Inspection on 10/10/05 for Fairview House

This inspection was carried out on 10th October 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Fairview House 28/08/08

Fairview House 04/03/08

Fairview House 19/09/07

Fairview House 30/04/07

Fairview House 08/06/06

Fairview House 24/05/05

Fairview House 16/12/04

Fairview House 30/07/04

Fairview House 14/01/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Fairview House 14 Fairview Drive Westcliff On Sea Essex SS0 0NY Lead Inspector Christine Bennett Unannounced Inspection 10th October 2005 10:00 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 House DS0000015435.V255237.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Fairview House DS0000015435.V255237.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Fairview House Address 14 Fairview Drive Westcliff On Sea Essex SS0 0NY 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) 01702 437555 01702 432835 Strathmore Care Mrs Kornelia Boorman Care Home 55 Category(ies) of Dementia - over 65 years of age (55), Old age, registration, with number not falling within any other category (55) of places Fairview House DS0000015435.V255237.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. The number of service users for whom personal care can be provided shall not exceed 55. (Total number not to exceed fifty five). Personal care is to be provided to service users who are over the age of 65. (Total number not to exceed fifty five). Personal care to be provided to no more than 55 service users with dementia over the age of 65. (Total number not to exceed fifty five). The Registered Manager to attend a minimum 5 day registered course in dementia care within 3 months of registration. The Registered Manager to complete NVQ Level 4 in Management and Care by 2005. 24th May 2005 Date of last inspection Brief Description of the Service: Fairview House is a large purpose built home situated in a residential area of Westcliff on Sea. Accommodation is provided on three floors for 55 residents in 49 single bedrooms and 3 shared bedrooms, 28 of which have en suite facilities. A passenger lift provides access to all three floors. Communal facilities are situated throughout the home with the main dining and lounge area being located on the ground floor. Fairview House is within easy reach of local shops and a bus route. There is ample parking space and gardens to the front and rear of the property. The home is registered for older people and older people who have dementia. Fairview House DS0000015435.V255237.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over 10 hours. The inspection process included discussions with the manager, five members of staff, eight residents and five visitors to the home. A tour of the premises took place and a random sample of records was examined. Discussion of the inspection findings took place with the manager and guidance given. What the service does well: What has improved since the last inspection? The staff have been issued with new lightweight uniforms as they were finding they were too warm in the old ones. When the staff handover information to the next shift, they will often use it as an opportunity to have a mini teaching session and as a result the manager feels the staff are more aware of residents’ needs. Fairview House DS0000015435.V255237.R01.S.doc Version 5.0 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. Fairview House DS0000015435.V255237.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fairview House DS0000015435.V255237.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 6 The Statement of Purpose needs to be updated to accurately inform potential residents of the service it offers. Pre admission assessments do not give the information to ensure care needs will be met. EVIDENCE: The Statement of Purpose needs to be updated to more accurately reflect the service that is being offered at Fairview House, this relates to dementia care, the manager’s details and CSCI details. Prior to admission to the home, an assessment is done by the Placement Coordinator or occasionally the Manager, to ensure a resident’s suitability to the home. There have been no changes to the pre admission procedure and the information recorded is not sufficient to ensure staff know the care that is needed for individuals. Visitors confirmed that they were able to visit the home beforehand and were involved in reviews to ensure that the home remains suitable, if care needs change. The home does not provide intermediate care. Fairview House DS0000015435.V255237.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Shortfalls in the completion of care plans and medication records could mean that the care needs of the residents are not fully met. EVIDENCE: A random sample of care plans was seen for three residents. There were shortfalls in the recording of information in these care plans. One of these gave no indication of the personal care required by the resident and no risk assessments relating to her mobility. Another identified that the resident had a medical problem by a letter from the local hospital, but no reference was made to it in the care plan to indicate what action needed to be taken. Regular reviews had taken place but there was no evidence to show that residents or their relatives had been involved, and relatives confirmed that they had not been involved in any care planning, although they are involved in reviews with Social Services. These shortfalls were discussed with the manager at the inspection and