Inspection on 17/02/06 for Fairview

This inspection was carried out on 17th February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Fairview 25/07/08

Fairview 27/07/07

Fairview 23/08/06

Fairview 19/09/05

Fairview 11/01/05

Fairview 10/08/04

Fairview 10/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Fairview 42 Hill Street Kingswood South Glos BS15 4ES Lead Inspector Sam Fox Unannounced Inspection 17th February 2006 08:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Fairview DS0000034844.V279955.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Fairview DS0000034844.V279955.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Fairview Address 42 Hill Street Kingswood South Glos BS15 4ES 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) 0117 9352220 0117 9476234 Mrs June Phillips Mr Gordon Norman Brooking, Mr Derek Marsh Mrs Jacqueline Yvonne Reed Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Fairview DS0000034844.V279955.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate up to 24 persons aged 65 years and over requiring personal care May accommodate one named individual aged under 65 years with a physical disability, this condition will be removed when this resident leaves the Home or reaches the age of 65, whichever is the sooner 19th September 2005 Date of last inspection Brief Description of the Service: Fairview is situated in a quiet cul-de-sac in Kingswood and is close to local shops and amenities. Private parking is available in the front of the house. The home is registered to provide personal care and accommodation for up to 24 persons who are over 65 years of age. The home is an older property arranged over three floors. There is a large communal space separated into a lounge and dining area. Bedrooms have been refurbished. There is a shaft lift servicing all floors except for bedrooms 20 and 21. These two rooms are accessed by a small flight of stairs and can only be used by ambulant residents. Fairview DS0000034844.V279955.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, the purpose of which was to check on progress and to ensure that residents were settled and content. In addition to this other major focuses were training, staff recruitment and health and safety. Evidence was gathered from discussion with staff and residents. Opportunity was taken to join them with their lunchtime meal, which allowed time for more observation and discussion. Key records were also examined. Not all standards were inspected and this report should be read in conjunction with others so a fuller picture of the home can be gained. Three requirements made at the last inspection have not been met. It was agreed that these would be carried forward with extended timescales. Consideration will be given to further enforcement action if these continue to be unmet. What the service does well: What has improved since the last inspection? The boilers and hoists have been serviced, thus meeting a requirement made at the last visit. This makes the house safer. The medication system was inspected and found to be safe and regular stock checks are being made. This meets with a requirement made at the last inspection. Staff are now more fully recording residents’ wishes in the event of their death. Fairview DS0000034844.V279955.R01.S.doc Version 5.1 Page 6 The flooring in a bedroom has been replaced, thus reducing the odour and making it a more pleasant environment. In addition to this a carpet, identified as being a tripping hazard at the last visit, has been stretched, thus making it safer. 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. Fairview DS0000034844.V279955.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fairview DS0000034844.V279955.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4,5 There are effective systems in place to ensure that residents’ needs are assessed prior to admission. Action, however, need to be taken to ensure that the home is not providing a service outside of their registration category. EVIDENCE: All residents are issued with a contract – these were randomly inspected and found to be up to date and include signatures. These also include a schedule of fees. This meets with requirements of the legislation. An initial assessment is carried out for all new residents prior to their admission. Those seen were detailed and enable the manager to ascertain whether Fairview has the resources and skills to meet need. They also included past medical histories and information from next-of-kin. Fairview DS0000034844.V279955.R01.S.doc Version 5.1 Page 9 At the last visit it was noted that there was one resident with a diagnosed mental health need who resides at the home with their relative because of this. They are independent in most aspects of their care and as such are not living at Fairview due to their ageing needs. The home must submit an application to vary their registration so that they are not operating out of category. They must also ensure staff have training to meet these needs and are aware of trigger points which may indicate this resident is becoming unwell. In addition to the above it was identified in their initial assessment that a major risk would be if they were to refuse to take medication and that this had a high likelihood of resulting in a hospital admission. The home must outline within the care planning system how the home supports the resident and monitors this. Residents confirmed that they were able to visit the home and have trial visits before moving there. Fairview DS0000034844.V279955.