Inspection on 26/10/06 for Fairview

This inspection was carried out on 26th October 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 25 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fairview 12/04/07

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 26th October 2006 09:30 Fairview DS0000062524.V315701.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.V315701.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.V315701.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.V315701.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th May 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. 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 May 2006. 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.V315701.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 six hours. The lead inspector was accompanied by another regulation inspector, Jane Ray, throughout the inspection. The manager was available during the majority of the inspection, and the inspectors also had the opportunity to speak to the area manager and three staff members. The inspectors met with six 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. They 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. The home exceeds the national minimum standard in the number of staff trained to NVQ level 2 or above. 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. Fairview DS0000062524.V315701.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Residents should have a review with a social worker at least annually, and records of these meetings should be maintained. The confidentiality of documents stored in the office must be safeguarded. Residents should be supported to dress appropriately and to arrange a holiday of their choice. Reliance on convenience foods should be avoided and fresh fruits should be available to residents at the home at all times. Health care appointments should be monitored so that residents are encouraged to attend routine checkups. Tighter medication procedures are needed to ensure the safety of residents. An immediate requirement was made that all staff undertake training in the protection of vulnerable adults. Evidence was provided to the CSCI within the set timescale, that this training had been undertaken by the majority of staff members. All staff should be trained in the management of challenging behaviour and appropriate procedures produced for the home. A suitable area must be made available for staff on sleep-in duty at the home which does not include the residents’ lounge area. Actions must be taken to address security issues within the home. Fairview DS0000062524.V315701.R01.S.doc Version 5.2 Page 7 A number of identified repairs/replacements must be made to the home environment. It remains required that the kitchen cupboards, dining room tables and residents’ bedroom curtains and lampshades must be replaced according to their preferences. Staff stability within the home must be monitored and those being inducted must be surplus to requirements whilst undergoing inductions. A number of improvements needed to the recruitment procedures, as of late, have also been identified. Staff training audits should be undertaken and they must receive mental health training. The manager must be supervised regularly and a quality assurance audit must be undertaken for the home. Old information in the office must be archived and the fire safety risk assessment for the home must be updated. 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.V315701.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.V315701.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. One new resident had been admitted since the previous inspection. Whilst not all appropriate information had been provided to the home prior to admission, the inspectors were satisfied that the registered person had requested the information as appropriate. It was not possible to speak to the most recently admitted resident as they had been admitted to hospital following an incident at the home. The inspectors discussed with the registered person, the information provided about this service user prior to admission, and ways that the registered person might minimise the possibility of future omissions in information regarding prospective residents. Fairview DS0000062524.V315701.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 adequate. 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. However they would be further protected by ensuring regular reviews with their social workers. Risks are recorded appropriately with strategies in place to ensure that residents are protected as far as possible, whilst being encouraged to develop independence skills. Insufficiently rigorous confidentiality procedures place the rights of staff and residents at risk. EVIDENCE: Residents told the inspectors that they were free to come and go and make their own decisions with support from staff as needed. Regular residents meetings are held, in which they are encouraged to participate. Fairview DS0000062524.V315701.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. Five care plans were inspected and were found to be satisfactory including regular reviews, records of one-to-one sessions with residents and risk assessments clearly detailing control measures. As required at the previous inspection records indicated that risk assessments had been reviewed within the last six-months for each resident. However it was of concern that not all residents had been reviewed by their social workers within the last year. A requirement is made accordingly. The inspectors were also concerned to note that staff files and other confidential information, whilst being stored in the office at the home, was not locked away as appropriate. This is required in order to protect the confidentiality of staff and residents. Fairview DS0000062524.V315701.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 adequate. 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. However their leisure needs with regard to having a holiday away from the home had not been met this year. They are encouraged to take responsibility for the running of the home and to develop independent living skills. However more support is needed to ensure that residents’ clothing needs are met appropriately. Dietary needs of residents are catered with a varied selection of food, however this could be improved by less reliance on convenience foods. 