Inspection on 30/04/07 for Fairview House

This inspection was carried out on 30th April 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 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 08/06/06

Fairview House 10/10/05

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 Michelle Love Unannounced Inspection 30th April 2007 09:00 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.V336278.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 House DS0000015435.V336278.R01.S.doc Version 5.2 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.V336278.R01.S.doc Version 5.2 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. 8th June 2006 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. The current weekly fees charged to residents as of 23rd April 2007, was between £379.47 and £497.00 per week. Extra charges as detailed on the homes pre inspection questionnaire relate to hairdressing, chiropody, toiletries, newspapers and Dial a Ride. The home has a Statement of Purpose and Service User Guide and a copy of the last CSCI inspection report in the entrance hall. The Annual Quality Assurance Assessment received at the Commission on 30th May 2007 detailed that 4x people are privately funded and 50x people are funded by either a Local Authority or Healthcare Trust (Essex County Council, Southend Borough Council and The London Borough of Tower Hamlets). Fairview House DS0000015435.V336278.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was undertaken as part of the homes `key` unannounced inspection. The inspection was conducted by Michelle Love, Regulation Inspector and lasted approximately 9.45 hours. The inspection was conducted with the assistance of the registered manager, deputy manager and senior care staff. As part of the inspection process a tour of the premises was undertaken and a random sample of records relating to care planning, healthcare documentation, staff recruitment, training and policies and procedures were examined. Case tracking was undertaken in relation to five residents living at Fairview House. Following the site visit 10 surveys were forwarded to relatives requesting their views about the quality of the service provided at the care home. Comments documented within the survey forms are highlighted within the main body of the report. Additionally the inspector spoke with a number of residents and senior/care staff throughout the site visit. Feedback pertaining to the inspection was given to the registered manager at the end of the inspection. What the service does well: What has improved since the last inspection? Continued refurbishment and redecoration is being undertaken at the care home to improve the environment for people living there. Fairview House DS0000015435.V336278.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 House DS0000015435.V336278.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 House DS0000015435.V336278.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): 3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has an adequate system for assessing the needs of prospective residents prior to admission. EVIDENCE: On inspection of three care files for the newest residents, pre admission assessments were noted to have been completed. Following discussions with the registered manager and from inspection of documentation it was evident that the assessment process is undertaken by the organisations placement coordinator and that there is little or no evidence to indicate that admissions to the care home are agreed in conjunction with the registered manager and/or staff team. The registered manager advised that neither, she or other senior staff are consulted and do not undertake an active role within the admission process. This is seen as inappropriate and not best practice as it is unclear that Fairview House DS0000015435.V336278.R01.S.doc Version 5.2 Page 9 the placement co-ordinator has taken into account the dependency levels of existing residents and/or their complex needs. In general terms assessments were seen to be adequate, however in some cases there was no information recorded as to the rationale for the decision to admit the resident on the same day as the assessment and it was unclear that it had been undertaken as an emergency admission. Additionally within two assessments information pertaining to challenging behaviour/inappropriate behaviours had not been detailed within the pre admission assessment process. In addition to the homes pre admission assessment format, the home had received information and/or assessments carried out through care management arrangements. Within one assessment there was evidence to indicate that the resident visited the care home prior to admission. There was no evidence to indicate that the registered provider had formally written to the prospective resident and/or their representative to confirm that the home could meet their needs. The home does not provide intermediate care. Fairview House DS0000015435.V336278.