she recognised that further training is necessary to ensure that the information recorded accurately reflects the care needs of the individual. This was an area that was highlighted at the last inspection. Fairview House DS0000015435.V255237.R01.S.doc Version 5.0 Page 10 Despite records held not showing all the individuals’ needs, the care staff appeared to have a good knowledge of the residents and their individual needs, and residents and relatives were very positive about the care that was being given. Comments made were, “the staff care for me well” and “the care is very good and the staff are very nice”, however the care plans did not evidence the quality of the care witnessed. Medication records were checked at random. Two of the records had gaps on the MAR sheets and the amount of medication held by the home did not agree with the amount dispensed. Another resident was being given an antibiotic, which had been handwritten, but not signed on her medication record. Specimen signatures are held for staff dispensing medication and all the sheets had picture identification. Controlled drugs held by the home had been dispensed satisfactorily. Staff have not had recent training in the administration of medication. Residents and relatives confirmed that the staff treat the residents kindly and respect their privacy. One lady told how she has a telephone in her bedroom and chooses to have her meals in her room. Fairview House DS0000015435.V255237.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 Some social activities are organised, but need to be developed to meet all the residents’ needs. EVIDENCE: Opinions varied on the quantity and quality of the activities offered by the home. There is no designated activities co-ordinator, therefore the care staff are responsible for the provision of any entertainment. Some staff were positive and said they enjoyed this role and spoke of karaoke, card games and board games and felt there was enough for residents to do, whilst others felt there wasn’t enough and would like more time to spend with residents. Residents were asked about the activities and comments made were, “I think it would be nice if we did have more activities” and “I don’t do much at all”. Visitors to the home also had varying opinions saying, “It’s lacking activity, I never see any” and “there is lots going on, sing songs, karaoke, exercises and skittles”. They confirmed that they were able to visit the home whenever they chose and were always made to feel welcome, but there is little opportunity for residents to leave the home unless their relatives take them out. Residents are encouraged to maintain their independence, one lady manages her own finances and residents are able to bring their own possessions when coming to live in the home to make their rooms more personal. Fairview House DS0000015435.V255237.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The residents living in the home are protected by the complaints procedure and staff training relating to abuse. EVIDENCE: The home has a satisfactory complaints procedure. There has been one complaint since the last inspection and the home was able to evidence that it followed their complaints procedure when carrying out an investigation. However the outcome of this investigation was not recorded, giving no indication if the complaint had been upheld or not and if the complainant was satisfied with the results. There have been no POVA issues at the home and all staff spoken with, had a good understanding of abuse and how to report it. Fairview House DS0000015435.V255237.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23, 24, 26 Areas of the home need to be refurbished in order to make it a safe, homely place for the residents. EVIDENCE: The service support manager did an inventory at the beginning of the summer, identifying areas that need attention and redecorating and furniture that needs replacing. As yet no indication has been given as to when these matters will be addressed. Areas of concern are fastenings on fire exit doors, as identified by the Fire Authority in May 2005 and secure locks to doors to prevent residents who have dementia from leaving the building unaccompanied. A bathroom and toilet on the ground floor does not have a hand washbasin, and staff confirmed that this bathroom is used on a regular basis. This is an area that poses concern regarding infection control and must be addressed. The bedrooms are personalised and people are encouraged to bring their own possessions but some of the communal areas are in need of redecoration. One visitor said, “I feel the decoration needs to be uplifted”. Fairview House DS0000015435.V255237.R01.S.doc Version 5.0 Page 14 The home is involved in a pilot scheme with the local PCT regarding fall prevention, and a representative for this scheme visits the home on a regular basis. The manager explained that it has been very successful at night and although it is not always possible to prevent a fall, at least staff are made aware immediately and can come to the assistance of the resident. One staff member said that as more of the residents need assistance, it would be beneficial to be supplied with an extra hoist. Two visitors to the home confirmed that it is always clean when they visit and there are no offensive odours. They commented that the residents always look clean and their clothes are washed and ironed to a high standard. Fairview House DS0000015435.V255237.