Inspection on 27/11/06 for Fairview

This inspection was carried out on 27th November 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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fairview 15/11/07

Fairview 30/01/06

Fairview 14/09/05

Fairview 09/03/05

Fairview 25/10/04

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

15 Bramble Close

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Fairview 68 Freeland Road Clacton On Sea Essex CO15 1LX Lead Inspector Pauline Dean Key Unannounced Inspection 10:30 27th November – 7th December 2006 Fairview DS0000017814.V324871.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 DS0000017814.V324871.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 and 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 DS0000017814.V324871.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fairview Address 68 Freeland Road Clacton On Sea Essex CO15 1LX 01255 427150 01255 223641 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) Wilkinson03@aol.com Mr Paul Wilkinson Mrs Catherine Covey Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (2), Physical disability (1) of places Fairview DS0000017814.V324871.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 5 persons) One person, under the age of 65 years, who requires care by reason of a learning disability who also has a physical disability and whose name was supplied to the Commission in April 2003 Two named service users, over the age of 65 years, who require care by reason of a learning disability, whose names have been made known to the Commission The total number of service users accommodated must not exceed 5 persons 30th January 2006 Date of last inspection Brief Description of the Service: Fairview is a residential care home offering care to five service users with a learning disability. One service user also has a physical disability and three of the current service user group are over 65 years of age. The home is located in a semi-detached property in a residential area in Clacton on Sea. The local shops, cinema, theatre, sea front and hospital are within a half-mile radius. Each service user has their own room; two of the rooms have en-suite facilities. A further bathroom/shower room and separate toilet are found on the first floor, with a ground floor separate toilet. Alongside this there are communal facilities of a lounge, dining room, conservatory and rear enclosed garden. Service user accommodation is found on the three floors of the home. The office/training room for the home is found in a detached building in the garden, with further office accommodation on the second floor of the home. At the front of the property there is a paved area and off-street parking in the driveway. Fairview DS0000017814.V324871.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection covered all key National Minimum Standards and standards detailed in the last inspection’s Requirements and Recommendations. In addition consideration was given to all recent records relating to the service, including information sent to the Commission by the provider. A record of inspection was collated prior and during the inspection process. Regulation Inspector Pauline Dean completed a site visit to the home on 27th November 2006 and a second announced visit on 7th December 2006. A total of 6½ hours was spent on the site visits. At these visits, the inspector was able to speak with service users, Mrs Cathy Covey, the registered manager on the second site visit and care staff. A tour of premises was completed and there was observation of care practice and the sampling of records. Where possible, the site visits focussed on the experience of a sample of two service users, a process known as case tracking. Of the twenty-five National Minimum Standards inspected on this occasion, eleven were met and fourteen nearly met. Of the requirements six were repeat requirements. The outcomes for two sections in the report were assessed as good, that is the section on Lifestyle and the Environment. Sections, which were assessed as adequate, were Choice of Home, Individual Needs and Choices, Concerns, Complaints and Protection and Conduct and Management of the Home, with section on Staffing assessed as poor. This is particularly disappointing, for all five National Minimum Standards inspected at this inspection were assessed as nearly met as at the previous inspection. Clearly no progress has been made on this aspect of care. Within the inspection report it can be seen that there have been some improvements in care practice and record keeping in the home. All three outcomes for these sections – Choice of Home, Individual Needs and Choices and Lifestyle were found to be good. Policies and procedures, environment issues and management and staffing still require attention, for whilst they were noted to have adequate outcomes, issues such as the Regulation 26 visit and report by the registered provider still require attention. Issues around the premises and outstanding repairs and decoration also require attention. What the service does well: Fairview offers a homely environment. The premises are bright and light, with the individual service users able to influence the décor in their home, especially in their own rooms. Fairview DS0000017814.V324871.R01.S.doc Version 5.2 Page 6 The majority of the service users have lived at Fairview for several years and are therefore settled and established in Clacton on sea. All five service users had completed with some assistance from care staff the Commission for Social Care Inspection (CSCI)’s survey forms and all were positive regarding their care, staff and the home. 