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 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care plans that are in place are poorly developed, contain some out of date information and do not fully reflect the person and/or their specific care needs. Recording of actual medication administered to individual residents was seen to be poor. EVIDENCE: On inspection of a random sample of five individual care plans, information recorded was noted to be basic, not detailed, comprehensive or person centred. Evidence suggested that the care plan is not used as a working document and does not consistently reflect the care being delivered i.e. the care records for one resident highlighted that the resident exhibited both physical and verbal aggression, refused to take their medication on occasions and had poor dietary intake. The care plan did not reflect this information and there were no clear guidelines in place for staff to follow. Not all formal assessments as contained within each care file were completed i.e. assessment Fairview House DS0000015435.V336278.R01.S.doc Version 5.2 Page 11 tool for memory, nutritional assessment, dependency profile and moving and handling etc. Where residents were diagnosed with dementia, in some cases no care plan was devised detailing the effects and impact of their dementia on their everyday life and how this was to be managed by care staff. Life histories were not completed for all residents. The registered manager was advised that knowing a person’s `life story` can help staff to communicate with those people who have dementia. Not all care plans were observed to have been reviewed and updated i.e. the care plan for one resident admitted on 15.2.07 evidenced that not all elements of the care plan had been reviewed. Risk assessments were not completed for all areas of assessed risk i.e. the daily care records for one resident made reference to the individual person being very agitated and aggressive towards others, refusing to take medication on occasions not eating or drinking well. No risk assessment was recorded detailing the nature of the specific risk and how this was to be managed by care staff. Daily care records for residents were in general to be written daily and after every shift. On some occasions records were not completed daily and evidence of staff interventions/care provided to residents poorly completed i.e. the care records for one resident detailed that they were found naked within another resident’s bedroom and trying to physically lift the other resident up off of the floor. No records were recorded pertaining to staff’s interventions, support given to either resident, actions undertaken and outcomes. Records were noted to state “had a settled night through all checks still in bed”. The registered manager was advised that daily care records are a good source of evidence to show that care is being provided, as detailed in the care plan. Daily care records when well written help ensure a consistent approach and good quality of care for residents. Detailed daily care records assist the manager to audit the care being provided to residents and ensure that staff are following the guidelines within the care plans. It is in the homes interests to be able to show what they have done, along with providing the evidence on which to base the monthly review and to record that they are following the assessment of needs. There was little evidence to indicate that individual care plans had been devised with the resident and/or their representative. On inspection of the homes medication storage facilities these were seen to be appropriate and actual administration procedures by senior staff to individual residents was also observed to be in keeping with good practice procedures and legislation. However on inspection of Medication Administration Records (MAR), several omissions of signatures/initials were observed, whereby staff had not signed the MAR record to indicate that medication had been administered to and received by residents. The registered manager must Fairview House DS0000015435.V336278.R01.S.doc Version 5.2 Page 12 ensure that appropriate systems are devised to ensure that this does not happen in the future. The homes pre inspection questionnaire submitted to the Commission suggests that those staff who administer medication to residents has undertaken medication training within the last 12 months. On inspection of 2x senior staff employment files, evidence of medication training was available and confirmed that this had been undertaken on 27.9.06 and 19.1.07. Fairview House DS0000015435.V336278.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents residing at the care home are given the opportunity to participate within a limited activity programme. Mealtimes are not an enjoyable experience for residents. EVIDENCE: Since the last inspection an activities and entertainment questionnaire has been devised and implemented for all existing residents. A recreational activities rota has been devised for each week and the registered manager advised that one member of staff provides an activity each afternoon i.e. nail care, bingo, sing a long, painting, seated exercise, dancing, arts and crafts, ball games, karaoke, foot spa, quiz and flower arrangement. In addition to the above one resident was able to confirm that a visitor comes into the home to play cribbage with them twice weekly, the registered manager confirmed that all residents are formally registered with Dial a Ride, that there is input from South East Essex Advocacy Services and monthly wherever possible external entertainment and/or community activities are provided i.e. Easter Party, Theatre Trip, BBQ, Pub Trip etc. In addition to the above Holy Communion is Fairview House DS0000015435.V336278.R01.S.doc Version 5.2 Page 14 available once monthly. Evidence on the day of the site visit suggested that in the main activities are provided for those residents who have good communication and/or cognitive development, however those residents with more complex needs do not have the opportunity to achieve their full potential. The care plans for some residents detailed that staff were unable to ascertain resident’s preferences to social activities and hobbies as a result of their dementia. The majority of activities provided are group orientated and there is little evidence to indicate that one to one activities are provided for those people with dementia. The minutes