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 Shortfalls in the recruitment process, and staffing shortfalls could leave residents at risk. EVIDENCE: Recruitment files were examined for three new members of staff. All of these files evidenced that they had commenced employment at the home prior to clearance from the Criminal Records Bureau and POVA 1st had not been applied for on any of them. One of the files had only one reference and this was from a friend, and this same file identified a gap in employment from January 2005 that had not been investigated. Interviews had been recorded but with scanty information, as it was a tick box format which did not always give a clear response. This recruitment practice poses a potential risk to residents. The duty rota was examined for the week of the inspection and it was noted that the majority of staff are working excessive hours. The home operates on nine care staff in the mornings. The manager is not supernummary in these numbers and is therefore not available if she is carrying out her managerial duties. On one day, six of the other staff members were working a long shift from early morning until the night staff came on duty. Some of the staff were working in excess of 60 hours a week. The manager explained that one member of staff is on maternity leave and another is on long term sick leave and this has meant that the existing staff are doing extra shifts. Staff spoken with confirmed that they do get tired and although they are not obliged to do the extra hours, they want to help the staff team. Fairview House DS0000015435.V255237.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 38 The registered manager provides leadership and guidance to staff to ensure residents receive consistent quality care. EVIDENCE: The registered manager has been in post since October 2004 and has recently completed her NVQ level 4 training in Care and Management. She has also undertaken additional training to keep herself updated. Staff were positive about her management style and said she is approachable, with comments, “very helpful, keeps everything properly”. Residents and visitors were also complimentary. One visitor said, “she is very warm, good disposition and caring”. Fairview House DS0000015435.V255237.R01.S.doc Version 5.0 Page 17 The home has regular staff and residents’ meetings. Some visitors said they had been involved in residents’ meetings if they happen to have been visiting but would be interested in a more formal arrangement for relatives. This information was given to the manager, and discussion took place regarding collating the information gleaned from these meetings and other sources and formalising an annual plan as part of the home’s quality assurance. The registered provider is not supplying the CSCI with a monthly report regarding the conduct of the home as required by regulation. A random sample of money belonging to residents and held by the manager for their personal expenditure was checked and was found to be correct. One resident handles her own financial affairs. Fairview House DS0000015435.V255237.R01.S.doc Version 5.0 Page 18 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X 3 3 X 3 STAFFING Standard No Score 27 2 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 1 X 3 X X 3 Fairview House DS0000015435.V255237.R01.S.doc Version 5.0 Page 19 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 OP3 Timescale for action 14(b) The registered person must carry 01/02/06 out a pre admission assessment and record it appropriately This is a repeat requirement 15 The registered person must 01/02/06 prepare a written plan as to how a resident’s needs will be met This is a repeat requirement 13(2) The registered person must 01/01/06 ensure that medication is administered and recorded This is a repeat requirement 4(a) 13(4) The registered person must 01/01/06 23(4) comply with the requirements of the local fire service and identify any risks to the safety of residents and so far as possible eliminate them. This refers to the security of the building This is a repeat requirement 23(2)(j) The registered person must 01/04/06 provide a washbasin in the downstairs bathroom with liquid soap and paper towels This is a repeat requirement 18(1)(a) The registered person must 01/01/06 monitor staffing levels. This refers to hours worked and the length of the working day DS0000015435.V255237.R01.S.doc Version 5.0 Page 20 Regulation Requirement 2 OP7 3 OP9 4 OP19 5 OP21 6 OP27 Fairview House 7 OP29 19 8 OP33 24, 9 OP33 26 This is a repeat requirement The registered person must operate a thorough recruitment programme. This refers to obtaining a CRB prior to commencement of work The registered person must maintain a quality assurance system for reviewing and improving the quality of care provided The registered person must prepare a written report, as detailed in this regulation, on the conduct of the home and supply a copy to the manager and CSCI monthly 01/12/06 31/03/06 01/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard 1 12 20 16 Good Practice Recommendations Information in the Statement of Purpose and Service User’s Guide is updated To continue to develop activities, especially for residents with dementia, to stimulate them and occupy their time To replace worn and damaged furniture and have a programme of redecoration To maintain a record of the outcome of complaints Fairview House DS0000015435.V255237.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Fairview House DS0000015435.V255237.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!