Inspection on 24/01/07 for Fairmead Lodge

This inspection was carried out on 24th January 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 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

Fairmead Lodge 17/12/07

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 Key Inspection 24th January 2007 3.15pm Fairmead Lodge DS0000015496.V317766.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.V317766.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.V317766.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.V317766.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th February 2006 Brief Description of the Service: Fairmead Lodge is registered to provide care and accommodation for three service users with a learning disability. Accommodation is offered in a family style house in keeping with other houses in the locality. There are two bedrooms, bathroom, toilet and office on the first floor. The ground floor consists of the third bedroom, small laundry, toilet, kitchen and lounge/diner. The range of fees was provided by the manager as being £420 - £1700.00 per week. Additional charges should be discussed directly with the home. A current copy of the home’s Statement of Purpose/Service User’s Guide is available from the home upon request. The home is currently developing a more ‘user friendly’ version of the Service User’s Guide. Fairmead Lodge DS0000015496.V317766.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection site visit. The inspection was undertaken over a six-hour period. At this inspection, all key standards (plus others as appropriate) were assessed. A partial tour of the home took place. Records were selected at random and viewed and staff, residents (clients), and a relative were spoken with. In preparation for the visit, the Commission sent out questionnaires to health/social care professionals associated with the home. Unfortunately only one social care professional responded. The completed questionnaire was positive about the home. In addition, a positive questionnaire was received from a relative. During the afternoon and evening of the inspection, the home was warm, friendly and comfortable. Management and staff were hospitable and engaging. The inspection process was carried out with ease and the cooperation of all those involved was appreciated. The inspection process was ‘client led’ from beginning to end. Clients clearly wanted to be involved as much as possible and their ‘first hand’ opinions and thoughts regarding many aspects of care within the home was invaluable and appreciated. What the service does well: What has improved since the last inspection? What they could do better: The home should review and update recording systems as identified and referred to within the report. Fairmead Lodge DS0000015496.V317766.R01.S.doc Version 5.2 Page 6 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.V317766.R01.S.doc Version 5.2 Page 7 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.V317766.R01.S.doc Version 5.2 Page 8 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): 1, 2 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information about the home was readily available. An admission policy/procedure was in place. Clients ‘terms and conditions’ document is being reviewed. EVIDENCE: A current copy of the Statement of Purpose/Service User’s Guide was available. The Statement of Purpose is currently subject to review, as some slight amendments need to be made i.e. complaints procedure and the repeated reference to the National Care Standard Commission. The home is also working on a more ‘user friendly’ version of the Service User’s Guide. No client has been admitted to the home since the last inspection. The home has a clear admission criteria policy/procedure in place. A relative spoke positively about her experiences during the process of the last admission. A client ‘terms and conditions’ document was available, but was being further developed. This process will be completed very shortly. Fairmead Lodge DS0000015496.V317766.R01.S.doc Version 5.2 Page 9 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 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care planning process within the home is detailed, comprehensive, and orderly and provides a sound basis for the provision of good care. Clients are involved in all aspects of their personal care and daily living activities. EVIDENCE: Those care plans seen were detailed, current and comprehensive. Risk assessments were current and informative. Text within the documentation was written in the ‘1st person’ and signed by the respective client. Clients spoken with knew what was in their plan of care and their recollection tallied with the written text. The home has an established key worker. Staff spoken with had a good understanding of individual clients assessed care needs. Interaction between staff and clients during the visit was warm, natural and friendly. There was a lot of good humour in the home and clients were often overheard laughing about something that had been said or about an Fairmead Lodge DS0000015496.V317766.R01.S.doc Version 5.2 Page 10 activity they were involved in at that stage. Conversations around the ‘dining room table’ are very much part of the home. Each client has a structured ‘day/evening’ activity schedule and individual detailed ‘daily log’ records are kept. Care should be exercised about what is recorded in the communal daily logbook. All text relating to individual clients should be recorded in their personal records only. Life within the home is clearly ‘client focused’. This was evident through documentation and discussions with family, staff and the clients themselves. Records relating to clients personal monies being held by the home were viewed at random and found to be in good order. Fairmead Lodge DS0000015496.V317766.R01.S.doc Version 5.2 Page 11 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, 14, 15, 16 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Clients are encouraged and supported to live a full and active life and to develop to their full potential. EVIDENCE: One of the main strengths of the home remains that all clients are encouraged and supported to live a full and active life. Clients continue to access a wide and varied range of educational, social and leisure activities. Established systems are in place enabling clients to enjoy an independent life as possible according to the assessed abilities. The home is commended on this aspect of care. Client’s personal relationships are encouraged and the home enjoys the company of regular visitors. Clients told the inspector how the menu planning was achieved, where the shopping was done, times of meals etc and how they all participated in these Fairmead Lodge DS0000015496.V317766.R01.S.doc Version 5.2 Page 12 activities. The home maintains a detailed record of food eaten by clients. This record demonstrates that clients are encouraged to eat a healthy diet. Fairmead Lodge DS0000015496.V317766.R01.S.doc Version 5.2 Page 13 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 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clients personal and health care needs continue to be consistently managed and met by the