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. The summary of this inspection report can be made available in other formats on request. Fairview DS0000017814.V324871.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Fairview DS0000017814.V324871.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall, documentation ensures that service users move into the home knowing that their needs will be met. EVIDENCE: There has been one new admission since the last inspection. Prior to moving to Fairview, this service user had lived at the sister home of the group. Whilst the registered manager was able to outline the processes for the transfer of this service user; there were no records within care planning documents to evidence that a full assessment had been completed prior to the move to Fairview DS0000017814.V324871.R01.S.doc Version 5.2 Page 9 ascertain the appropriateness of the placement. It was also not clear as to the involvement the service user had had in this process. As this service user is over 65 years, the registered manager was advised of the need to make a minor variation to accommodate this service user. Details of how to obtain the application form for a minor variation on the Commission for Social Care Inspection (CSCI) website were given. Fairview DS0000017814.V324871.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14 and 33 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome are is adequate. This judgement has been made using available evidence including a visit to this service. Some care planning documents detailed health, personal and social care needs, with limited risk assessments in place. Further revision of care planning documentation and risk assessments is required as current documentation does not ensure that service users are supported to take risks. EVIDENCE: Fairview DS0000017814.V324871.R01.S.doc Version 5.2 Page 11 A plan of care had been developed for both service users involved in this case tracking exercise. Eight or nine care plan objectives were set. These covered all aspects of personal and social support and healthcare needs. From the records seen and discussion, it was not possible to ascertain whether there had been service user involvement in drawing up these care plans. Monthly key worker notes detailed changes in leisure activities pursued, but no reference had been made to these changes in the service users’ care plan. In addition an occupational therapist assessment had been completed, but this too had not been referenced in their care plan. A review date of six months had been set for the two care plans seen and these were due in December 2006. In a second care plan sampled, there was reference in daily record keeping to changes in the service user’s behaviour, but these changes had not been detailed or reflected on in the care plan. This was referred to in the health care visit records, but had not been added to the care plan of the service user. Records were seen on file for each service user with regard to the management of finances. Records sampled evidenced that service users are enabled to make decisions about their lives. Within the records there were examples of service users making choices as to the activities they wish to take part in and the friends they wish to make. Within the sampled care plans only one risk assessment had been completed. This related to supporting a service user as they climbed the stairs. This was very brief and lacking in detail for it did not identify the level of risk and the action to be taken in full. On the second care plan sampled there was no evidence of risk assessments, which would appear lacking for this service user had been noted as having increased confusion in care planning notes. Fairview DS0000017814.V324871.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers Standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Fairview DS0000017814.V324871.R01.S.doc Version 5.2 Page 13 Quality in this outcome are is good. This judgement has been made using available evidence including a visit to this service. Service users’ wishes and interests in respect of their lifestyle were fully integrated into the service provided. Overall, service users’ receive a healthy, nutritious varied and balanced diet to promote their health and well-being. EVIDENCE: None of the current service user group wish to pursue social, emotional, communication and independent living skills. Of those sampled, one of the service users had attend a craft group activity and one service user was said to regularly attend a church group. From speaking to care staff, service users and management, the inspector was informed that service users are encouraged to use community resources. One service user had attended a craft activity sessions. They had been supported and encouraged to attend. The majority of the service users access the town centre of Clacton on sea. Public transport is used as they wish. The registered manager said that all service users are encouraged to maintain contact with relatives and friends. Evidence of this was noted in the daily records. Contact can be either by telephone call or by letter. Service users are able to make decisions and take responsibilities in their daily lives. Within the sampled care plans there was evidence of a service user choosing when and where to have their meals and what time they get up or go to bed. Within another care plan the records detailed how a service user had made a choice and how it had been actioned. Fairview operates a four-week rotation planned menu. Preferences and choices are offered, with the main meal of the day at lunchtime. On the day of the first site visit, all service users had chosen one of the choices for lunch. At breakfast however, nutrition records showed that service users made choices, for there were a variety of cereals and grapefruit served at this meal. This was further confirmed by two of the service users who outlined their preferences for breakfast. Fairview DS0000017814.V324871.R01.S.doc Version 5.2 Page 14 Whilst the majority of nutrition records were complete, entries were not found for two recent dates, prior to the first site visit. Fairview DS0000017814.V324871.