of a resident meeting conducted on 10.1.07 record that residents had requested more activities and entertainment. Observation of the lunchtime meal provided to residents was noted to be very poor and not an enjoyable experience for several residents. This is in relation to some residents having finished their meal whilst others had yet to receive their food (some 45-50 minutes after food had been initially served), some people receiving both their main meal and dessert at the same time, one resident having food placed in front of them for 10-15 minutes and given no staff assistance however their meal had gone cold, one resident being given their dessert before their main meal and staff not being aware until the inspector advised them and one resident being given their dessert but did not have a spoon and having to shout on several occasions to gain staff’s attention. Additionally the maintenance person was observed to undertake work on the homes electrical system at the same time as the lunchtime meal was being served to and eaten by residents. As a result the lights within the dining area/lounges were noted to intermittently go on and off and on occasions these areas were dark with poor lighting. Two residents were overheard to state “isn’t it dark in here”. The delivery of the lunchtime meal was seen to be disorganised and rushed, and it was evident that both senior staff and care staff were not cohesively working as part of a team. The registered manager was aware of the situation and made several attempts to engage staff in better working practices and at handover discussed her observations and disappointment with staff. Verbal interaction between staff and individual residents was observed on most occasions to be poor. On a positive note dining tables were laid (table mats, cutlery and salt and pepper pots). The menu for the day was displayed within the dining area and observed to be in a written format. Initially only two jugs of orange squash were available, however the registered manager provided a jug of lemon and blackcurrant squash and residents were offered a choice. Pureed meals provided for those residents who require a soft diet were portioned separately, some residents were asked if they wanted more food and those residents who did not want roast lamb were given an alternative of their choice i.e. fish fingers/sausages. A sample of menus were forwarded to the Commission for Social Care Inspection with the pre inspection questionnaire. Menus indicated that during the week residents are given a choice of cereals, eggs, toast, porridge for Fairview House DS0000015435.V336278.R01.S.doc Version 5.2 Page 15 breakfast and on a Sunday a cooked breakfast is readily available. For lunch there are two choices of main meal and dessert and for supper there is a choice of hot and cold items. Fairview House DS0000015435.V336278.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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service has a complaints policy and procedure and there is not a high incidence of complaints received at the care home. Some training deficits were noted in relation to challenging behaviour training. EVIDENCE: The home has a clear complaints policy and procedure. The registered manager was advised that the complaints procedure needs to be amended to reflect that the Commission for Social Care Inspection no longer has any statutory responsibility to investigate complaints. Any complaints received at the Commission will be referred back to the registered provider or to the local authority if they are contractually involved. As part of the inspection process inspectors will examine how the registered provider has dealt with issues and as to whether regulations are being met. The homes complaint records indicated that there have been few complaints received. Records detailing the specific nature of the complaint, investigation and action taken to address the issues were available. The registered manager was advised that the outcome of complaints should also be recorded. The home was observed to have an adult protection policy and procedure. Training records suggest that staff have undertaken protection of vulnerable Fairview House DS0000015435.V336278.R01.S.doc Version 5.2 Page 17 adults but only a limited number of staff have received training relating to challenging behaviour. The latter deficit is seen to be inadequate as a number of residents residing at the care home exhibit lively/inappropriate behaviours. Fairview House DS0000015435.V336278.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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Areas of the home continue to require refurbishment and redecoration. EVIDENCE: At the time of the site visit it was evident that an, extensive programme of redecoration and refurbishment is being conducted by the registered provider. Since the last inspection new windows have been fitted on the ground floor, a number of residents’ bedrooms have been redecorated and new sinks have been placed within three bathrooms. The Commission acknowledges the work so far undertaken, however there are a lot of areas, which require renewal and updating. The registered provider must write to the Commission advising as to the approximate timescale of works/redecoration to be completed and how this will impact on residents residing at the care home within 14 days. Fairview House DS0000015435.V336278.R01.S.doc Version 5.2 Page 19 Of those resident’s bedrooms inspected, all were seen to be personalised and individualised, however none of the bedrooms inspected were noted to have accessible call alarm cords. The registered manager advised the inspector that she was aware of the deficit and steps have