Inspection on 12/04/07 for Fairview

This inspection was carried out on 12th April 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fairview 26/10/06

Fairview 05/05/06

Fairview 22/11/05

Fairview 13/06/05

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

CARE HOME ADULTS 18-65 Fairview 33 Bridgend Road Enfield Middlesex EN1 4PD Lead Inspector Susan Shamash Key Unannounced Inspection 12th April 2007 09:30 Fairview DS0000062524.V333365.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 Fairview DS0000062524.V333365.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. Fairview DS0000062524.V333365.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fairview Address 33 Bridgend Road Enfield Middlesex EN1 4PD 019 9271 1693 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) Avon Lodge UK Ltd Needyanand Raya Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Fairview DS0000062524.V333365.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th October 2006 Brief Description of the Service: Fairview is a care home registered to provide care for ten adults, aged 18 to 65, who have a learning disability. A private provider owns the home. Fairview is situated in a large purpose built care home, which also houses a care home for older people. The two homes are separated by a fire door. There are ten single bedrooms, including one en suite room. The home is situated close to a busy road, Bullsmoor Lane in Enfield. The amenities of Enfield Town are a bus ride away. Weekly fees are £1000 - £1400 according to needs as of April 2007. Residents purchase their own toiletries, travel fares, hairdressing etc. and contribute towards holidays. CSCI inspection reports are made available to residents in the dining area and they are informed when a new report has been received. Fairview DS0000062524.V333365.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was a routine visit to the home in order to check on compliance with requirements made at the previous inspection. The visit lasted approximately seven hours. The manager was available throughout the inspection, and the inspector also had the opportunity to speak to the area manager and two staff members. Two residents had moved out since the previous inspection, one into more independent accommodation and one to alternative residential care. One resident was in hospital at the time of the inspection. The inspector met with five residents independently during the inspection, and observed routines and interactions within the home. A tour of the building was conducted, although some residents’ rooms could not be inspected in their absence, as their permission could not be obtained. Residents’ records, staff files and maintenance records for the home were also inspected. What the service does well: The home provides a specialised service for residents with learning disabilities who also have mental health problems. Residents feel at home and have good relationships between themselves at the home. They speak positively about the support provided to them by staff. One resident told the inspector “this place has given me so much self confidence and really taught me to stand up for myself” for which the home is commended. Residents attend a number of social groups and clubs and are encouraged to form networks outside of the home. A group of residents play football regularly in a nearby park. Residents have the opportunity to go on holiday with others from the home every year. Admission and care planning processes are appropriate for the home. Care plans are in place for all residents and their progress in meeting goals set is reviewed regularly. They are encouraged to develop independence skills so that they can move on to more independent living settings. Residents are encouraged to be involved in all aspects of home life and a group of residents take pride in maintaining the home’s garden. Fairview DS0000062524.V333365.R01.S.doc Version 5.2 Page 6 The home is inspected at least monthly by a responsible individual on behalf of the provider organisation, and copies of the reports for these visits are sent to the local CSCI area office. What has improved since the last inspection? Action had been taken to ensure that residents have a review with a social worker at least annually as required. The confidentiality of documents stored in the office had been further safeguarded. Residents were being supported to dress appropriately and to arrange a holiday of their choice. Reliance on convenience foods had been reduced with fresh fruits available to residents at the home at all times. Health care appointments were being monitored so that residents are encouraged to attend routine checkups. Tighter medication procedures had been put in place to ensure the safety of residents. Staff had undertaken training in the protection of vulnerable adults, management of challenging behaviour and appropriate procedures had been produced for the home. A suitable area had been made available for staff on sleep-in duty at the home. Liaison was taking place with the local police service to address security issues within the home. A number of identified repairs/replacements had been made to the home environment. The kitchen had been refurbished, to a more domestic style setting with more space available for residents, which presents a significant improvement. Residents’ bedroom curtains and lampshades had been replaced according to their preferences. New staff at the home had been inducted, and worked must be surplus to requirements whilst undergoing inductions as required. Improvements had been made to the home’s recruitment procedures. Staff training audits had been undertaken to ensure that they are appropriately trained to meet the needs of residents. Fairview DS0000062524.V333365.R01.S.doc Version 5.2 Page 7 The manager was being supervised regularly and a quality assurance audit had been undertaken for the home. Finally old information in the office was being archived and the fire safety risk assessment for the home had been updated. 