Inspection on 14/03/07 for Fairview Court

This inspection was carried out on 14th March 2007.

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 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

Similar services:

Fairfields Country Rest Home

Fairfax House

Claremont Nursing Home

Doveridge Care Home

Dunmore

Chatsworth

Dunraven Lodge

Eastleigh Care Homes, South Molton

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

CARE HOMES FOR OLDER PEOPLE Fairview Court 42 Hill Street Kingswood South Glos BS15 4ES Lead Inspector Melanie Edwards Key Announced Inspection 09:15 14 and 15th March 2007 th 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 Court DS0000067811.V327254.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 Court DS0000067811.V327254.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fairview Court 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 935 3800 Linksmax Ltd Mrs Sheena McNeil Helyer Care Home 49 Category(ies) of Dementia - over 65 years of age (49) registration, with number of places Fairview Court DS0000067811.V327254.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate up to 34 Persons over the age of 65 with dementia requiring nursing care May accommodate up to 15 persons over the age of 65 with dementia requiring personal care Not applicable. Date of last inspection Brief Description of the Service: Condition of registration: The Home will care for people with Dementia- aged over 65 years. The Home is registered to accommodate up to forty-nine four older people with dementia. Each of the single bedrooms has a wash hand basin and ensuite facility. The property is arranged over three floors with shared space on each floor. There is a central courtyard, which is pleasantly laid out with flower and plant containers and exterior furnishings. The Home is close to shops, amenities and bus routes. The fees that are charged for staying at the Home are around £550 a week. There are extra charges for chiropodist, and hairdresser services. Fairview Court DS0000067811.V327254.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Please note due to their differing levels of confusion some of the residents are unable to express their views verbally. The inspector was able to meet a number of the thirty-four residents currently living at the Home. The registered manager Mrs McNeil Helyer, the deputy manager, three care staff and the cook were interviewed about their roles and responsibilities, their training needs, and how they assist and support residents. A sample of records relating to the day-to-day running and management of the Home were inspected. A selection of resident’s care records and care plans were also inspected. Susan Fuller a Commission Pharmacist Inspector inspected the medication standards in the Home. The Home was operating within the required conditions of registration set down by the Commission. The conditions of registration detail the type of care and the needs of residents, and the numbers of residents who may stay at the Home. What the service does well: What has improved since the last inspection? This is not applicable as this is the first key inspection of the Home since it opened in November 2006. Fairview Court DS0000067811.V327254.R01.S.doc Version 5.2 Page 6 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 Court DS0000067811.V327254.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fairview Court DS0000067811.V327254.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3. Quality in this outcome area is good. Residents assessed needs are met by caring staff. Residents and their representatives are provided with information to make an informed choice about living at the Home. However this not in an accessible, or an easy to understand format. This judgement has been made using available evidence including a visit to this service. EVIDENCE: To find out how prospective residents and their representatives are helped to find out about the Home a copy of the service users guide and the statement of purpose were inspected. Each resident and their families are given their own copy of the guide so they have access to helpful information about life in the Home. Fairview Court DS0000067811.V327254.R01.S.doc Version 5.2 Page 9 The guide includes information about the service provided, the qualifications of the staff employed, and the accommodation. The philosophy of the Home and how the service aim to meet residents needs is included. The complaints procedure is in the document for residents to know how to complain about the service. However the statement of purpose and the service users guide have not been written in a format that is `user friendly’. Also there are no pictures of the Home, or community included in the guide to help inform the reader about the service. Residents would benefit if the service users guide was written in a format that is easy to read and more accessible to people who are confused. To find out how residents’ care needs are assessed and how the care they need is being planned, three residents assessment records were looked at in detail. The assessments included a range of information, and detailed each resident’s range of complex care needs. There are also risk assessments in place to support residents to demonstrate they are being encouraged to live an independent and fulfilling life. This helps residents to maintain independence despite experiencing varying levels of confusion that has an impact on their daily lives. Three residents commented positively about the staff, one resident said, ‘ they are very good here’. Comments made by relatives were positive about the staff and their caring attitude. These comments help to demonstrate that residents’ relatives feel their needs are being met, and that they are treated well at the Home. There were a number of survey forms returned to the Commission before the Inspection. There were many positive comments made by residents’ relatives about the standard of care, and how well they feel the Home is meeting their relatives’ needs. A number of comments were made about how kind, caring, and supportive staff are when helping residents with their needs. Fairview Court DS0000067811.V327254.