home. EVIDENCE: Clients are supported and encouraged to manage all aspects of their personal and health care needs according to ability. The home spoke of a good relationship with the GP. Health care records were in good order. Only one client receives prescribed medication. Staff have been trained in safe medication administration procedures. The home should however further develop the existing ‘PRN’ (as/when) medication administration protocol and ensure that when medication administration instructions are changed by the GP the information is recorded more accessibly. Staff were very clear about what changes had been made and had a good insight into why the changes had been made. There was no immediate risk to the client, but the method of recording should be reviewed. Fairmead Lodge DS0000015496.V317766.R01.S.doc Version 5.2 Page 14 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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has procedures, polices and guidance in place concerning complaints and adult protection issues. Staff have received training. EVIDENCE: Records were available to demonstrate that staff have received training. Those staff spoken with demonstrated competence in managing any potential adult abuse incident and were able to locate a designated complaint record book. The complaints procedure within the Statement of Purpose was noted to require an amendment in order that the stated process is in line with regulation. When clients were asked about whom they should talk to if they were worried about anything, they spoke (or referred to) a number of people who they would feel comfortable with. All clients have contact with their respective families and attended a wide range of leisure/social activities. Those clients spoken with intimated that they would feel comfortable about expressing their views to staff in the home. Residents are actively encouraged and supported to voice the opinions and thoughts and this management style was evident during the inspection. As part of the inspection, a relative was spoken to about this aspect of care. The response was very positive and reassuring. Fairmead Lodge DS0000015496.V317766.R01.S.doc Version 5.2 Page 15 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, 25, 26, 27 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a safe, well-maintained homely environment that meets clients’ needs. EVIDENCE: Fairmead Lodge is an end of terraced house, which is in keeping with other houses in the locality. A small garden is located to the rear of the house. One client kindly showed the inspector around the home. All clients have their own bedrooms and there are adequate communal facilities. Clients expressed their satisfaction about the home and in particular their respective bedroom space. The home was clean, tidy and odour free. The standard of decoration, furnishings and general maintenance was good. The atmosphere within the home was warm, homely and comfortable. Fairmead Lodge DS0000015496.V317766.R01.S.doc Version 5.2 Page 16 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, 33, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels, skills and abilities are appropriate to meet the assessed needs of clients. EVIDENCE: Staffing rotas indicated the agreed staffing levels continue to be provided and met. The staff rota for the day was accurate and reflected the staff on duty. Staff records indicated that staff receive appropriate training opportunities. Records demonstrated that staff are trained and skilled to undertake their designated responsibilities. There was every indication that staff work well together as a team. The home is not reliant on agency staff to maintain agreed staffing levels. The records of the two most recently recruited members of staff were seen. Records were in good order. Staff employment contracts are currently being reviewed. Fairmead Lodge DS0000015496.V317766.R01.S.doc Version 5.2 Page 17 There are good communication systems within the home. The home acknowledges that the ‘informal’ staff supervision that takes place on a regular basis should be formalised. In total 4 members of staff were spoken with, all presented as being competent and pleasant. Two members of staff came in especially to ‘experience’ an inspection. Clients demonstrated a natural warm relationship with staff and the relative spoken with was complementary about the staff team. Fairmead Lodge DS0000015496.V317766.R01.S.doc Version 5.2 Page 18 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, 42 & 43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home continues to be managed well by the registered provider/manager. EVIDENCE: The registered provider/manager has managed the home since it opened in 1997 and holds a City & Guilds 325/3 Advanced Management in Care. The manager also has extensive experience with this client group. Staff and the relative spoke positively of the management style within the home. Clients are constantly involved in the day-to-day management of the home. Fairmead Lodge DS0000015496.V317766.R01.S.doc Version 5.2 Page 19 The home has recently completed and submitted an Annual Quality Development Plan. A random sample of polices, procedures and records were found to be adequately maintained. All records are securely held in the home’s office. Fairmead Lodge DS0000015496.V317766.R01.S.doc Version 5.2 Page 20 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 3 2 3 3 X 4 X 5 3 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 3 26 3 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 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 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X 3 3 3 Fairmead Lodge DS0000015496.V317766.R01.S.doc Version 5.2 Page 21 No 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. Standard Regulation Requirement Timescale for action 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 YA1 Good Practice Recommendations The registered person should review the content of the Statement of Purpose to ensure compliance with regulation and continue to develop a ‘client friendly’ Service Users Guide. Some slight amendments need to be made as detailed within the report. Amended copies should be sent to the Commission. The registered person should continue to develop and then provide every client with a current ‘Terms & Conditions’ of residence. The registered provider should ensure all text written about a client is made within their respective personal notes, not in the communal logbook. The registered person should ensure that all documentation regarding medication changes is clear. This record should be made within the clients personal records for ease of reference. The registered person should develop terms & conditions of staff employment. DS0000015496.V317766.R01.S.doc Version 5.2 Page 22 2 3 4 YA5 YA6 YA20 5 YA34 Fairmead Lodge 6 YA42 The registered manager should further develop safe working practice risk assessments within the home. Fairmead Lodge DS0000015496.V317766.R01.S.doc Version 5.2 Page 23 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.V317766.R01.S.doc Version 5.2 Page 24 - 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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