been undertaken to address. Some areas of the home were not well lit on the day of the inspection as a result of the maintenance person completing electrical works. The Commission must be notified in writing within 14 days that these works have been completed. One relative survey returned to the Commission stated “The home is slowly now improving it’s appearance and facilities”. Two health and safety issues were highlighted at the time of the site visit pertaining to contractors leaving wood on one corridor floor and where handrails had been removed, brackets were left exposed and jutting out. Prior to the inspection a Regulation 37 Notification was received by the Commission detailing that a resident breached the homes security and was found by a passer by walking along the street. The registered manager assured the inspector that appropriate measures have since been undertaken to minimise the future risk. The aforementioned resident’s relative was notified promptly and advised the inspector (relatives survey) that this had happened on only one occasion. In general terms the home was observed to be clean, tidy and there were no unpleasant odours. The homes laundry systems were observed to be appropriate. One relatives survey returned to the Commission advised that items of clothing are not always returned to their member of family promptly. Fairview House DS0000015435.V336278.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The level of staffing on occasions restricts the ability of the service to deliver person centred support. The homes recruitment procedures do not fully meet regulatory requirements. Some staff training deficits were observed. EVIDENCE: The registered manager advised the inspector that the homes staffing levels are 8x staff between 08.00 a.m. to 14.20 p.m., 7x staff between 14.00 p.m. and 20.20 p.m. and 4x waking night staff between 20.00 p.m. and 08.20 a.m. Neither the registered manager or deputy manager has supernumerary hours to complete necessary paperwork, undertake staff supervisions etc. This is seen as not good practice and consideration should be given by the registered provider to ensure that the registered manager/deputy manager is given sufficient opportunity to undertake some supernumerary hours/shifts. On inspection of four weeks staff rosters it was evident that staffing levels have not always been maintained and do not always meet the needs of the people using the service. The inspector believes that the level of staffing on occasions restricts the ability of the service to deliver person centred support and this is evidenced by routines within the home being quite rigid. The registered manager was advised that any agency staff utilised at the care Fairview House DS0000015435.V336278.R01.S.doc Version 5.2 Page 21 home must be recorded on the staff roster. Additionally the staff roster indicates that some staff have been undertaking long days/double shifts (12.20 hours) on occasions. The registered manager was advised that this places both staff and residents at potential risk and is seen as not good practice. Throughout the site visit, the deployment of staff within lounge areas was observed to be very poor and in one instance no staff visited one lounge area for at least 20 minutes. This was of concern as residents were observed to be frail and have poor communication skills and their needs were not met promptly. A random sample of six staff recruitment files, were examined. Records indicated that the majority of records had been sought however in some cases a full employment history had not been explored, dates of actual employment undertaken not recorded, no evidence that staff recruited with a POVA 1st and no Criminal Record Bureau check had been supervised, no evidence of experience/qualifications, no recent photograph and one person had a Criminal Record Bureau check from a previous employer and not Strathmore Care. A record of induction was evident for all newly appointed staff. The registered manager advised the inspector that she is not involved in the recruitment of staff. One relative survey forwarded to the Commission detailed that in their opinion, culturally care staff do not have the right skills and experience to look after people living in the care home and that 95 of residents are white (British) and 95 of staff have predominately an Asian or African ethnicity. This is confirmed within the homes Annual Quality Assurance Assessment. A random sample of staff training files were inspected for 8x members of staff. Records and the homes pre inspection questionnaire evidenced staff have received training relating to personal safety, mental capacity act, protection of vulnerable adults, health and safety, food hygiene, medication, moving and handling, fire awareness, pressure ulcer training and infection control within the last 12 months. There was little evidence at the site visit to indicate that staff have received training which relates to the needs of older people i.e. sensory impairment, dementia, diabetes, Parkinsons Disease, incontinence, first aid etc. The pre inspection questionnaire details future training planned for bereavement, grief and mourning, incontinence, dementia, chair-based exercises and appointed first aid. The Annual Quality Assurance Assessment received at the Commission on 30th May 2007 details that one member of catering staff and only 38 of care staff have up to date food hygiene training. The document also details that only 9.5 of staff have NVQ Level 2 or above and two members of staff are currently working towards achieving a NVQ Level 2 qualification. Fairview House DS0000015435.V336278.