Inspection on 25/07/08 for Fairview

This inspection was carried out on 25th July 2008.

CSCI found this care home to be providing an Adequate service.

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 27/07/07

Fairview 23/08/06

Fairview 17/02/06

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 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Fairview 42 Hill Street Kingswood South Glos BS15 4ES Lead Inspector Grace Agu Unannounced Inspection 25th July 2008 09:15 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.V365342.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 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.V365342.R01.S.doc Version 5.2 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 jackiereed@btconnect.com Mrs June Phillips Mr Gordon Norman Brooking, Mr Derek Marsh Manager post vacant Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Fairview DS0000034844.V365342.R01.S.doc Version 5.2 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 27th July 2007 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. The cost per week to reside at Fairview will range from £348.00-£480.00. Fees are reviewed annually and if care needs increase. This weekly fee does not include provision for items such as hairdressing, chiropody, dental, ophthalmic, or audiology services. Prospective residents can be provided with information about the home by accessing the Service Users Guide, which will detail the services and facilities available at the home. Fairview DS0000034844.V365342.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes This was an unannounced site visit that took place over one day totalling eight hours as part of the key inspection. On arrival we spent time talking to staff and a group of residents in the lounge area whilst waiting the arrival of the Group Manager Mrs Gill Evans who stated that she is also the acting manager since the previous manager left in January 2008. We also conducted a tour of the building and had the opportunity to talk to residents who are in their bedrooms about their care and how they spend their day. Later on in the day we spoke with four relatives who were visiting on the day. Approximately four hours of the day was spent looking at care, recruitment and other relevant records in order to check the working practices of the home and to follow up the requirements made at the last inspection. Prior to the site visit surveys went sent to the home for residents, their relatives and health professionals to complete. 5 resident relatives forms were returned and one general practitioner completed a comment card. At the end of the visit we discussed some of the outcome feedback with to Mrs Gill Evans the Group manager of the organisation/acting manager of the home. What the service does well: The home offers a relaxed, friendly and homely environment and all residents and their relatives spoken with and surveyed confirmed that they are happy living there. Daily routines are flexible and staff accommodate individual lifestyle choices, whilst enabling residents to remain as independent as possible. Care planning records clearly evidence the home’s person-centred approach to the care of its residents. The home believes that dignity is important for all the residents and that they are made to feel safe I and comfortable with their living accommodation. The home offers a varied menu, which allows for individual choice and preferences, and residents enjoy their meals in a relaxed and pleasant environment. Fairview DS0000034844.V365342.R01.S.doc Version 5.2 Page 6 Staff observed during the visit were seen to interact well with residents and attended to their needs in a patient and understanding manner. Comments made by residents and their relatives include: “ I am always able to go out to the shops and I am offered a bath. I am happy with my key worker”. “All staff are very polite and helpful. Other comments include “mum has been here for a number of years. She is well cared for. Staff are brilliant and kind. Mum is allowed to walk around. The food is very good”. The home stated in the Annual Quality Assurance Assessment that it builds trusting relationships with residents and their families/representatives, verbal aggressive outburst are rare, staff are trained to deal with these appropriately, ensuring the safety of all residents, expression of frustration are responded to in a measured and effective manner. The AQAA also stated that staff communicate well through verbal and written reports on a daily basis. Evidence of this was noted on the day of this visit. What has improved since the last inspection? What they could do better: Whilst touring the building we noted that the flooring in one resident’s room had raised areas with a potential to cause accident/ fall to the person living in the room. We discussed our observation with the Group manager and were informed that the flooring will be replaced to reduce the risk of fall Fairview DS0000034844.V365342.R01.S.doc Version 5.2 Page 7 Ensuring that medication is signed for after administering and stating the reason if not administered would prevent drug error and protected the residents. 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 DS0000034844.V365342.R01.S.doc Version 5.2 Page 8 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.V365342.