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome are is good. This judgement has been made using available evidence including a visit to this service. Overall, the home’s arrangements for supporting the healthcare of service users were satisfactory. EVIDENCE: From speaking to service users and discussion with staff and management it was evident that service users are enabled to choose their own clothes and hairstyles. Technical aids and equipment are in place for a service user to enable them to have maximum independence and another service user Fairview DS0000017814.V324871.R01.S.doc Version 5.2 Page 16 chooses to rise and go to bed at a different time to other service users. This is managed well. Individual record sheets detailing health care needs were seen for the two service users involved in the case tracking exercise. Records were seen of visits to dentists, chiropodist and an occupational therapist assessment. From this record keeping and from discussion with a service user it could be seen that the health needs of service users are reviewed and considered with action taken. Medication administration and record keeping was sampled and inspected. They were found to be in good order for the two service users who were part of the case tracking. Records were seen of medication entering the home and the care worker on duty was able to clearly detail the management of returns. Fairview DS0000017814.V324871.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome are is adequate. This judgement has been made using available evidence including a visit to this service. Overall, service users were well treated and listened to, with complaints and adult protection procedures in place. EVIDENCE: Fairview had two complaints procedures. There were differences in the information contained in these documents. The home therefore needs to review their complaints procedure for they need to ensure that reference to the Commission is with regard to inspection and regulation and not as an investigator of complaints and it clearly details the manner in which complaints are dealt with. The adult protection procedures in place at Fairview need to be reviewed and expanded to incorporate the Essex County Council procedure for Protection of Fairview DS0000017814.V324871.R01.S.doc Version 5.2 Page 18 Vulnerable Adults (POVA) referrals. The current policies and procedures need to be reviewed and amended to ensure that they are accurate and appropriate to the local authority procedures. Mrs Covey said that the home had recently received an adult protection training DVD pack and she was proposing to use this as a training resource in the home. Fairview DS0000017814.V324871.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome are is good. This judgement has been made using available evidence including a visit to this service. The home provides a safe, well-maintained environment that is accessible to service users, homely and meets individual needs. EVIDENCE: Fairview DS0000017814.V324871.R01.S.doc Version 5.2 Page 20 Fairview is a semi-detached house with service users accommodation on all three floors. The property is in keeping with the surrounding accommodation, which consists of residential accommodation. Overall, the premises are well maintained and decorated; this was particularly noticeable in the home’s communal areas. The lounge was bright and light and well furnished. The dining area was also well decorated with Christmas decorations and place settings evident on the second site visit to Fairview. The only exception to the overall high standard of furnishing and fittings was the hall and stair carpet. Whilst this did not present as a hazard, but it was worn and faded and did not present a good first impression of the home. Mrs Covey said that replacement carpets are being considered as part of the planned maintenance and renewal programme of the home. On the first site visit, the inspector was able to view all but one of the bedrooms. These were all well decorated and furnished to the individuals liking. Care staff said that the bedroom of the most recent admission had been decorated to their liking. This was confirmed by the service user who said that they were very happy with their room. They confirmed that they had been able to choose the colour scheme and had added their own personal belongings to create a homely setting. At present they had a radio in their room, but as they preferred to spend time in their room, they said that they were looking to having a television in their room. In the past year, both the kitchen and utility area have been re-fitted with new units and work surfaces. Both were clean, tidy and in good order. A washer and a dryer of domestic type are located in the utility area of the home. Care staff said that this was found to be sufficient, with laundry completed daily as required. Fairview DS0000017814.V324871.