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, 33, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is qualified and has the necessary experience to run the care home. EVIDENCE: The registered manager advised the inspector that she has managed Fairview House for the past 6 years, has been employed by the organisation for 10 years and has attained NVQ Level 3 and 4 and has undertaken the Registered Managers Award. The registered manager stated that she gets support from the organisations care consultant and operations manager and that the registered person provides formal supervision approximately twice yearly. Of Fairview House DS0000015435.V336278.R01.S.doc Version 5.2 Page 23 those staff spoken with, all were complimentary regarding the management of the home. There was clear evidence to indicate that regular staff meetings are conducted i.e. once monthly and evidence of minutes were readily available. In addition residents meetings are also conducted. Although documents relating to residents financial matters were not inspected, one relative survey stated that they would like more information on the financial needs of their member of family i.e. hairdressing (frequency and cost). On inspection of a random sample of staff employment files, it was positive to note that staff are receiving formal supervision, however this is not in line with the frequency as detailed within the National Minimum Standards for Older People. A random sample of records as required by regulation were inspected pertaining to the homes gas and electrical safety certificates, clinical waste contract, the homes hoists/slings, the homes fire alarms and emergency lighting systems, the homes fire equipment, the homes passenger lift, employers liability certificate, fire risk assessments, records of fire drills and hot water temperatures from baths and wash hand basins. All records were seen to be satisfactory. Fairview House DS0000015435.V336278.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 1 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 X X X 2 X 3 Fairview House DS0000015435.V336278.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 Requirement Ensure that pre admission assessments are detailed and that written confirmation has been forwarded to the resident and/or their representative detailing that the home can meet the individuals needs. Timescale for action 14/07/07 2. OP7 15 Previous timescale of 1.10.06 not met. 14/07/07 Ensure that care plans are detailed, comprehensive and include details of the residents care needs and how these are to be met by care staff. Ensure that care plans are regularly reviewed and reflect changes to the residents care needs. Previous timescale of 1.10.06 not met. Ensure that residents and/or their representatives are involved in the care planning processes. Ensure that risk assessments are devised for all areas of assessed risk. Ensure that appropriate DS0000015435.V336278.R01.S.doc 3. OP7 15 14/07/07 4. 5. OP7 OP9 13(4) 13(2) 14/07/07 14/07/07 Page 26 Fairview House Version 5.2 6. OP12 7. OP14 8. OP15 9. 10. OP18 OP19 arrangements are made for the safe recording of medication on MAR records. This refers specifically to omissions of staff signatures on the MAR sheet. 16(2)(m) Ensure that all residents receive and (n) a regular programme of activities which provide meaningful stimulation. 12(2) Ensure that residents are enabled and empowered to make decisions and choices and that there is clear evidence to depict this. 12(1)(a), Ensure that the dining (4)(a) and experience for residents is 16(2)(i) improved upon and that residents receive adequate food. 13(6) Ensure that all care staff receive appropriate training relating to challenging behaviour. 13,16,23 The registered person must replace old and worn furniture, ensure the environment is refurbished and decorated to a good standard. 21/07/07 14/07/07 14/07/07 01/10/07 01/09/07 11. 12. OP19 OP27 13(4) 18(1)(a) Previous timescale of 1.10.06 not met. Ensure that all areas of the home 14/07/07 are free from hazards and health and safety risks to residents. Ensure at all times that there are 14/07/07 sufficient numbers of staff on duty at all times to meet the needs of residents residing at the care home. This refers specifically to the rosters not being reflective on occasions of sufficient staff on duty and some staff working long days/double shifts. Previous timescale of 1.10.06 not met. The registered person must operate a thorough recruitment programme. DS0000015435.V336278.R01.S.doc 13. OP29 19 14/07/07 Fairview House Version 5.2 Page 27 14. OP30 18(1)(c) and (i) 18(2) 15. OP36 Previous timescale of 1.12.06 not met. Ensure that all staff receive appropriate training related to the specialist needs of older people. Ensure that all staff receive regular supervision in line with regulatory requirements. 01/10/07 14/07/07 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 OP7 OP16 OP28 OP3 OP29 Good Practice Recommendations Ensure that daily care records are detailed, informative and reflective of how individual residents spend their day. Ensure that the homes complaints procedure is updated to reflect that the Commission has no statutory duty to investigate complaints. A minimum of 50 of staff should obtain NVQ2 or above or the equivalent. The registered provider should consider enabling the registered manager to participate within the pre admission assessment process for residents. The registered provider should consider enabling the registered manager to participate within the recruitment process of staff to the care home. Fairview House DS0000015435.V336278.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 House DS0000015435.V336278.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. 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!