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The process of admission is well planned and managed with clear information to enable the residents to make a decision about the services provided at the home. EVIDENCE: The home has a Statement of Purpose and a Service Users Guide. These two documents have recently been updated. This is to ensure that accurate and required accurate information are provided to prospective service users and their relatives when they visit the home or make enquiries to enable them to make an informed choice about moving into the home. The care files of one recently admitted person showed that the resident was assessed before admission to the home. The home stated in the Annual Quality Assurance Assessment (AQAA) that the home uses a validated needs Fairview DS0000034844.V365342.R01.S.doc Version 5.2 Page 10 assessment tool that supports the community assessment tool used by health and social care professionals. This assessment covers physical health, psychological health and social needs. The AQAA also stated those potential service users and their relatives or advocated are encouraged to visit the home for a day and will be offered a meal. This is to enable the service user and or their relative to meet the existing residents and discuss the services provided before making a decision. Following the initial assessment key workers draw up care plans and ensure that these are reviewed regularly and record any changes, significant events and social activity. The individual is made aware of the one-month trial period during which they can change their mind. There was evidence of the home’s contract stating the costs and services provided as well as the individual’s rights. Fairview DS0000034844.V365342.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home offers care and support to service users throughout their lives and towards the end. It protects service users by appropriate risk assessments and care plan review with the involvement of doctors and other health professionals. Medication administration practices are unsatisfactory. EVIDENCE: On the day of this visit we looked at two care files. There was evidence of preadmission assessment before admission of one new resident to the home. This assessment was to determine whether the home is suitable and able to meet residents’ needs. The residents are reassessed on admission before care plans are provided detailing how the assessed needs are to be met. This is followed up by monthly reviews and intervention as needs change. Service users spoken with confirmed that staff treated them with respect and knocked at the door and waited for an answer before entering to attend to Fairview DS0000034844.V365342.R01.S.doc Version 5.2 Page 12 their personal hygiene needs. One service user spoken with said Staff are very kind ‘I get up when I want to’. We noted on the care file that there were risk assessments; manual handling risk assessments, nutritional risk assessment and weight monitoring records. These were regularly reviewed. There was evidence of visits from the optician, chiropodist and other health professionals on the care files reviewed. Medication administration was reviewed and some practices were noted unsatisfactory. Medicines prescribed to be given regularly were given as ‘when required’. The Group manager stated that this was agreed with the doctor verbally but had not been altered or confirmed in writing to reduce the risk of medication errors from happening. A requirement has been issued to remedy this unsatisfactory practice. The Group manager (Mrs Gill Evans) stated that she would contact the General Practitioner to review the identified medication and would ensure that records of all refused medicines are clearly documented including the reason for refusal. We will be monitoring this at the next visit. Records show that the home has a medicine policy was in place, there was evidence of receipt and disposal of medication and these were properly recorded. Action has been taken to provide training about medicines for staff, and this is good practice to help staff administer medicines safely. A local pharmacy supplies medicines monthly using a blister pack monitored dosage system. Some records seen show that the medicines refused by service users have not been recorded in the Medication Administration Record Sheets and no reason for refusal was noted in the daily record. There was evidence in the care files viewed of details of service users’ wishes in the event of death. One staff member that we spoke with showed awareness of policies and the procedure regarding dealing with a dying individual and at the time of death. The staff member was aware of the importance of keeping information about service users’ confidential. Fairview DS0000034844.V365342.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are enabled to maintain links with their families; they are also provided nutritious meals and meaningful activities. EVIDENCE: Care plans reviewed contained a social assessment form, which is completed by the resident, or their representative on admission to enable the home to plan a suitable activity based on the details given. The home has an activities coordinator who ensures that as many residents as possible participate in the activities organised by the home. The activities person is shared between the sister home in the adjacent premises owned by the same organisation. The individual enables the residents to participate in activities on Tuesdays and Thursdays presently, however the Group Manager stated that a care worker has been appointed as an activities person for the home on full time and will be starting as soon as possible and that this would provide more activity hours for the home. Fairview DS0000034844.V365342.R01.S.doc Version 5.2 Page 14 Whilst walking round the building we observed that there were a group of service users participating in flower arranging activities in one of the lounges individuals that were able to engage in conversation told us that they were very happy and that they enjoyed what they were doing. During a discussion, the activities organiser stated that there is a list of monthly activities for special events, weekly planned activities that include outings and trips. Activities recorded included exercise every morning, musical bingo, reminiscence on 40s and 60s, throwing the ball, sing songs music movement. There are also one to one activities for the residents who prefer to be in their rooms. There were also organised group outings. For example the re was a