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Residents can expect to have their health care needs met and the medication system is safe. In order to promote dignity and respect the use of bedrooms for staff use should cease. Care plans should be developed to ensure more consistency and to evidence that residents are given a choice. EVIDENCE: Opportunity was taken to view four residents’ files. These contained information about residents’ needs, including initial assessments, preferred daily routines and care plans. These are reviewed at monthly intervals. Information held is inconsistent. A recommendation continues to be made that these be further developed. Residents are supported to see the relevant health professionals and specialists. They confirmed that they regularly saw the opticians, dentists and chiropodist if they needed it. They were all satisfied with arrangements in this respect. Fairview DS0000034844.V279955.R01.S.doc Version 5.1 Page 11 The home operates a monitored dosage system for the administration of medication. Records held were found to meet with requirements of the legislation. The manager explained that there had been some difficulties but these had been resolved through discussion with the pharmacist. All residents consulted with spoke highly of the staff team and it was apparent, through observation, that relationships between the two were respectful and friendly. It was observed that residents had their own style of dress, hair and make up and that staff ensure that residents are supported to retain their individuality. The payphone is located in the hallway – it is, however, on a high ledge, which may not be accessible to residents with physical disabilities. It is recommended that this be moved to a more suitable position for ease of use for those who don’t have their own telephone line. It was noted that interviews and staff training take place in a resident’s bedroom. This practice is unacceptable and, in order to protect residents’ privacy and dignity, alternative arrangements should be sought. Personal files indicated that residents are now being more consistently asked their wishes in the event of their death. Fairview DS0000034844.V279955.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,15 Residents can expect to be supported to maintain links with people who are important to them and to receive nutritious and wholesome food. EVIDENCE: A number of residents explained that they have regular visitors, including family and friends. The manager confirmed there are no restrictions on these visits and this was observed at the time of the inspection. All visitors were observed being made to feel welcome and being offered refreshments. Menus indicated that residents’ benefit from a variety of nutritious meals and that there is a main choice every day. Opportunity was taken to join residents’ with their lunchtime meal. This was well presented and tasty. All residents on the table enjoyed this and one was given a further alternative on request. All those consulted with had no complaints about the food. It was served in a sensitive and unhurried manner. Fairview DS0000034844.V279955.R01.S.doc Version 5.1 Page 13 The manager displayed an awareness of the need to cater for different dietary requirements according to medical need. In addition to this it was observed that residents can have their meals in their bedrooms of they choose to or if they are unwell. The environmental health officer recently visited the home and was satisfied with standards of cleanliness and procedures in the kitchen. Fairview DS0000034844.V279955.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Residents can be confident that staff will listen to their concerns and that they will be protected from abuse. EVIDENCE: All residents spoken with praised the staff and said they would have the confidence to speak with them if they had any concerns. The complaints procedure is displayed in the hallway of the home and has been updated. This meets with requirements of the legislation. There have been no new complaints received by the home since the last inspection. Fairview has a protection of vulnerable adults policy and staff confirmed that they receive training about this. Fairview DS0000034844.V279955.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,23,24,26 Residents can be re-assured that they will live in a comfortable, homely and clean environment. EVIDENCE: Fairview is situated within the heart of Kingswood and many residents lived within the community before they moved there. It has spacious grounds, which are well maintained. As noted at the last inspection there is a small lip to the front door which causes difficulties for people with mobility difficulties or when staff are manoeuvring wheelchairs. Action needs to be taken to get ramped access here. This is a repeated requirement. All bedrooms seen continue to be personalised and to reflect individual tastes – indicating that choice and independence are prompted in this area. One resident has had their flooring replaced, which has improved the odour. Fairview DS0000034844.V279955.R01.S.doc Version 5.1 Page 16 The home continues to be cleaned to a good standard. One toilet on the ground floor had an unpleasant odour. This had been identified by the manager as being caused by a leaking toilet and was being replaced on the day of the inspection. Fairview DS0000034844.V279955.