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. Fairview DS0000062524.V333365.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 Fairview DS0000062524.V333365.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. An appropriate system is in place to assess residents’ needs and goals effectively and ensure that these can be met. EVIDENCE: All residents’ files that were inspected included detailed assessments of their needs. Residents spoken to advised that they were involved in the assessment process and that their needs were being met appropriately. In previous inspections residents had told the inspector that they had had the opportunity to visit the home for meals, overnight and weekend stays prior to moving into the home. No new residents had been admitted since the previous inspection. Fairview DS0000062524.V333365.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, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs and goals are assessed and responded to effectively ensuring that they are met according to their choices. Risks are recorded appropriately in risk assessment formats with strategies in place to ensure that residents are protected as far as possible, whilst being encouraged to develop independence skills. Appropriate confidentiality procedures are in the place to protect the rights of staff and residents. EVIDENCE: Residents told the inspector that they remained free to come and go and make their own decisions with support from staff as needed. They also advised that regular residents meetings are held, to discuss the way in which the home is run. Fairview DS0000062524.V333365.R01.S.doc Version 5.2 Page 11 Support provided by the home in assisting residents with their finances, is documented, and residents are encouraged to be involved in the food shopping for the home. Care plans included evidence of support provided to meet residents’ goals as well as limitations placed on individual residents, where appropriate. Residents’ signatures evidenced that they had been consulted about the content of their care plans. Those spoken to confirmed that this was the case. Three care plans were inspected and were found to be satisfactory including regular reviews, records of some one-to-one sessions with residents and risk assessments clearly detailing control measures. However although staff spoken and residents spoken to described a high level of support provided to them, this was not clearly evidenced in their care files. One resident told the inspector “this place has given me so much self confidence and really taught me to stand up for myself” for which the home is commended. However support provided to two residents who were due to move out into more independent accommodation was not documented, and this was therefore difficult to verify. It is required that more detailed records be maintained of the support provided by designated key workers to assist residents in meeting their goals, to evidence that adequate support is provided to all residents. Risk assessments had been reviewed within the last six-months for each resident as appropriate. At the previous inspection it was required that the manager ensure that residents have regular reviews with their social workers. Written evidence was presented to the inspector that the manager had corresponded with the relevant social workers to arrange reviews as required. As required, new filing cabinets had been provided in the office for the storage of staff files and other confidential information. The inspector observed that these documents were being locked away as appropriate to protect the confidentiality of staff and residents. Fairview DS0000062524.V333365.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, 14, 15, 16 and 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents have varied lifestyles with access to meaningful activities both in the community and in the home and are supported to maintain links with their friends and families. They are encouraged to take responsibility for the running of the home and to develop independent living skills. Dietary needs of residents are catered with a varied selection of food. EVIDENCE: Staff and residents spoken to confirmed that residents are encouraged to go out and follow their individual interests. Most go out independently, and are involved in activities including various clubs in Enfield, Edmonton and Palmers Green, playing snooker, going to the cinema, shopping and meeting friends. Fairview DS0000062524.V333365.R01.S.doc Version 5.2 Page 13 Several residents are also involved in planting and tending to vegetables and flowers in the garden and keeping it tidy taking pride in their work. Three residents attend college courses and two are self-employed on a part time basis and two attend supported employment projects. Most residents spoken to indicated that they had active social lives. They also confirmed that they are supported to maintain contact with their relatives and attend places of worship of their choosing if they so wish. Residents usually go on an annual holiday with the home, however at the previous inspection several of those spoken to expressed disappointment at not going on holiday last year, and a requirement was made accordingly. The manager advised that a holiday had been