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.V315701.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. No residents attend college but one is self employed on a part time basis. Most residents spoken to indicated that they had active social lives. They are also 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 several of those spoken to expressed their disappointment at not going on holiday this year. A requirement is made accordingly. At the previous inspection the manager advised that he was looking into the possibility of future trips abroad for residents who are interested. Residents spoken to said that the food provision in the home was generally good, but some noted that fresh fruit is not always available and they sometimes purchase their own fruit. Residents are able to help themselves to food from kitchen cupboards and support is available from staff in cooking food, thus encouraging greater independence. The inspectors were concerned to observe that two residents were not dressed appropriately at the time of the inspection, due to ill fitting or torn clothing, and this was discussed with the manager. A requirement is made accordingly. Stocks of food available to residents in the home included some fresh vegetables, and large stocks of frozen and convenience foods including some foods reflecting cultural diversity as reflected in the menus. No fresh fruit was available to residents at the time of the inspection and several residents advised that they regularly bought their own fruit. This situation was rectified during the inspection, however it is required that stocks of fruit be replenished regularly to ensure that fresh fruit is available to residents at all times and that menus rely less on frozen and convenience foods. Fairview DS0000062524.V315701.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 adequate. 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. However there is insufficient evidence to show that they are prompted to attend routine health care appointments. Insufficiently rigorous medication procedures place residents at risk of 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 recommended that residents’ health care appointments be recorded separately from other daily notes so that they can be monitored easily. However although health care logs had been started for each resident, these had not been backdated to show when each resident last saw the dentist, optician etc. Evidence was therefore not available that residents were being encouraged to see the dentist and other health care professionals regularly and a requirement is made accordingly. Fairview DS0000062524.V315701.R01.S.doc Version 5.2 Page 15 Medication records were generally 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, however there were no written guidelines for when this resident should take this medication (Lorazepam). It is also required that preprinted medication administration records be updated to ensure that discontinued medicines are no longer recorded. The inspectors were concerned to note that a short course of a liquid antibiotic, for an identified resident was being stored inside the residents’ refrigerator in the kitchen. It was thus easily accessible to all residents and not locked away as appropriate, presenting a health and safety hazard. Action was taken on the day of the inspection to relocate this medication to a refrigerator in a storeroom, which is kept locked. A requirement is made accordingly. Fairview DS0000062524.V315701.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 poor. 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. Although procedures are in place, insufficient evidence was available that staff had undertaken adult protection training to ensure the protection of residents from abuse. Residents’ safety is also compromised by insufficient guidelines and training for staff in addressing challenging behaviour. 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. At three previous inspections it was required that all staff undertake training in the protection of vulnerable adults. The manager advised that this training had been undertaken by all but the newest staff members, however evidence of this was not available at the time of the inspection. An Immediate Requirement was therefore issued requiring evidence to be provided to the CSCI within two days of the inspection. Copies of staff training certificates were provided to the CSCI within this timescale as appropriate, alongside evidence that all new staff members had been booked onto adult protection training courses. Fairview DS0000062524.V315701.R01.S.doc Version 5.2 Page 17 Following recent incidents prior to the inspection it is 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. Staff members spoken to indicated that they would find such training and guidance useful. Fairview DS0000062524.V315701.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 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. Further replacement of bedroom fittings is needed to ensure a comfortable environment for residents. 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 (still to be completed) and adequate communal space. Refurbishment since the previous inspection has resulted in a double bedroom being converted into two single rooms, and relocation of the manager’s office into the activities room. Fairview DS0000062524.V315701.R01.S.doc Version 5.2 Page 19 The cleanliness within the kitchen was of a satisfactory standard. However although the provider had advised of the intention to replace the kitchen cupboards, at the previous inspection, this had not been undertaken. Neither had the requirement that a timetable for their replacement be provided to the CSCI been met. The manager advised that advice had been sought from an occupational therapist in ensuring that the kitchen is accessible as possible. It remains required that the kitchen cupboards be replaced. It is also required that a new microwave be obtained for the home. The staff room in the home had previously been converted into a food storage area including a refrigerator and freezer. At the previous inspection it was recommended that a bed or thicker mattress be provided for staff on sleepingin duty in the home. A new bed had been provided for staff as required, however 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 