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29,30 Recruitment procedures must be reviewed to ensure their adequacy in protecting vulnerable adults. EVIDENCE: Staff rotas indicated that there are three care assistants on duty throughout the waking day, reducing to two at night. There are some ancillary staff, including a housekeeper and cook. The manager explained that, at some points throughout the week, she is supernumerary to these hours so she can have time to carry out her managerial duties. This was not clear on the rota and should be highlighted to further evidence that she has enough time to carry out these tasks. This is particularly important given the shortfalls in recording identified during this visit. At the time of this inspection two new staff had been recently employed, one of who was having induction. Opportunity was taken to examine their personal files. There were application forms in place. These, however, were incomplete and there were no dates for past employment so it was difficult to gain a clear history. It was also unclear whether acknowledged gaps in employment had been discussed. Referees also commented that they had difficulty filling out requests for references, as they did not know the position applied for. Fairview DS0000034844.V279955.R01.S.doc Version 5.1 Page 18 Neither of the employees had had a police check. On further discussion it was also noted that they did not have a povafirst check and one had yet to send off their CRB form. The manager was informed that all new members of staff should have a povafirst check as a minimum before they work in the home, even if they were under supervision. One of these members of staff was rostered to work at the weekend and the manager was informed they could not do so until this check had been obtained. The manager must review recruitment systems to ensure they are more robust. The manager said that new staff had received induction training. There was, however, no records of this so it was difficult to established fully what they had undertaken and whether this met with national minimum standards. Fairview DS0000034844.V279955.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38 Record keeping needs to be improved and health and safety checks need to be carried out more regularly so that residents are kept safe. EVIDENCE: Record –keeping is an area for weakness within the home and this needs to be improved upon for them to more clearly evidence that they are meeting with requirements of the legislation. This has been an issue noted throughout the report (and particularly in relation to health and safety checks). This was also the case in relation to the recording of staff meetings and supervision. It was not clear the reasons for this, for example, whether the manager has enough time. It is recommended that work practice in this respect be reviewed. Fairview DS0000034844.V279955.R01.S.doc Version 5.1 Page 20 The fire logbook evidenced that whilst some tests and checks are being carried out regularly others are not. More spefically in the case of testing the emergency lighting and checking the fire fighting equipment. The home must ensure that these take place at the appropriate intervals and that this is fully recorded. Also the last recorded fire drill was on the 8/4/05 – these should be formally carried out at six monthly intervals. In addition to the above there was no work place fire risk assessment in place. There were a number rof health and safety risk assessments in place. These should be reviewed annually. The last formal record of hot water checks was on the third of December 2005. The home must ensure that these are carried out more regularly. All portable appliances had been tested within the last year. It was noted that the boiler and hoists had been serviced within the last six months – this meets with requirements made at the last inspection. Also the lift had received its annual check. There was an up to date insurance certificate. Fairview DS0000034844.V279955.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 1 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X 3 3 X 3 STAFFING Standard No Score 27 3 28 X 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X 2 1 Fairview DS0000034844.V279955.R01.S.doc Version 5.1 Page 22 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 OP4 Regulation 12 Requirement Make application to vary the registration certificate for two residents with identified mental health needs. Repeated requirement Timescale for action 15/03/06 2. 3. OP4 OP25 12(1)(a) 23(4)(c) Develop risk assessment for one resident regarding medication. Conduct routine maintenance of all fire doors (and fully record when this has been actioned) Repeated requirement 15/03/06 15/03/06 4. 5. 6. 7. OP10 OP19 OP29 OP29 12(4)(a) 23(2)(n) 18(1)(a) 19 Stop using residents’ bedrooms for staff interviews and training. Provide ramped access to front Repeated requirement 18/02/06 30/03/06 30/03/06 18/02/06 8. 9. 10. 11. Fairview OP30 OP38 OP38 OP38 18(1)(a) 23(4) 13(4)(a) 23(4)(e) Review recruitment procedures to ensure that they are followed appropriately Ensure all new staff have a povafirst check as a minimum if they are to work on the premises. Ensure that all new staff have a full induction and this is recorded. Develop workplace fire risk assessment Review health and safety risk assessments Conduct a fire drill DS0000034844.V279955.R01.S.doc 18/02/06 30/03/06 30/04/06 15/03/06 Page 23 Version 5.1 12. 13. OP38 OP38 23(4)(c) 13(4)(a) Ensure tests and checks of fire fighting systems are carried out at the appropriate intervals Ensure hot water outlets are tested at regular intervals. 18/02/06 18/02/06 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 OP7 OP10 OP37 Good Practice Recommendations Further develop care plans Move pay phone so it is in a more accessible position Review procedures in relation to record-keeping Fairview DS0000034844.V279955.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Fairview DS0000034844.V279955.R01.S.doc Version 5.1 Page 25 - 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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