booked for all residents to Clactonon-Sea for a week in July. In addition a holiday was being planned in Scotland for one resident over the summer, with staff support. Although there had been a decrease in activities towards the end of 2006, this was raised at residents meetings and action had been taken to address this issue, with days out for residents wishing to attend, arranged weekly in recent months. The manager and residents told the inspector that they had recently been to Madame Tussaurds, Canary Warf, the Maritime Museum and Greenwich, Ikea and the cinema, and photographs were also available from some of these trips. Residents spoken to said that the food provision in the home had improved, and fresh fruit was available. Residents were seen helping themselves to foods from kitchen cupboards. Staff were also seen supporting residents to prepare their own breakfasts, thus encouraging their independence. All residents were dressed appropriately at the time of the inspection as required, following concerns raised at the previous inspection. Stocks of food available to residents in the home included some fresh vegetables, and indicated less reliance on frozen and convenience foods as required. This was confirmed by residents and staff members spoken to. There were also some foods reflecting cultural diversity as reflected in the menus. Fresh fruit was available in the home for residents at the time of the inspection and residents advised that this was generally the case. Fairview DS0000062524.V333365.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 receive appropriate physical and emotional support in accordance with their needs and choices. Appropriate medication procedures are in place to protect residents from harm. EVIDENCE: Residents advised that their choice of time to go to bed, get up, take meals etc. were respected. Records indicated that the home seeks specialist support from external agencies where needed, to meet residents’ needs. At the previous inspection it was required that residents’ health care appointments be backdated to show when each resident last saw the dentist, optician etc. This had been undertaken as required providing evidence that residents were being encouraged to see the dentist and other health care professionals regularly as appropriate. Medication procedures were also found to be satisfactory, with appropriate records of medicines brought into the home and disposed of, and no gaps found in the medication administration records. Only one resident was prescribed PRN (as and when) medication, and written guidelines for when this Fairview DS0000062524.V333365.R01.S.doc Version 5.2 Page 15 resident should take this medication were provided as required. Pre-printed medication administration records had also been updated to ensure that discontinued medicines are no longer recorded. An alternative refrigerator is available for medication that requires refrigeration, however there was no such medication prescribed for any residents at the time of the inspection. Records were also available of visits from the local pharmacy to monitor the storage and administration of medicines in the home. Discussion with the manager and residents indicated that two residents were due to move out into more independent accommodation shortly. The inspector was concerned to note that no steps had yet been taken to support these residents to administer their own medication. Only one resident was self medicating at the time of the inspection. It is therefore recommended that staff support more residents to commence self-medicating in preparation for more independent living. Fairview DS0000062524.V333365.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. The home has a satisfactory complaints procedure to ensure that the concerns of residents are acted upon effectively. Procedures and appropriate training are in place to ensure the protection of residents from abuse. EVIDENCE: The home had appropriate procedures for investigating complaints and addressing adult protection and whistle blowing. Complaints, disclosures or allegations received since the previous inspection had been addressed appropriately. An Immediate Requirement was made at the previous inspection due to a failure to ensure that all staff are trained in adult protection. This was met within the timescale set, with training certificates within staff files to evidence this. One staff member had been unable to attend the training but they were booked to attend a relevant course shortly. Following incidents prior to the previous inspection it was also required that all staff be provided with external training in the management of challenging behaviour and that a copy of the updated challenging behaviour policy and procedures be sent to the local CSCI area office. Records indicated that this had been undertaken as required. Staff members confirmed that they had undertaken this training and found it useful. Fairview DS0000062524.V333365.R01.S.doc Version 5.2 Page 17 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 and 30. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Although significant improvements were made over the last few inspections, there remains further room for improvement to the environment in which residents live, in order to improve their quality of life. There is an adequate standard of cleanliness and provision of hand-washing and drying facilities throughout the home to ensure hygienic procedures for residents. EVIDENCE: Ten single bedrooms are provided in the home, along with five toilets, three bathrooms, a new en suite shower room and adequate communal space. The kitchen had been refurbished with new cupboards and working tops presenting more space and providing a less institutional feel. The cleanliness within the kitchen was of a satisfactory standard. The manager advised that advice had been sought from an occupational therapist in ensuring that the Fairview DS0000062524.V333365.R01.S.doc Version 5.2 Page 18 kitchen is accessible as possible. A new microwave had also been obtained for the home as required. The staff room in the home had previously been converted into a food storage area including a refrigerator and freezer. At the previous inspection the inspectors were concerned to note that since the managers office had been relocated to the activities room, sleeping-in staff were sleeping in the lounge. This was not appropriate as it prevented residents from accessing the lounge at night, and a requirement was made accordingly. The manager, staff and residents confirmed that this was no longer the case, with space available in a spare room, or the office for staff to sleep on a fold-up bed provided. As required new curtains and lampshades had been provided in residents’ rooms according to their preferences. Dining room chairs had been replaced and dining tables had been ordered and were due to be delivered within two weeks of the inspection. Since the previous inspection residents had experienced further problems with security at the home from young people in the neighbourhood. As appropriate the provider had sought advice from the local police in addressing the problem, however they had not yet made firm plans as to physical deterrents to be implemented e.g. fencing, CCTV cameras or shutters. It is required that they continue to liaise with the local crime prevention unit and act upon their advice to ensure the security of the home without delay. There were problems with hot water in some parts of the home at the time of the inspection and it was required that this be rectified. However although this problem had been partially addressed, there remained problems with hot water to at least two bedrooms in the house. It is required that this problem be addressed without delay. As required the bench near the back door had been replaced and the lock on the garden shed had been repaired. However due to repeated break-ins to the garden shed alternative storage arrangements had been made for residents to store their bikes away safely. As recommended new curtains had been provided in the lounge. The pool table had also been replaced. Fairview DS0000062524.V333365.R01.S.doc Version 5.2 Page 19 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, 35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A key group of experienced staff members support residents. Recruitment procedures are appropriate to safeguard residents. Staff members require some further training to ensure that the needs of residents at the home are met. Staff are supervised regularly to ensure that they meet the needs of residents effectively. EVIDENCE: No new staff had commenced employment at the home since the previous inspection. Staff files for four staff employed at the home were inspected. They were found to include the necessary documentation as required under the Care Homes Regulations 2001 Schedule 4 as appropriate. Two staff members were spoken to, and appeared to be knowledgeable about their role and responsibilities at the home and cultural needs of residents accommodated. They advised that they were receiving sufficient support and supervision from management at the home. Records indicated that regular supervision sessions are occurring between management and staff members. However no staff members had had appraisals and this is required. Fairview DS0000062524.V333365.R01.S.doc Version 5.2 Page 20 Residents spoken to advised that staff working in the home were supportive and met their needs appropriately whilst encouraging them to be as independent as possible. At the previous inspection discussion with staff members and observation of rotas indicated that staff stability within the home had been a problem and a requirement was made that this situation be monitored to ensure continuity of care for residents in the home. As recommended the manager had commenced a system of exit interview questionnaires, to address this. As required, induction records were available for all staff members. The manager advised that notes would be maintained of all prospective staff members’ interviews, and that they would be interviewed by at least two representatives from the home. It was not possible to verify this as no new staff had been recruited since the previous inspection. At the previous inspection the training matrix for staff members in the home did not tally with the certificates available for each staff member. As required this had been addressed for all staff members and all but one staff member had undertaken training in addressing challenging behaviour and adult protection. However it is required that the identified staff receive training in food hygiene and administration of medication. It is recommended that informal training be provided to the staff team in working with residents who have mental health problems. Two staff members had an appropriate NVQ level 2 qualification and one had an NVQ level 3. This only amounts to one third of the staff, which is below the national minimum standard of at least fifty per cent qualified staff. Adequate training must be put in place to ensure that at least fifty percent of staff employed have a minimum qualification of NVQ level 2 in care or equivalent. The area manager advised that as recommended the application form used by the home for recruitment, was being updated to include a statement by the candidate of their reasons for applying, and what they can contribute to the home. It remains recommended that residents should be encouraged to be involved in the interview process for new staff. Fairview DS0000062524.V333365.R01.S.doc Version 5.2 Page 21 Fairview DS0000062524.V333365.