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome are is poor. This judgement has been made using available evidence including a visit to this service. Fairvew’s recruitment policy did not meet requirements and therefore does not support and protect service users. There was not sufficient evidence to demonstrate that staff were adequately supervised, trained or supported in their roles. EVIDENCE: Fairview DS0000017814.V324871.R01.S.doc Version 5.2 Page 22 There have been some staff changes at Fairview. Of a total of seven care staff working at the home, three care staff have either a National Vocational Qualification (NVQ) Level 2 in care or a Level 3 in care and two care staff are currently working on their NVQ Level 2 in care. Fairview is therefore looking to achieve the requirement of 50 of care staff in the home with a NVQ Level 2 in care. On the first site visit to the home – 27th November 2006, there was only one care staff member on duty. In the absence of the registered manager who was on annual leave the carer made every effort to bring a second carer on duty. Eventually in the afternoon shift, two care workers came on duty. Whilst it is acknowledged that every effort had been made to find a second staff member, the registered manager is advised to review staffing arrangements in her absence ensuring that there are sufficient staff to call on. In addition, staff rotas need to be reviewed for they did not those seen did not detail the registered manager’s hours and shifts and they did not identify who was in charge of the shift. Staff recruitment documentation was sampled and inspected. The paperwork of two new care workers was seen. These were found to be incomplete. One care worker had an incomplete employment history and no Criminal Record Bureau (CRB) disclosure. They had commenced working at Fairview in September 2006. The second staff files sampled had only one reference, which was brief and very limited for the carer. This care worker had been working at Fairview since April 2006. It is disappointing to find that yet again staff recruitment practices are incomplete. Mrs Covey is reminded of the current guidance to be found on the Criminal Record Bureau (CRB) and the Commission for Social Care Inspection (CSCI) website regarding the employment of staff without clearance. The practice of employing the care worker whilst awaiting clearance is not acceptable, unless a through recruitment process has been followed, the Protection of Vulnerable Adults (POVA) First check has been completed and the staff member is closely supervised at all times. Similarly the practice of taking on new staff members without full references is not acceptable and displays poor recruitment practices which need to be reviewed immediately. Within the home and from discussion with a new care staff member it is understood that there is a structured induction training programme. Whilst, there was some evidence of basic training – five staff had recently attended a First Aid course, the need to introduce a training and development plan was evident. Records have been kept of some training completed, but this needed to be updated and reviewed to fully detail training needs and requirements. Fairview DS0000017814.V324871.R01.S.doc Version 5.2 Page 23 As at the previous last two inspections, records evidenced that staff supervision had commenced. Three staff files evidenced supervision sessions in May and July 2006 only. Mrs Covey is reminded of the need to ensure that staff have regular recorded supervision meetings at least six times a year. Fairview DS0000017814.V324871.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Fairview DS0000017814.V324871.R01.S.doc Version 5.2 Page 25 Quality in this outcome are is adequate. This judgement has been made using available evidence including a visit to this service. The home has a qualified, competent and experienced manager to run the home. The home has to develop a quality assurance and quality monitoring system to help ensure that the home is run in the best interests of the service users. Overall, safe working practices are promoted, with the exception of equipment safety certification. EVIDENCE: At the first site visit, Mrs Covey was not present. A second site visit was arranged with Mrs Covey. As at the last inspection, Mrs Covey confirmed that she has completed the National Vocational Qualification (NVQ) level 4 in care and the Registered Manager’s Award. She operates as the Registered Manager of two care homes. She said that she allocates her time equally between the two homes. Mrs Covey normally operates as a manager/third carer on a morning or afternoon shift of each care home. A service users’ satisfaction survey had been completed in January 2006 and four service users had taken part. This survey work had covered topics such as food, daily living, premises and management. To develop into an effective quality assurance and quality monitoring system the home needs to develop an annual development plan for the home, based on a systematic cycle of planning-action-review, reflecting aims and outcomes for service users. Regulation 26 visit reports have been re-introduced and a copy of the most recent visit in November 2006 was seen at the care home. This report had also been sent to the Commission for Social Care Inspection (CSCI). Staff recruitment records had shortfalls as detailed earlier in this report (see National Minimum Standard 34). The need