is not appropriate as it prevents residents from accessing the lounge at night, and a requirement is made accordingly. As required new chairs had been provided in residents’ rooms and a new bed was provided in the identified resident’s room. It remains required that new curtains and lampshades be provided according to their preferences. Dining room chairs had been replaced but it remains required that the dining tables be replaced. New laundering machines and a new vacuum cleaner had been purchased for the home. Residents spoken to confirmed that they had been provided with keys to their individual bedrooms as required at the previous inspection. Since the previous inspection residents had experienced some problems with security at the home from young people in the neighbourhood. It is required that a security audit be undertaken for the home with actions taken as appropriate. As required the worn carpet at the entrance to the office had been replaced/made safe. There were problems with hot water in some parts of the home at the time of the inspection and it is required that this be rectified. It is required that the bench near the back door be replaced and that the lock be repaired on the garden shed so that residents can store their bikes inside safely. It is recommended that new curtains be provided in the lounge. Fairview DS0000062524.V315701.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 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, however this support is compromised by a recent high turnover of staff. Recruitment procedures are not sufficiently rigorous to safeguard residents. Inappropriately arranged induction training for new staff may also place staff and residents at risk. Staff members require further training and appropriate procedures 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: Staff files for new staff employed at the home since the previous inspection were inspected. They were found to include the necessary documentation as required under the Care Homes Regulations 2001 Schedule 4 as appropriate. Three 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. Fairview DS0000062524.V315701.R01.S.doc Version 5.2 Page 21 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. Discussion with staff members and observation of rotas indicated that staff stability within the home had been a problem over the last few months with a number of inexperienced new staff commencing work at the home. It is required that this situation be monitored to ensure continuity of care for residents in the home. On the day of the inspection a new staff member was working at the home (on their first day) with one experienced staff member, rather than being surplus to the statutory numbers during their induction. Clearly this places staff and residents at risk and a requirement is made accordingly. Observation of staff files and discussion with the registered manager indicated that notes are not always maintained of prospective staff members’ interviews, and that they are not always interviewed by at least two representatives from the home. A requirement is made accordingly. It is also required that information about staff members working at the home on a regular basis, from other homes owned by the provider, must also be available within the home. The training matrix for staff members in the home did not tally with the certificates currently available for each staff member. It is required that this be rectified and that staff undertake training in working with residents who have mental health problems, addressing challenging behaviour and adult protection. Induction records must be available for all staff members and it is recommended that the application form used by the home for recruitment, should be updated to include a statement by the candidate of their reasons for applying, and what they can contribute to the home. It is also recommended that residents be encouraged to be involved in the interview process for new staff and that exit interviews be conducted for staff leaving employment at the home. Fairview DS0000062524.V315701.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 and 42. Quality in this outcome area is adequate. 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, however they require regular supervision to ensure that residents needs are fully met. There is consultation with staff and residents regarding the way in which the home is run, but an annual quality assurance audit is needed to ensure that high standards are maintained. The home’s record keeping procedures do not facilitate residents’ current needs being met appropriately. The fire risk assessment for the home needs to be updated to ensure that residents’ health and safety is fully protected. EVIDENCE: Fairview DS0000062524.V315701.R01.S.doc Version 5.2 Page 23 The registered manager has managed the home over several years, and the inspectors were satisfied that the home is generally managed effectively and competently with the best interest of residents in mind. However, as agreed at a strategy meeting held prior to the inspection, the manager must have regular supervision sessions and these must be recorded. The manager should also retain 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. It is also required that a quality assurance audit must be undertaken for the home with a copy of the results 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. However 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 is therefore required that outdated information be archived. 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 a fire risk assessment. However it is required that the fire risk assessment be updated to include further relevant information and evidence must be available that fire alarms are serviced regularly. Fairview DS0000062524.V315701.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 1 ENVIRONMENT Standard No Score 24 1 25 2 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 2 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 2 X 2 2 X Fairview DS0000062524.V315701.