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9. Quality in this outcome area is adequate. Residents are supported with their needs by caring staff and there are informative care plans in place. However assessment records are not being reviewed on a regular basis. Medicines are stored securely and records indicate that medicines are given as prescribed. Some records of receipt of medicines need to be improved and advice about crushing of medicines needs to be reviewed This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were detailed assessments to accompany residents care plans setting out what needs the person had, and what sort of support they required. However one of the assessment records inspected had not been reviewed and updated on a regular basis. The resident concerned had very specific physical nursing care needs. It is essential that registered nurses ensure residents assessed nursing needs are regularly reviewed and updated. This is required to ensure staff keep up to date about what residents needs are, and the course of action that will needs to be taken to meet them. Fairview Court DS0000067811.V327254.R01.S.doc Version 5.2 Page 11 Three resident’s care plans were read to find out how well residents care is being planned and delivered by the Home. There was a range of information written for each resident stating how to support the person with his or her range of needs. Care plans included information showing how to support residents who have varying levels of confusion, due to their dementia. The three care plans that were read had been regularly reviewed. This helps demonstrate residents’ needs are being kept under review and updated. Residents are registered with local GP surgeries. During the inspection a GP visited the Home to attend to one residents physical health needs at the request of the nursing staff. This is good evidence that residents’ health needs are being closely monitored. Residents are further supported with their health needs by the psychiatrist and their team who review residents’ health care needs. There is a medical health record maintained for each resident. This records when residents see a doctor, optician, dentist and chiropodist and the reasons for the referral, and any outcomes, including what treatment was required. Residents on the residential side of the Home are also supported by Community Psychiatric Nursing staff when required, to assist them with their needs mental health needs while they are in the Home. The pharmacist inspector looked at the handling of medication in Fairview court. Medicines are supplied by a local pharmacy using a monthly monitored dosage blister pack system. Staff said that they have good support from the pharmacy to help them manage medication safely. For example all the medicines administered by staff are printed on the medicines administration record sheet including some over the counter medicines provided for one resident by their relatives. No residents are able to self-medicate. Some creams and ointments are kept in residents’ rooms and are applied by care staff. One care plan looked at showed clear guidance for the use of the creams and also a record by care staff that they had been applied. A small number of homely remedies were seen on the residential wing but no policy for their use was seen. It is recommended that the home develop a homely remedy policy and agree this with the residents’ doctors. Medicines seen were stored securely on each floor. Blister packs indicated that meds had been given as prescribed. Some medicines supplied in standard packs and prescribed, When required could not be easily audited. It is recommended that staff introduce a system that allows them the easy checking of medicines that have been supplied in standard packs. Some eye preparations had not been dated on opening. For safe use these must be discarded 28 days after opening. Fairview Court DS0000067811.V327254.R01.S.doc Version 5.2 Page 12 Warfarin dose instructions received following blood tests are kept in the file with medicines administration record sheet, this helps to makes sure that the correct dose of Warfarin is given. A medication policy was see, this has general principles but is not specific to procedures used at Fairview Lodge. It is recommended that a policy specific to Fairview Lodge is also available to provide guidance for staff on procedures in place here. I saw that staff giving lunchtime medicines checked the medicines administration record sheet and labels before administering the medicines and signing the record. The pharmacy provides printed medicines administration record sheets. Action needs to be taken to makes sure that holes punched in the sheets do not obscure the medicine name. No gaps were seen in the administration records. For some medicines prescribed with a variable dose, for example Paracetamol, it was not clear how much had been given and this must always be recorded. Some medicines are prescribed to be given When required, these included dosage instructions and a maximum daily dose. In one case clear guidance for the use of a medicine was not available for staff on either the medicines administration record sheet or the care plan. The manager said she would discuss this with the resident’s doctor and this medicine had not been needed recently and was probably no longer necessary. Changes in dose of medication were signed and dated by the person making the change and a reason given, and this is good practice. On the nursing unit several residents have sheets, signed