to ensure that all record keeping was up-to-date and accurate was highlighted with Mrs Covey. In addition, the need to review and revise the Policy and Procedure manual held in the home was highlighted. These will need to be dated, monitored, reviewed and amended. Fairview DS0000017814.V324871.R01.S.doc Version 5.2 Page 26 A certificate of compliance dated February 2006 was seen for a mobile hoist. The next inspection was said to be due August 2006. This and the maintenance certificate had not been completed. Similarly, a certificate of compliance and maintenance is required for a wheelchair used by a service user. Mrs Covey was advised to check this out to ascertain the required frequency of the inspection and the last date of inspections. Fairview DS0000017814.V324871.R01.S.doc Version 5.2 Page 27 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. Where there is no score against a standard it has not been looked at during this inspection. 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 2 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 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 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 2 CONDUCT AND MANAGEMENT Standard No Score 37 3 38 X 39 2 40 X 41 2 42 2 43 X 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Fairview Score 3 3 3 X DS0000017814.V324871.R01.S.doc Version 5.2 Page 28 Yes 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 YA2 Regulation 14(1) Schedule 3(1)(a) Requirement Timescale for action 05/02/07 2. YA6 15(1) Schedule 3(1)(b) 3. YA9 13(4), 14(2) The registered person must ensure that new service users are admitted only on the basis of a full assessment, involving the prospective service user in this process. The registered person must 05/02/07 review and revise the current service users plan of care and records to ensure that all aspects of the health, personal and social care needs of the service user are met. The registered person must 05/02/07 ensure that staff enable service users to take responsible risks following the completion of individual risk assessments and risk management strategies. (This is a repeat requirement from the last three inspections. Timescales of 01/05/05, 04/011/05 and 07/04/06 were not met.) 4. Fairview YA17 13, The registered person must DS0000017814.V324871.R01.S.doc 05/02/07 Version 5.2 Page 29 Schedule 3&4 5. YA22 4(11) 22 ensure that nutrition records detail that service users are offered a healthy, varied diet to suit their needs and preferences The registered person must 05/02/07 ensure that there is a clear and effective complaints procedure, which includes the stages of, and time scales, for the process, and that service users know how to complain. The registered person must ensure that service users are protected from abuse, neglect and self-harm. This is with regard to the adult protection policy and procedure. The registered person must ensure that service users are supported by an effective staff team. Staff rotas must clearly detail all staff working and the person in charge of the shift. The registered person must operate a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. This is with regard to Criminal Record Bureau (CRB) disclosures. (This is a repeat requirement from the last three inspections. Timescales of 01/05/05, 04/11/05 and 07/04/06 were not met.) 05/02/07 6. YA23 13, 21 7. YA33 18(1)(a) 05/02/07 8. YA34 19, Schedule 2 05/02/07 9. YA35 18(1) 10. Fairview YA36 18(2) The registered person must ensure that there is a staff training and development programme, which meets Sector Skills Council workforce training targets. The registered person must DS0000017814.V324871.R01.S.doc 05/02/07 05/02/07 Page 30 Version 5.2 ensure that staff are supported and supervised as detailed in National Minimum Standard 36. (This is a repeat requirement from the last two inspections. Timescales of 04/11/05 and 07/04/06 were not met.) 11. YA39 24 The registered person must 05/02/07 ensure that effective quality assurance and quality monitoring systems are in place to measure success in achieving the aims, objectives and the statement of purpose of the home. (This is a repeat requirement from the last three inspections. Timescales of 01/05/05, 04/11/05 and 07/04/06 were not met.) 12. YA41 17, 18, 24, 25, The registered person must review record keeping ensuring that records for the effective and efficient running of the business are maintained, up to date and accurate. This is with regard to staff recruitment records. (This is a repeat requirement from the last three inspections. Timescales of 01/05/05, 04/11/05 and 07/04/06 were not met.) 13. YA42 13(4) The registered manager must ensure, so far as is reasonably practicable the health, safety and welfare of service users and staff. This is with regard to safety certification and inspection of a wheelchair and mobile hoist. 05/02/07 05/02/07 Fairview DS0000017814.V324871.R01.S.doc Version 5.2 Page 31 (This is a repeat requirement from the last inspection. Timescale of 07/04/06 was not met.) 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. Refer to Standard YA32 Good Practice Recommendations The registered person should ensure that staff have the competencies and qualities to meet service users’ needs and achieve Sector Skills Council workforce strategy targets e.g. 50 of care staff achieve a care NVQ Level 2. Fairview DS0000017814.V324871.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 DS0000017814.V324871.R01.S.doc Version 5.2 Page 33 - 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!