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 14(2) Requirement The registered persons must ensure that all service users have a review with a social worker at least annually and that records are maintained of these meetings. The registered persons must ensure the confidentiality of documents stored within the office. They must be locked away securely as appropriate. The registered persons must ensure that service users have the opportunity to go on holiday according to their wishes and make bookings as appropriate. The registered persons must ensure that all service users are encouraged to dress appropriately. The registered persons must ensure that reliance on frozen/convenience foods is avoided and that a variety of fresh fruits are available to service users within the home at all times. The registered persons must DS0000062524.V315701.R01.S.doc Timescale for action 22/12/06 2. YA10 12(4) 17(1a,2) 10/11/06 3. YA14 16(2n) 22/02/07 4. YA16 12(1b) 10/11/06 5. YA17 16(2i) 17/11/06 6. Fairview YA19 12(1) 22/12/06 Page 26 Version 5.2 13(1b) 7. YA20 13(2) ensure that health care appointment logs for each service user are backdated to include the last appointment with each health care professional. Dental appointments should be checked to ensure that service users are encouraged to visit the dentist regularly. The registered person must 15/12/06 ensure that guidelines are available for the identified service user who is prescribed Lorazepam on an ‘as and when required’ basis. Medication administration records must be updated so that discontinued medicines are no longer recorded. Suitable storage arrangements must be available for the storage of medicines that must be stored within a refrigerator. IMMEDIATE REQUIREMENT: The registered persons must ensure that all staff undertake training in the protection of vulnerable adults. Evidence must be provided that all staff have been booked onto an appropriate training course. (Previous timescales of 16/09/05, 03/02/06 and 30/06/06 not met). This requirement was met within the timescale set. The registered persons must ensure that all staff are provided with external training in the management of challenging behaviour. The registered persons must ensure that a copy of the DS0000062524.V315701.R01.S.doc 8. YA23 YA35 13(6) 18(1ci) 28/10/06 9. YA23 13(6,7) 18(1ci) 23/02/07 10. YA23 13(6,7) 08/12/06 Fairview Version 5.2 Page 27 11. YA24 23(3) 12. YA24 13(4) 23(1) 13. YA24 23(2cd) 14. YA24 23(2p) 15. YA24 16(2j) 23(2c) 16. YA24 12(4a) 23(2bd) updated challenging behaviour policy and procedures are sent to the local CSCI area office. The registered persons must ensure that a suitable sleeping area is available for staff on sleep-in duty at the home. This must not include the service users’ lounge area. The registered persons must ensure that a full security appraisal is conducted for the home and actions to be taken, including timescales are provided to the local CSCI area office. The registered persons must ensure that a new microwave oven is provided for the home, the bench near the back door is replaced, and ensure that the shed is lockable for service users’ use. The registered persons must ensure that the hot water system is fully functioning across the home. The registered persons must ensure that the kitchen cupboards are replaced. (Previous timescale of 30/06/06 not met). The registered persons must ensure that:- new dining room furniture is provided - new curtains and lampshades are provided in service users’ rooms according to their preferences. (Previous timescale of 30/06/06 not met). The registered person must DS0000062524.V315701.R01.S.doc 03/11/06 22/12/06 22/12/06 03/11/06 28/02/07 15/12/06 17. Fairview 18(ab) 08/12/06 Page 28 Version 5.2 YA32 YA33 21(2) 18. YA34 17(2) 19 Schedule 2 monitor staff team stability within the home and ensure that new staff work surplus to staffing requirements whilst undergoing induction. A record of induction training must be available for all staff. The registered persons must 08/12/06 ensure that prospective new staff are interviewed by at least two representatives from the home, and that notes are recorded regarding each candidate’s interview. Copies of the staff files for staff who work regularly within the home but are based at other homes owned by the provider, must also be available within the home. The registered persons must ensure that the training matrix for the home is updated to include only courses undertaken by staff members which can be evidenced by certificates. All staff must undertake training in working with service users who have mental health problems. The registered persons must ensure that the manager is supervised at least monthly and that this is recorded. The manager should maintain a copy of their monthly supervision records. The registered persons must ensure that a quality assurance audit is undertaken for the home and a copy of the results is sent to the local CSCI area 19. YA35 18(2) 26/01/07 20. YA37 18(1ci) 08/12/06 21. YA39 24 26/01/07 Fairview DS0000062524.V315701.R01.S.doc Version 5.2 Page 29 office. 22. YA41 17 The registered persons must ensure that out dated information maintained on service user files is archived and that the office is reorganised to enable easier access to current records. The registered persons must ensure that the fire safety risk assessment is updated to include: - all potential risks including smoking and arson and appropriate actions to be taken, - weekly fire alarm testing, fire drills, fire alarm and emergency lighting servicing, checking of fire doors self-closing and evacuation routes, and - the evacuation plan. A copy should be sent to the local CSCI area office alongside evidence that the fire alarms have been serviced regularly. 22/12/06 23. YA42 13(4) 23(4a) 22/12/06 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. Refer to Standard YA24 YA34 Good Practice Recommendations It is recommended that new curtains are provided in the lounge. It is recommended that the application form used by the home for recruitment should be updated to include a statement by the candidate of their reasons for applying, and what they can contribute to the home. It is recommended that service users should be DS0000062524.V315701.R01.S.doc Version 5.2 Page 30 3. Fairview YA34 4. YA34 encouraged to be involved in the interview process for new staff. It is recommended that the registered persons should conduct exit interviews for any staff leaving employment at the home. Fairview DS0000062524.V315701.R01.S.doc Version 5.2 Page 31 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.V315701.R01.S.doc Version 5.2 Page 32 - 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. You have been warned!