by the doctor, authorising medication to be crushed before it is given. The reason for crushing the medication was not clear. In some cases medication had been changed and the sheet was out of date, in some cases liquid forms of the medicine are available and in other cases staff said that the resident did not need the medicine to be crushed. Action is needed to review these sheets with both the doctor and pharmacist to make sure that medicines are always given in the safest and most appropriate way. Staff record the receipt of medicines into the home on the medicines administration record sheet. Records must also be kept of medicines brought in by residents on respite care. Records are kept of the disposal of medication. Copies of the patient information leaflets for medicines used in the home were not generally available. These provide useful information about the safe use of medicines for both residents and staff. It is recommended that staff request that the pharmacy send copies of the patient information leaflets for the medicines used in the home. Fairview Court DS0000067811.V327254.R01.S.doc Version 5.2 Page 13 Medication training has been provided for care staff involved with medication administration. The manager also said that staff have been enrolled on an NVQ level 2 medication course via City of Bath College Fairview Court DS0000067811.V327254.R01.S.doc Version 5.2 Page 14 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): 12,13,15. Quality in this outcome area is good. Residents are able to keep close contact with relatives,friends and the community.Residents are offered a varied and nutritious diet, and can take part in a range of social and theraputic activities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents take part in a variety of social and therapeutic activities. There are two part time activities organisers employed to organise social activities. These include bingo, exercise groups, musical afternoons, and one to one sessions .The Home has also commenced trips to areas of interest in the community. On the second day of the inspection a small group of residents went on a trip to Chew Valley lakes. A group of residents were observed taking part in a gentle exercise session with staff and they looked as if they were enjoying the social activity. There is a hairdresser who attends to residents in the Homes own salon. Residents were observed having their hair attended to during the inspection, and looking as if they were having an enjoyable time. Residents were observed walking around the Home, and approaching staff, and looking relaxed and settled in their environment. Fairview Court DS0000067811.V327254.R01.S.doc Version 5.2 Page 15 During the inspection a number of visitors came to see friends or family at the Home. Staff were warm and friendly in manner to visitors. Visitors also said that staff are friendly and welcoming. One visitor said that they have lunch with their wife who is a resident on a weekly basis, which they very much enjoy. This is good evidence that the Home support and encourage residents to keep close contact with families and friends if they so wish. The residents menu was inspected to find out what sort of meals choices are provided. The Home operates a rotating flexible menu. The menu choices were checked and were all well balanced, traditional and varied. Residents can make a choice at meal times of the meal they would like to have. Catering staff have an up to date record of residents likes and dislikes to help ensure residents preferences are accommodated. The daily menu is written on a large notice board in the dining room to assist residents to know what is for lunch or dinner. There are dining rooms for residents to have their meals in on each floor. A portion of the lunchtime meal was sampled; this consisted of a choice of roast turkey with stuffing, or sausages, roast potatoes, parsnips, and green beans. There was a choice of homemade bread and butter pudding with custard, or fresh fruit salad for dessert. The meal was tasty, and well cooked. Residents who needed extra help with their meals with being helped by staff in a sensitive and discrete way. Fairview Court DS0000067811.V327254.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 adequate. Residents’ and their representative can be confident that complaints will be taken seriously and acted upon. The Homes protection of vulnerable adults procedure is not up to date and does not show how to protect residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a copy of the complaints procedure on display in the reception area. This includes the contact information for the area office of the Commission for Social Care Inspection. A copy of the complaints procedure is included in the service user guide. The complaints book record was reviewed and there had been one complaint recorded since the last inspection. This related to the loss of an item of residents laundry. The complaint had been dealt with promptly and thoroughly by the Home. Visitors said they felt very able to speak to any of the staff if they had any concerns. They said staff would respond promptly and take their concerns seriously. The Home has its own `protection of vulnerable adults from abuse’ procedure. However the procedure is not up to date, as it does not reflect current guidance. The procedure needs to refer to South Gloucestershire Councils Vulnerable Adults guidance strategy as the basis for actions taken in the event Fairview Court DS0000067811.V327254.R01.S.doc Version 5.2 Page 17 of an allegation of abuse. This is so that all staff follow the correct course of action to protect residents in the event of an allegation of abuse. There was evidence in the staff training records that staff attend training on the protection of vulnerable adults from abuse, to help ensure residents are protected. The staff demonstrated in discussion an understanding of the topic of `protection of vulnerable adults from abuse’ and how to protect residents in their care. Fairview Court DS0000067811.V327254.