of this was that a resident clearly felt comfortable about raising an issue which they were unhappy about, the manager reported it in accordance with the ‘safeguarding adults from harm’ procedures, the matter was investigated by the local authority who then asked the manager to deal with it. The resident, the manager and the local authority are satisfied with the outcome. During the inspection we asked all residents individually if they knew what to do if they were unhappy about something. All residents spoke confidently about whom they would speak with. Residents have a number of contacts, for example, the manager and staff in the home, their own family and relatives, ‘one to one’ with an advocacy service, day centre staff, work experience staff and social club staff. Fairmead Lodge DS0000015496.V353987.R01.S.doc Version 5.2 Page 17 The home does not display a complaints procedure. It was explained to the manager that although residents are clear about whom they would speak with if they were unhappy, a procedure should be displayed so that any visitors to the home are aware of the complaints process. The manager agreed to do this by the end of January 2008 and to ensure that the format is suitable for residents to understand. Within their completed surveys, relatives said that they knew how to make a complaint or to raise a matter of concern. They also felt comfortable that any matter of concern would be dealt with appropriately. Fairmead Lodge DS0000015496.V353987.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to live in a clean and comfortable environment. EVIDENCE: During the afternoon one of the residents showed us around the home. In the evening, another resident showed us some other aspects of the home. The resident told us that staff always knock on the door or call out before they go into their bedroom. Both residents were happy to shown us their bedrooms. These rooms were very personalised and comfortable. In general the home was clean, tidy and free from any unpleasant odours. Communal facilities in the home are adequate for the size of the home. The manager acknowledged that there is no designated space for residents to receive their guests in private. The manager said that the home’s small office on the 1st floor could be used if needed. The kitchen and laundry areas were clean and tidy. Residents had decorated the home well for Christmas. Fairmead Lodge DS0000015496.V353987.R01.S.doc Version 5.2 Page 19 Within the home’s AQAA it is recorded that since the last inspection a new TV, a new washing machine and a new cooker has been purchased. Some areas of the home need redecoration and refurbishment. For example, the dining room chairs are not in good condition, the lounge and hallway carpet is stained and paintwork throughout the home needs attention. The manager said that in the new year, carpets are to be replaced and some redecorated is going to be carried out. One resident bedroom has already been redecorated, refurbished and has a new carpet. The resident confirmed that they had chosen the wallpaper and colour of the paintwork. The atmosphere within the home was warm, homely and comfortable. Fairmead Lodge DS0000015496.V353987.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect to be cared for by a team of committed staff but cannot be assured that all staff employed have been subject to a robust recruitment process. EVIDENCE: One of the residents’ showed us the current staff rota that reflected staff on duty. A member of staff explained that during the day when all three residents are at home there are two staff on duty. At other times depending on which resident(s) are at home, there is always one or two staff on duty. The variation depends on individual residents care needs and the amount of support required. There is one ‘awake’ member of staff on duty at night. The home does not have any staff ‘sleeping in’ facilities. Both staff members told us about the established ‘on call system’ which they can use. The manager said that since the last inspection two members of staff have left employment and two have been recruited. The recruitment files of these two new members of staff were viewed. There was no documentation to evidence that these staff had received a formal induction. Fairmead Lodge DS0000015496.V353987.R01.S.doc Version 5.2 Page 21 The manager said that one member of staff had received some informal induction and confirmed that the second member of staff had not received any induction. On the second file there was evidence of only one reference being received. On the application for employment form, there was no history of employment or education. The applicant had not dated the application form. Without a robust recruitment process being in place, residents are at potential risk of an unsuitable person being employed to care for them. The home’s AQQA states that residents are involved in staff interviews. Staff on duty told us about their recent training courses. Staff indicated that the training they had received was sufficient to meet residents assessed needs. Within the home’s diary, there were entries where staff had attended training and where proposed training was planned. The manager explained that the process by which staff training is recorded and certificates filed was not robust. We were informed that in the new year an IT system is going to be introduced which will show what training is required, what courses have been attended and when ‘refresher’ sessions are required. The manager acknowledged that it is important to get the new system up and running as soon as possible as the current system is not clear and difficult to use. Staff spoken with expressed confidence and competence in their work and had a good understanding of residents care needs. From observation, residents related well to staff. Staff conversed with residents in a natural way and were overheard to be asking for residents opinions, preferences and views on matters of the day. Staff confirmed that a team meeting has recently taken place and informal staff supervisions take place. The manager acknowledged that these sessions should be more formal and documented. Staff spoke of a good team spirit and felt that they worked well together. Relatives completed surveys said that they felt staff were skilled and experienced. Staffs completed surveys said that knew how to raise any matter of concern with the manager, they thought that there was adequate staff on duty at any one time and considered that they were provided with enough information to undertake their duties. Staff acknowledged that they were provided with training opportunities and felt supported by the manager. Fairmead Lodge DS0000015496.V353987.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to live in a home where their interests and overall wellbeing are managed well. EVIDENCE: The manager holds a City and Guilds Advanced Management in Care certificate and has a wide range of management experience with this client group. The manager said that there are plans to commence the Registered Manager’s Award and NVQ level 4 course during 2008. The ethos of the home is to support and enable residents to reach their full potential and enjoy life within the security of a residential setting. From discussion with residents and staff and from comments within surveys, the home is managed in a way to enable this to happen. Fairmead Lodge DS0000015496.V353987.R01.S.doc Version 5.2 Page 23 From observation of care practices and from the interaction of residents during the inspection, we felt that residents’ views and opinions underpin the day-today management of the home. Examples of residents’ interaction during the inspection have been recorded within the report. Residents clearly wanted to be involved and as such, provided much of the information and documentation requested by us. The home completed their last Annual Quality Development Plan in January 2007 and another one is due next year. A random selection of service maintaince certificates was noted to be current. The manager recognised that the home does not have any safe working practice or environmental risk assessments in place. The manager said that this would be addressed. The home did have washing machine operating instructions displayed in the laundry and there was a short health and safety/infection control policy in the kitchen. Within the home’s AQAA it was recorded that the policies and procedures are due to be reviewed. The manager advised that this would be carried out as soon as the new IT system is fully functional. Relatives completed surveys said they thought the home was managed well. Fairmead Lodge DS0000015496.V353987.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 Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 4 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X 3 2 3 Fairmead Lodge DS0000015496.V353987.R01.S.doc Version 5.2 Page 25 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 YA34 Regulation 18 Requirement Staff recruitment records must be kept in line with regulation. All staff must be provided with a structured induction programme. This is to ensure that residents are not cared for by unsuitable people and all new staff know how to care for residents in line with their job description and the home’s policies and procedures 2 YA42 13 Safe working practice and environmental risk assessments must be developed and made available to staff. This is to ensure that staff are aware of potential risks and how they can prevent accidents from happening. 28/02/08 Timescale for action 31/01/08 Fairmead Lodge DS0000015496.V353987.R01.S.doc Version 5.2 Page 26 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 YA20 Good Practice Recommendations A second member of staff should check all handwritten medication administration entries made by a member of staff. This practice will minimise any errors. A suitable document explaining how to make a complaint and how the home will investigate it should be made available for everyone to see. The manager should ensure that the home’s procedures and policies are up to date. This is to ensure that staff are able to reference current guidance on care practices. 2 YA22 3 YA41 Fairmead Lodge DS0000015496.V353987.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Fairmead Lodge DS0000015496.V353987.R01.S.doc Version 5.2 Page 28 - 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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