Inspection on 23/11/05 for Fairview

This inspection was carried out on 23rd November 2005.

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

Fairview 10/06/09

Fairview 29/05/07

Fairview 27/06/05

Fairview 05/01/05

Fairview 07/07/04

Similar services:

Elmleigh Convent

Eastfield Farm Residential Home Limited

Cranwell Court Care Home

Cottingham Hall

Cranmer Scheme

Fairburn Mews

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

CARE HOMES FOR OLDER PEOPLE Fairview Brooklands Avenue Leeds LS14 6NW Lead Inspector Sue Dunn Announced Inspection 23rd November 2005 09:30 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 DS0000033206.V256595.R01.S.doc Version 5.0 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 DS0000033206.V256595.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Fairview Address Brooklands Avenue Leeds LS14 6NW 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) 0113 2738980 0113 2738980 Leeds City Council Department of Social Services Mrs Carol Burton Care Home 37 Category(ies) of Dementia - over 65 years of age (37) registration, with number of places Fairview DS0000033206.V256595.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27 June 2005 Brief Description of the Service: Fairview is a two storey care home owned and operated by Leeds City Council to provide care for older people with dementia. It is situated in the Seacroft area of Leeds within easy reach of public transport routes and local amenities. The home has 34 permanent beds, the remainder being available for short term respite care. The first floor has passenger lift access. Bedrooms offer single occupancy but do not have en suite facilities. Communal areas offer sufficient space for residents to meet visitors in private. Restriction of movement within the home is kept to a minimum. Signs and pictures are used around the building to provide prompts which assist people to find their way around the home. The building opens onto an enclosed courtyard and has safe surrounding gardens. Care staff are trained to NVQ standard and receive other training related to their work. Fairview DS0000033206.V256595.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector undertook the inspection, which was announced. The inspection started at 9.30am and finished at 2.15pm. The purpose of the inspection was to ensure the home was operating and being managed for the benefit and well being of the residents. A pre inspection questionnaire and comment cards were sent to the home before the inspection. Three relatives returned completed comment cards. What the service does well: The officer team in the home know the residents and though not involved in the day to day care had a good understanding of their needs. The manager expects a high standard and has systems to ensure the standards are maintained and the home is run in the interests of the residents. Staff supervision is used effectively to develop staff skills and care practices. Care files are orderly and would provide guidance for any member of staff about how each resident is to be cared for. The home has a care plan for people on respite care. This is updated and reviewed at the start and end of each period of care. The home has a programme of activities suited to the abilities of the residents. Staff who have an interest in this area are encouraged to develop their skills further. There was evidence to show that staff understood their responsibilities for protecting residents from abuse. Odour control in the home was good. This does not come without hard work and commitment from the staff team. Bedrooms and communal areas are pleasant and ‘domestic’ in appearance with a range of comfortable seating and a variety of décor to identify one area from another. The manager monitors training to ensure each member of staff has the opportunity to discuss the effectiveness of each training course. The training programme is relevant to the skills and knowledge staff need to work with people with dementia. The shift handover system gives all staff the information they need to provide continuity of care. Fairview DS0000033206.V256595.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Fairview DS0000033206.V256595.R01.S.doc Version 5.0 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 DS0000033206.V256595.R01.S.doc Version 5.0 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 Service users and their families are involved in the admission process. Information is used positively to form the basis of a care plan which supports people to retain existing abilities. EVIDENCE: Each person who moves into the home has a licensing agreement setting out the terms and conditions of their occupancy. Where one contract had not yet been signed the reasons for this had been recorded to show that it had not been overlooked. Each file inspected contained social workers assessments identifying the needs behind the referral for care. The home’s own assessment to establish if needs could be met was of high quality. The assessment identified needs and the resources required to meet the needs in a way which showed the level of support required and provided the basis for a care plan. There was evidence to show that residents and their families had been involved in this process and the manager had liaised with support workers in the community Fairview DS0000033206.V256595.R01.S.doc Version 5.0 Page 9 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 The health and personal care needs of residents are met and care plans, which are regularly reviewed, provide clear and detailed instructions for staff to follow. Residents are treated with respect and their privacy is upheld. EVIDENCE: Care files were well presented with an index of contents and clear sections. This led to a consistency of layout, which made it easy to find information. Efforts had been made to gather background information that helped staff to know enough about each person to be able to care for them in a person focussed way. Each file gave guidance for staff on what information was relevant to put in a care plan. Care plans were reviewed, including those for people using the respite service, and a plan of action recorded. Accident records and violent incident reports could be cross referenced with more detailed information in the files. The records, audited each month by the manager, showed appropriate action is taken. A summary of risks shows the area of risks rated and a risk reduction plan introduced into the care plan if required. Fairview DS0000033206.V256595.R01.S.doc Version 5.0 Page 10 Daily records are regularly archived so some information was more difficult to cross reference. It is recommended that daily records remain in the file for a couple of months at a time. Some staff were better at others than recording relevant information. It is suggested that some staff co-work on recording in order to develop skills in this area. The member of staff administering medication proved to be knowledgeable and competent. People on PRN medication were offered choice. Staff were observed to approach residents and offer assistance in a discreet manner. One resident indicated that her summer weight skirt was rather lightweight for the season. Staff must bear this in mind when assisting residents with their choice of clothing. Fairview DS0000033206.V256595.R01.S.doc Version 5.0 Page 11 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): 