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): 19,20,21,23,24,25,26. Quality in this outcome area is good. The Home looked satisfactorily maintained, clean and tidy and suitable for residents needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Fairview Court is a purpose-built Home close to private houses and a short distance from the town of Kingswood and near to bus stops. This helps ensure residents can be a part of the community. The Home is set in its own grounds. The garden was satisfactorily maintained and there are patio seats and a secure garden where residents can sit and walk safely. One resident was observed spending time sitting in the garden with their husband during the inspection. The Home is wheelchair accessible. The Home is a three-storey building, and residents have access to all areas on each floor. However there is a keypad entry system for exiting and entering the building, and for gaining access to the first and second floor. This is in place to protect residents who may be very confused and may leave the Home. Fairview Court DS0000067811.V327254.R01.S.doc Version 5.2 Page 19 There are adaptations in place to assist residents and visitors with disabilities throughout the Home. There are dining rooms and lounges on each of the three floors. Residents were observed sitting in the lounges and dining rooms, looking reasonably relaxed and comfortable in their environment. The bedrooms are situated on the ground, first floor, and second floor. There is lift access to all floors. Rooms are spacious and the standard of fixtures and fittings are of a high standard. The Home looked clean and tidy in all areas that were viewed. Bedrooms all have ensuite facilities in them for residents’ personal use. Bathrooms include specially adapted baths to assist residents who may have reduced mobility. Toilets are situated in readily accessible parts of the Home near to communal areas and bedrooms. The bathrooms and toilets were clean, and were well stocked with hand towels and soap to help minimize risk from cross infection in the Home. Fairview Court DS0000067811.V327254.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): 27,29,30. Quality in this outcome area is good. Residents are cared for by sufficient number of competent staff, provided with training to fulfil their roles and responsibilities .The recruitment procedures are robust and demonstrate the required safety checks when recruiting staff are being carried out. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A sample of staff files were inspected to find out if the Home operates safe recruitment practises. There are two written professional references taken up for all new staff prior to offering work with the Home. In addition, all staff sign to declare they have not committed a criminal offence prior to employment, as well as complete a Criminal Records Bureau check and a ‘POVA First’ Check before commencing employment. These checks are a further safeguard for vulnerable residents. The staff duty record for nursing and care staff the previous two-week period was checked to find out if residents are cared for by a sufficient number of staff on duty to ensure their needs are met. For the current number of residents there is a minimum of one registered nurse and seven care staff on duty every morning shift. There is one registered nurse and five care staff on an afternoon shift, and one registered nurse and three staff on duty at night. There was a small amount of sickness recorded, wherever possible the Home try and cover any shortages of staff with their own staff. There has been an occasional use of agency staff since the Home opened in November 2006. Fairview Court DS0000067811.V327254.R01.S.doc Version 5.2 Page 21 There are also domestic staff, catering staff, and laundry staff who work in the Home every day, however the numbers of these staff were not reviewed. Based on the evidence from the inspection the number of staff on duty is meeting residents’ needs. The training records of four members of staff were looked at to find out if staff are provided with a range of training opportunities These consisted of three care staff and one registered nurse. All of the staff concerned had attended recent training and update session on topics and matters relevant to the needs of residents in the Home. Training sessions staff had attended included courses in understanding dementia to further assist staff in understanding the needs of residents in their care. Staff also spoke positively about the range of training and development opportunities that they are able to attend. Fairview Court DS0000067811.V327254.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, 37,38. Quality in this outcome area is adequate. Residents’ benefit from an experienced and well-trained management team. Staff are well supervised in their work and have a good understanding of their roles and responsibilities However residents’ health and safety could be better protected.Also improvments should be made in staff record keeping in residents records. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents are cared for by a management team consisting of the Manager, Mrs McNeil Helyer and a deputy manager. Mrs McNeil Helyer is a first level registered nurse with many years of experience caring for residents who have dementia. She has also been registered as a manager of another care home in Avon providing nursing care. The deputy manager is also well qualified to fulfil his role. He has a significant number of years experience caring for residents Fairview Court DS0000067811.V327254.R01.S.doc Version 5.2 Page 23 with mental health problems he is also a first level registered mental health nurse, and a first level registered general nurse. The staff reported that staff meetings are held regularly. A sample of recent minutes were looked at that demonstrated staff are consulted, and their views sought by Mrs McNeil Helyer about the running of the Home. The monthly monitoring visits of the Home that must be carried out by a representative of the owners are being undertaken as required by law. There are detailed and informative records of these visits being sent to the Commission. The records demonstrate that the designated individual responsible for the visits spends time with residents and their representatives and observing staff carrying out their duties. Residents’ records were kept securely in filing cabinets on the first and second floor. However on the ground floor resident’s care records need to be stored more securely. Records were being stored in a lockable moveable metal trolley in the dining room. The trolley was not locked when checked by the inspector. Also storing this item in the dining room detracts from the homely appearance of the room. All records seen were legible, up-to-date and in satisfactory order. Also when reading a sample of records it was noted that a number of the entries had been written in a subjective, and negative tone. Staff need to keep accurate and objective records of residents health and wellbeing. The environment looked safe and satisfactorily maintained throughout. Staff are provided with regular training in health and safety matters including first aid, food hygiene training and moving and handling practises. This should help protect residents’ health and safety if staff are knowledgeable and well trained in these health and safety principles and practices. The fire logbook records showed fire alarm tests are being carried out. There are also fire drills carried out on a regular basis to help protect the health and safety of residents and staff. However to better protect the health and safety of residents, staff, and visitors there needs to be an up to date fire safety risk assessment for the Home. Currently there is an `interim’ safety risk assessment that has been carried out, however this is no full safety assessment of the Home. This is required to demonstrate how fire risks will be assessed and what actions will be taken to minimise them. The kitchen was tidy and organised when viewed .Up to date checks of kitchen fridges and freezers are maintained, to ensure they are operating within food safety guidance levels. There were also records to demonstrate that `high risk’ foods are temperature probed before serving to ensure the food has reached above minimum required temperature. The Home also won a four out of five possible stars food safety award, issued by South Glous. Council environmental health department. This demonstrates catering staff have a good knowledge of food safety practises and procedures. However during the inspection staff who Fairview Court DS0000067811.V327254.R01.S.doc Version 5.2 Page 24 are directly involved in personal care were observed serving food to residents and going into the kitchen without wearing suitable protective clothing over their uniforms. Staff should wear protective clothing to minimise the risk of cross infection from their uniforms onto food or surfaces in the kitchen. Fairview Court DS0000067811.V327254.R01.S.doc Version 5.2 Page 25 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 2 X 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 X 3 3 3 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X 2 2 Fairview Court DS0000067811.V327254.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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 2 Standard OP7 Regulation 14.2 13.6 Requirement Timescale for action 01/04/07 OP18 3 4 OP38 OP9 23.4(a) 13.2 Residents’ assessment records must be reviewed and updated on a regular basis. The Homes `protection of 15/05/07 vulnerable adults’ procedure must be up to date and reflect current guidance. There must be an up to date fire 15/04/07 safety risk assessment for the Home. The registered person shall make 01/05/07 arrangements for the recording, handling, safe keeping, safe administration and disposal of medicines received into the care home: - Records must be kept of the receipt of all medicines into the home - If medicines are prescribed with a variable dose the amount given must be recorded. - Action is needed to review sheets about crushing medication with both the doctor and pharmacist to make sure that medicines are always given in the DS0000067811.V327254.R01.S.doc Version 5.2 Fairview Court Page 27 safest and most appropriate way. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard OP1 OP37 OP38 OP37 OP9 Good Practice Recommendations The service users guide should be written in a format that is easy to read and accessible. Residents care records should be stored securely. Staff directly involved in personal care should wear suitable protective clothing when serving food or in the kitchen. Staff should undertake training in accurate objective record keeping. It is recommended that: Staff develop a homely remedy policy and agree this with the residents’ doctors. A system is developed to allow the audit of medicines supplied in standard packs. A medication policy specific to Fairview Lodge is available to provide guidance for staff about safe handling of medicines in the home. Copies of the patient information leaflets for the medicines used in the home are obtained from the pharmacy. These provide useful information about the safe use of medicines for both residents and staff. Fairview Court DS0000067811.V327254.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Court DS0000067811.V327254.R01.S.doc Version 5.2 Page 29 - 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. 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