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. The home is generally well run with a suitably qualified and experienced manager in place at the home. There is consultation with staff and residents regarding the way in which the home is run to ensure that high standards are maintained. Residents’ health and safety is protected appropriately. EVIDENCE: The registered manager has managed the home over several years, and the inspector was satisfied that the home is generally managed effectively and competently with the best interest of residents in mind. As required evidence was provided that he is having regular supervision sessions and these sessions Fairview DS0000062524.V333365.R01.S.doc Version 5.2 Page 23 are recorded, with the manager retaining a copy of their own supervision notes. Staff and residents spoken to advised that they were consulted with regard to their views about the home at regular meetings. Records of residents and staff meetings also confirmed their consultation about the way the home is run. The area manager conducts monthly visits to the home and reports of these visits are sent to the CSCI. As required a quality assurance audit had been undertaken for the home with a copy of the results sent to the local CSCI area office. Monies stored on behalf of two residents for safekeeping was inspected and records were found to be accurate and up to date as appropriate. At the previous inspection access to current records maintained in the manager’s office was hindered by the presence of many years worth of records for each resident. It was therefore required that outdated information be archived. Although some material had been archived, the inspector noted that there is still a great deal more information that can be archived. The manager advised that he was using the archiving process as an opportunity for staff to learn about the histories of their keyworking clients, and to produce written summaries of the information archived. The inspector commended the manager for this project. There was a record of fire extinguisher and fire alarm servicing, fire alarm testing and drills at the home. Up to date insurance, gas and electrical wiring and portable appliances testing safety certificates were available. Current risk assessments were available for the home as appropriate including an updated fire risk assessment, as required. Records indicated that fire drills were being held regularly, however it is required that records of fire drills include the staff and residents involved and any issues or lessons to be learned from each drill. Fairview DS0000062524.V333365.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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X 3 2 X Fairview DS0000062524.V333365.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES 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 YA6 Regulation 12(1b) 15(2) Requirement The registered persons must ensure that records are maintained of the support provided by designated key workers to assist residents in meeting their goals. The registered persons must continue to liaise with the local crime prevention unit and act upon their advice to ensure the security of the home without delay. The registered persons must ensure that the hot water system is fully functioning across the home for the comfort of residents. (Previous timescale of 03/11/06 not fully met). The registered persons must ensure that the identified staff receive training in food hygiene and administration of medication to meet the needs of residents safely. The registered persons must ensure that adequate training is put in place to ensure that at least fifty percent of staff employed have a minimum qualification of NVQ level 2 in DS0000062524.V333365.R01.S.doc Timescale for action 01/06/07 2. YA24 13(4) 23(1) 15/06/07 3. YA24 23(2p) 18/05/07 4. YA35 18(1ci) 03/08/07 5. YA35 18(1ci) 29/06/07 Fairview Version 5.2 Page 26 6. YA36 18(2) 7. YA42 23(4e) care or equivalent, to ensure best practice within the home. The registered persons must ensure that all staff receive annual appraisals regarding their performance, to ensure that high standards are maintained. The registered persons must ensure that records of fire drills include the staff and residents involved and any issues or lessons to be learned from each drill, to ensure the safety of residents. 29/06/07 01/06/07 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. 3. Refer to Standard YA20 YA34 YA35 Good Practice Recommendations It is recommended that staff support more residents to commence self-medicating in preparation for more independent living. It is recommended that residents should be encouraged to be involved in the interview process for new staff, so that they are further involved in the running of the home. It is recommended that informal training be provided to the staff team in working with residents who have mental health problems to further improve practice within the home. It is recommended that more outdated information maintained on residents’ files be archived, so that important information can be easily accessed. 4. YA41 Fairview DS0000062524.V333365.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Fairview DS0000062524.V333365.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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