trip to the Bristol Zoo and the garden centre in May 2008.Evidence of these were recorded in individual record of activities. The Activities coordinator met on the day also stated that some residents are taken over to the sister home to participate in activities of interest to them. One individual told the inspector the she still goes down to the shops to buy some personal items. One comment noted on the survey includes “I am always able to go out to the shops and I am offered a bath. I am happy with my keyworker. Residents spoken with stated that the home actively supports them to maintain contact with families, friends and representatives and that visiting time is not restricted. The home also stated in the Annual Quality Assurance Assessment (AQAA) that the home is open to visitors and relatives in accordance with the wishes of the residents, on a daily basis throughout the day and evening. This was confirmed by a group of relatives met attending their relative’s 90th birthday on the day of the visit. The menu on the day contained a choice of two nutritional meals and a choice of pudding. One of the puddings tasted by the inspector was delicious. The meal was relaxed and residents were given the meals based on the choices they made after consultation on the meals available to them. The home told us in the AQAA that residents enabled to eat their meals at a pace that they are comfortable with and encourage independent eating without assistance unless this is necessary. The kitchen was found clean, risk assessments in relation to various areas of the kitchen and hazardous equipments were in place and satisfactory. Records of fridge and freezer temperatures were up to date. Food in the fridge was labelled in order to reduce the risk of food poisoning. Fairview DS0000034844.V365342.R01.S.doc Version 5.2 Page 15 The cook stated that she is booked to undertake Advanced Food Hygiene Certificate to enable her to teach food hygiene to all staff at the home to ensure that the resident’s staff and visitors are adequately protected. The home was recently awarded five star rating following an Environmental Officer’s visit from South Gloucester Council. The cook stated that a new freezer and a new dishwasher had been purchased as a part of ongoing refurbishment at the home. Fairview DS0000034844.V365342.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are enabled to complain and are confident that the home will protect them from harm and abuse. EVIDENCE: A review of the complaints book showed that one complaints was recorded since the last inspection in relation to not giving enough notice to a relative to take an individual for hospital appointment. The Group manager satisfactorily investigated and resolves the complaint using the home complaint procedure. The home’s complaints procedure was noted displayed at the entrance of the home. The home has policy and procedure on Protection of Vulnerable Adult from Abuse. There was evidence that staff have attended training on this to ensure that the residents are adequately protected. The home has policy on Whistle blowing to enable staff to report any bad practices without reprisal. Staff files viewed showed that satisfactory Criminal Record Bureau disclosures had been obtained before commencement of employment to ensure that residents are protected. Fairview DS0000034844.V365342.R01.S.doc Version 5.2 Page 17 Fairview DS0000034844.V365342.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,25,26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents enjoy a clean, hygiene and pleasant home;However the home has not provided safe flooring in one identified resident’s room. EVIDENCE: There have been no changes in the services provided at the home since the last inspection. The location and layout of the home remain suitable for it’s stated purpose. Residents were found to be relaxed in the lounges and some in their bedrooms. The home was found clean, tidy, warm and free from offensive odour. Whilst touring the building it was also noted that one resident’s room had raised areas on the recently replaced flooring. This observation has the Fairview DS0000034844.V365342.R01.S.doc Version 5.2 Page 19 potential to cause falls and injury to the resident. This was discussed with the handyman and the Group Manager and the inspector was assured that the flooring would be replaced as soon as the contractor was contacted. It was agreed that that the home should contact the Commission. To enable us to monitor this agreement we contacted the home before this report was concluded and we were informed that the home had received some quotes for the replacement of the flooring. We have issued a requirement to ensure that this work has been undertaken to protect the individual. Other areas of the home were well maintained and we noted on the day that the handyman was redecorating the room of the resident who was attending a day centre for organised personal activities. The laundry area was found clean with good flooring and hand washing facilities. Staff spoken with was aware of infection control measures and would ensure that soiled linen are separated from normal laundry before washing to prevent cross infection. It was noted that the washing machines also have sluicing programmes to meet disinfection standards. The home has Control of substances Hazardous to Health (COSHH) policy. The staff member also stated that they have attended first aid, COSHH and would attend infection control training update scheduled 8 September. Fairview DS0000034844.V365342.