12,13,14,15 Residents are encouraged to participate in social and leisure activities, to maintain links with their friends and family and to exercise choice and control over their lives. A good, varied and nutritious menu takes into account individual choices. EVIDENCE: One relative felt it would be beneficial to have some activities each day however the records showed a range of activities on offer and the people who participated each day. The programme included drawing and colouring, singing and dancing, dominoes, board games, baking , reading and assisting with simple domestic tasks. One of the staff takes a lead role in organising activities and, with the manager, is to attend a training course on working with life story books. Relatives and friends were invited to the recent bonfire party. The midday meal served in the main dining room was held in a leisurely and relaxed atmosphere. Staff were observed to encourage and assist people as required. The meal offered an option of home made soup and sandwiches followed by dessert. The main meal is served at the end of the day. The manager is to review the menus after Christmas. Fairview DS0000033206.V256595.R01.S.doc Version 5.0 Page 12 The use of eye catching signs on doors to bedrooms and other communal areas provides residents with prompts to find their way around the home independently. Fairview DS0000033206.V256595.R01.S.doc Version 5.0 Page 13 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): 17,18 The level of staff understanding gives assurance that service users will be protected from abuse. Service users legal rights are protected. EVIDENCE: A recent incident in the home confirmed that the manager and staff are familiar with the whistle blowing policy, take action to protect the safety of the residents and understand the procedures for the Protection of Vulnerable Adults (POVA). The manager has taken advice from the electoral registry regarding the degree of support it is appropriate to give to people when exercising their right to vote. All residents in the home are placed on the electoral register. Fairview DS0000033206.V256595.R01.S.doc Version 5.0 Page 14 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): 19,20,21,23,24,25,26 The home offers a safe, well-maintained ‘homely’ environment for the residents. Visual prompts around the building assist people with memory loss to retain a degree of independence. EVIDENCE: The home was clean and free from any unpleasant odours. Some carpeted areas have been replaced with hard flooring, without appearing institutional, in order to assist in odour control. Staff clearly work hard to maintain standards of cleanliness and hygiene. Bedrooms and communal areas were pleasantly decorated and furnished with thought given to the details which made the home more ‘domestic’ in appearance. Bedrooms contained personal items and reflected individual preferences for bedding and pillows. Some duvets appeared rather lightweight for the season. The manager agreed to check that the night staff make extra bedding available if required. Eye catching signs around the building help residents to find their way around. Fairview DS0000033206.V256595.R01.S.doc Version 5.0 Page 15 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): 27,28,30 The staff training and supervision programme aims to ensure staff are trained to be able to understand and meet the needs of the service users. Staff are deployed in a flexible way to care for residents at peak times. EVIDENCE: A core group of staff have been employed in the home for many years. There have been some losses in the staff team since the last inspection. Any shortfalls caused by vacancies have been covered by agency staff who, whenever possible, are familiar with the home. The NVQ programme is ongoing to meet the target of 50 with the award. This has fallen behind as people with the award have left the home. Staff have attended other training relevant to their roles. The training records include a statement which staff sign to confirm that they have attended and understood the training. The records listed training on the complaints procedure, Data Protection, fire safety and understanding personal detractors(PD’s), which is particularly relevant to the care of people with dementia. The staff have information handover meetings between each shift and full staff meetings are held 2 monthly. The minutes of the last meeting in October included discussion about the care plans and provided good evidence of management issues discussed at the meeting. The manager gave an example of how the staff supervision programme was used to support staff and deal with any poor practices. Fairview DS0000033206.V256595.R01.S.doc Version 5.0 Page 16 Care and ancillary staff are deployed at peak times such as mealtimes to ensure residents needs are met. A relative felt that there did not always seem to be enough staff and staff felt that the one area in which they could do better would be to have enough staff to be able to take people out more frequently. Fairview DS0000033206.V256595.R01.S.doc Version 5.0 Page 17 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): 31,32,33,34,35,36,37,38 The home is well managed and the manager is well able to discharge her responsibilities. She offers good leadership to the staff and ensures the residents are protected and cared for in a correct manner. The standard of record keeping was high. EVIDENCE: The manager has achieved the Manager’s Award and is completing the care component. She continues to review the service and introduce action plans as required for the development of the home and in response to the resident and relatives suggestions. She has a forthright manner and provides strong leadership which leaves people in no doubt about her expectations for the quality of care for residents. Residents’ finances are held by families or by the department of Social services. The manager ensures that people have sufficient personal allowance Fairview DS0000033206.V256595.R01.S.doc Version 5.0 Page 18 money available to meet their requirements. Records are kept of all money spent on behalf of each resident. Health and safety records and staff training records were up to date and showed that the health and safety of staff and residents is promoted and protected. All the records inspected were in good order and easy to examine. Fairview DS0000033206.V256595.R01.S.doc Version 5.0 Page 19 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 4 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 3 18 3 3 3 3 x 3 3 4 4 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 3 3 4 4 3 Fairview DS0000033206.V256595.R01.S.doc Version 5.0 Page 20 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 2 3 4 Refer to Standard OP7 OP13 OP7 OP7 Good Practice Recommendations Daily records should remain on file for a long enough period to allow for information to be cross referenced There should be enough staff to allow time to take residents out into the local community Residents should be assisted to wear clothing which is suited to the weather conditions Some staff need support to improve the content of information they record about day to day events. Fairview DS0000033206.V256595.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 DS0000033206.V256595.R01.S.doc Version 5.0 Page 22 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. 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