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The recruitment procedure of the Home is robust and offers protection to residents at the Home. Staffing levels is satisfactory in line with the category of the residents living at the home. EVIDENCE: Staffing levels were found to be satisfactory on the day of inspection. There are staff for catering, domestic cleaning and laundry and a maintenance person. Staff were noted knocking at the doors and waiting before and assisting residents with personal care. Staff were also noted working together as a team. One staff spoken with stated that “ we work together as a team and we are committed to the residents and the home.” Evidence showed that the home is committed to ensuring that staff are appropriately trained to provide good standards of care for the residents. It is commendable to note that 12 care staff at the home have achieved National Vocational Qualification (NVQ) level 2 and 3 qualifications. Two care staff are undertaking NVQ 2 and one newly appointed staff is to commence soon. The Group Manager stated that staff training update on Infection Control and First Aid have been booked for 8 September and 7 August respectively. Fairview DS0000034844.V365342.R01.S.doc Version 5.2 Page 21 Evidence also show that staff members have attended First Aid training, to ensure that there would be a first aid qualified person in every shift at the home. Staff have also attended other relevant courses such as Manual handling Health and safety and the Protection of Vulnerable Adult from abuse. Each staff member had a training record book held in the office. This record is well maintained. This is to ensure accurate recording of individual training and development. It is also designed to monitor training attendance. Residents spoken with on the day stated that they were satisfied with the numbers of staff on each shift, feel safe and that the services provided by staff are “very good”. One visitor at the home on the day stated that “it is a nice home, residents are well looked after, and staff are friendly and very welcoming”. Recruitment files were held securely in the office in the home. The recruitment records demonstrated good practice with references Criminal Record Bureau checks and POVA checks made prior to appointment of new staff. Fairview DS0000034844.V365342.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has no registered manager but current leadership and management arrangement is satisfactory. Its practises offer full protection to the health and safety of residents. EVIDENCE: On the day of inspection, there was evidence of a friendly and interactive atmosphere in the home. Residents looked well cared for and staff were noted interacting with the residents in informal dignified and respectful manner. Whilst the home has no registered manager the acting manager Mrs Gill Evans who is also the Group Manager of the organisation showed good leadership qualities and professionalism throughout the inspection. Fairview DS0000034844.V365342.R01.S.doc Version 5.2 Page 23 Mrs Evans told the inspector that the company has appointed a manager and that the individual is yet take up the appointment and the Commission for Social Care Inspection would be informed as soon as this happens. Mrs Evans stated that since the previous manager resigned in January 2008 she had been working 40 hours a week at Fairview. Staff members spoken with stated that the acting manager is a good leader and had supported the home since the manager’s resignation. Staff told us that Mrs Evans is approachable and will listen and act on any concerns raised. Residents spoken with were complementary about the acting manager. One resident stated, “Gill is very good”. The fire log- book was well maintained and up to date. Staff have attended fire lectures and regular fire drills to ensure that residents are adequately protected in fire emergencies. It was also noted whilst reviewing the accident book that accidents noted in residents care files had been recorded and reviewed. There were risk assessment noted in the care file to prevent /minimise further occurrence The home has undertaken a generic risk assessment in regards to kitchen, hallway, lounges, and some bedrooms. Mrs Evans stated that the rest of the bedrooms would be risk assessed to ensure that all the residents are adequately protected. A copy of the homes current employers liability insurance was also displayed. Quality Assurance for the home was reviewed. The acting manager stated that the home has a formal auditing system, which is undertaken, through regular resident surveys to enable them to express their views about the services provided at the home. The home also receives feedback from residents, families care plan reviews; residents, staff meetings and complimentary feed back from General Practitioner surgeries. The home stated in the AQAA that it maintains good records on the control of the resident’s own money when they wish to hold their money. All residents’ confidential records were securely locked away. The home has updated policies and procedures to include complaints, medication, health and safety and Protection of Vulnerable Adults from abuse. Fairview DS0000034844.V365342.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 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 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 2 X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X X 3 3 Fairview DS0000034844.V365342.R01.S.doc Version 5.2 Page 25 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. 1. Standard OP9 Regulation 13 Requirement Ensure all prescribed medication are signed for when given. Furthermore all medication must be given as prescribed on the Medication Administration Record Sheet (MARS). Repair/ replace the flooring in identified service User’s room on the ground floor. Undertake risk assessment of the room and other rooms that have no risk assessment to ensure residents are adequately protected. Timescale for action 26/08/08 2. OP23 23 30/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Fairview DS0000034844.V365342.R01.S.doc Version 5.2 Page 26 Fairview DS0000034844.V365342.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 DS0000034844.V365342.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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