Inspection on 09/01/08 for Fairview House

This inspection was carried out on 9th January 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fairview House 30/01/09

Fairview House 18/08/06

Fairview House 01/02/06

Fairview House 06/09/05

Fairview House 26/05/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOME ADULTS 18-65 Fairview House Gypsy Lane Warminster Wiltshire BA12 9AR Lead Inspector Nicky Grayburn Unannounced Inspection 9th January 2008 10:30 Fairview House DS0000028080.V350050.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Fairview House DS0000028080.V350050.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Fairview House DS0000028080.V350050.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fairview House Address Gypsy Lane Warminster Wiltshire BA12 9AR 01985 847680 F/P01985 847680 fairviewhouse@rethink.org www.rethink.org Rethink 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) Vacant Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Fairview House DS0000028080.V350050.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th August 2006 Brief Description of the Service: Fairview House is registered to provide nursing care for ten adults with mental health problems. It is located in a residential area in the town of Warminster, Wiltshire, and has a local shop within walking distance. The home is domestic in character and offers comfortable single room accommodation. All communal rooms are light and airy, and furnishings are of good quality. A separate room is provided for people who wish to smoke. There is a large, secluded garden at the back of the house, with far reaching views over the local countryside and several seating areas as well as a paved patio. There are car parking spaces at the front of the house. Fairview House DS0000028080.V350050.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was Fairview House’s key inspection. It was unannounced and carried out over one day. The inspector met with the new manager; staff members; and many people who live in the home. A tour was also undertaken. Surveys were sent out and 6 surveys were returned from people living in the home; 4 surveys were returned from relatives, 2 surveys were from staff and 2 surveys from health care professionals. Other records were read prior to the inspection. Staff working in this home are Community Mental Health Workers, but for the purpose of this report, they are referred to as ‘members of staff’. What the service does well: What has improved since the last inspection? A new manager has started in the home and there has been mush positive feedback about her working there. Fairview House DS0000028080.V350050.R01.S.doc Version 5.2 Page 6 Fire drills now happen on a regular basis, which makes sure that everyone in the home know what to do in case of a fire. Medication is dispensed and managed better. Records are stored in a more organised manner and are more accurate. 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 DS0000028080.V350050.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fairview House DS0000028080.V350050.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People in the home do not have current information about the home. People are assessed prior to moving into the home ensuring the home can meet their needs. People do not have up-to-date contracts explaining the current fees and terms and conditions of their home. EVIDENCE: The home’s Statement of Purpose needs to be reviewed updated according to current practices within the home. It was agreed with the manager that this will be done within the next 6 months due to the amount of other work that is needed. This document must be sent to The Commission. There is a ‘Service User Guide’ in the lounge which some people read and use. All 6 of the surveys returned stated that they received enough information about the service before they moved in and 5 people stated that they were asked whether they wanted to move in. Fairview House DS0000028080.V350050.R01.S.doc Version 5.2 Page 9 Prior to moving into the home, people are assessed by their local authority. These are held in people’s files. These are mostly reviewed (please refer to Standard 6 for more information). People living in the home have ‘licence agreements’ which should detail their terms and conditions for living at Fairview House. These are dated from 2003 and need to be updated with the current fees and conditions and be in line with National Minimum Standard 5. A requirement has been made regarding this. There is currently one vacancy at the home and it is important for the home to update their information so that the prospective person will have all the relevant information to make an informed decision. Fairview House DS0000028080.V350050.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 Quality in this outcome area is adequate. People do not have complete service user plans. People living in the home are able to participate in the running of their home and are able to make decisions about their lives. People are able to take risks as independently as they can. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living in the home have 2 folders with information about them (Personal recovery folder and a Service User Recovery Folder). From the folders read, each person had a care plan assessment carried out by the relevant professionals (Psychiatrist; Care Coordinator; Community Psychiatrist Nurse); staff from the home (key worker, manager); family members, and themselves if they wish. Fairview House DS0000028080.V350050.R01.S.doc Version 5.2 Page 11 Some people’s recovery plans were blank and the care/support plans were not complete or tallied with the initial assessment. This was discussed with the manager and a requirement has been made regarding this. It must be further noted that 2 recommendations were made at the previous inspection for staff to sign and date people’s support plans and risk assessments when they complete them. This was seen to have been undertaken, and when the new documents are written, this must continue, along with the person’s signature (or refusal). There have been regularly ‘Resident Meetings’ held in the home. Minutes of these were read from the past 5 meetings. They showed that people can choose whether they attend or not, someone types up the minutes, and people are given an opportunity to voice their concerns and issues. Things which have been talked about include the cleaning of the home; proposed changes of the rooms, announcement of the new manager starting; key worker allocation and if anyone would like to be involved in interviewing members of staff. The AQAA stated that staff have been asking people to develop their own person specification and job description for new staff. It also stated that residents are encouraged to make autonomous decisions, and this was observed and talked out with people living at Fairview. When asked in the survey if they can make decisions about what they do each day, 3 people said ‘always’; 2 people ticked ‘usually’ and 1 person stated ‘never’. Risk assessments enabling people living at the home to take risks as part of their daily life are kept on the person’s file in the office. The ones which were read had been written recently and contained adequate information to ensure that people were safe. However, as discussed and agreed with by the manager, these do need to be reviewed in line with the care plans/recovery plans to ensure that they link together. Fairview House DS0000028080.V350050.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. People could be better supported to access the local community and preferred activities. People’s preferred routines are respected. People living in the home benefit from a healthy diet and enjoy their meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Some people are more independent than others and are able to access the local facilities of the area on their own. Some people need support from staff. It was discussed with the manager, and is written under ‘Staffing’, that the staff rota is being developed to allow people to access to activities and the community in the evening and over the weekends. Some people told me about their hobbies they do and the things they get up to which they seemed to enjoy. Fairview House DS0000028080.V350050.R01.S.doc Version 5.2 Page 13 Some people in the home have family contact and retain that contact with or without support from staff. Staff talked to the inspector about family situations and seemed aware and respectful of the issues involved. There is a small room with a pay phone in it which people were observed using and can close the door for privacy. Some people have keys to their bedrooms and keep their room locked when they are not at home. However, some people do not have keys and have refused to have keys. The AQAA stated that staff do not enter people’s rooms without their permission, and this was observed. It was noted, and observed during the visit that there have been some complaints made from people about other people entering their room without their permission, and on occasions, accusations have been made about people stealing money. This have been unproven but recorded. The staff are aware of this and dealt with the incident appropriately during the visit. It was observed that people’s daily routines are respected. All 6 people stated on their surveys that they can do what they want to do during the day, in the evening and at the weekend. Menus are on display in the kitchen and a person living in the home explained what happens during meal times. A meal was observed and was found to be relaxed and pleasant. The main kitchen had a good range of fresh fruit and vegetables, which were also available in the dining area. It was observed how people can make snacks and drinks whenever they wish. In their kitchen, each person has had a kitchen induction to ensure that they know where things are and how to be safe in the kitchen. Each person has signed their folder. Some people use a separate kitchen for all of their meals and drinks as part of their independent living. There is also a folder containing policies and assessments regarding the kitchen. The local authority awarded the home with a 5* star rating in August 2007. Fairview House DS0000028080.V350050.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is adequate. People will be better supported once care plans are in place. People are protected by robust medication procedures, which have been improved. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living at Fairview have complex mental and physical health needs. As stated under ‘Individual Needs and Choices’, the care plans do not specify what support people need and how it is to be given. However, the manager and staff were fully aware of the needs of the people living in the home and make regular contact with external professionals to ensure that their health needs are met. Some people attend their regular health care appointments (dentist, optician), and some choose not to. This was discussed with the manager, and details on how people are encouraged to maintain their health need to be written in their Fairview House DS0000028080.V350050.R01.S.doc Version 5.2 Page 15 care plans. Further, if people refuse to attend such appointments, this also needs to be recorded. Fairview house operates a key worker system, whereby each person living in the home has a designated member of staff with whom they can contact first with any issues. The key worker ensures that the person living in the home has everything they need and that their records are up together. Some people living in the home have epilepsy, and the manager has arranged training in the near future. This will followed up at the next inspection and certificates must be kept on the staff’s files as evidence. A requirement was made at the last inspection for accurate records of administered medication to be kept. A recommendation was also made for the records to be kept in a more methodical manner. Both the requirement and recommendation have been met. The inspector went through the home’s procedures and spot checked medication and records with the home’s deputy. People have medication reviews with their Psychiatrist. The medication is kept safe in a locked cabinet in the small office. The Medication Administration Records were checked and were all signed and in good order. There is currently one person who looks after their own medication and procedures are in place to ensure that they are safe. There are no controlled drugs kept on the premises. Staff receive training from the local college via distance learning. At the end of the 12 weeks, an assessment is carried out to ensure that staff are safe to administer medication. Fairview House DS0000028080.V350050.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service are mostly aware of how to make a complaint and feel listened to. People are protected from abuse but staff training is needed to ensure that this continues. EVIDENCE: The complaints procedure is within the Service User Guide. It was evident during the inspection that some people are very comfortable with raising their concerns with staff and the inspector. Complaints against the home have been received by the Commission and have been dealt with. The complaints logbook was read and contained details about the complaint and the action taken. The AQAA confirmed the numbers of complaints made to the home and stated that all of them were resolved within 28 days. From the surveys returned from the people living in the home, all 6 stated that they knew who to speak to if they were unhappy and 4 out of 6 stated that they felt listened to. However, when asked if they knew how to make a complaint, 3 stated ‘sometimes’; 2 stated ‘yes’ and 1 person ticked ‘no’. From the 4 relatives surveys, 3 ticked that they knew how to make a complaint, 1 person didn’t know. Fairview House DS0000028080.V350050.R01.S.doc Version 5.2 Page 17 It is recommended that when the Statement of Purpose is updated, copies are sent to relatives and people living in the home are reminded of the complaints procedure. There is a specific folder regarding the Protection of Vulnerable Adults (PoVA). Staff members have signed to state that they have read and understood the PoVA Scheme and the policies which accompany it. The AQAA stated that the training is carried out in-house and the subject is covered within the National Vocational Qualification course. However, procedures change and training should be updated on an annual basis. Training for this subject has been problematic to source. From the training files read, some people have not received any training on this subject. A requirement has been made regarding this. Referrals have been made to the local Safeguarding team, which have led to strategy meetings and action being taken to ensure people’s safety. There is an on-going issue currently with people’s health needs, which the Commission is aware of and is being kept informed by the manager. Incidents within the home are recorded but some should have also been reported to the Commission. This was discussed with the manager and she is now fully aware of what to report. 3 people’s personal monies were checked and the system of people’s finances were inspected. The personal monies were found to all be correct. There are issues with some people’s monies which the manager is looking into to make sure that people are as safe as possible. This will be followed up at the next inspection. Fairview House DS0000028080.V350050.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home live in a homely environment. People have personalised bedrooms, which suits their needs. The home was clean on the day of inspection. EVIDENCE: Fairview House is located in a residential area of Warminster and blends in very well with the neighbourhood. The home is large and has a fair sized garden around the back of the home. The inspector walked around the whole home, looked at all the shared areas and 6 bedrooms. Fairview House DS0000028080.V350050.R01.S.doc Version 5.2 Page 19 There is a large, light lounge central to the home, and there is a smoking room adjacent to it. There is a second lounge which is also light and has a pool table and entertainment facilities in it. The manager spoke of, and minutes from the staff meeting confirmed that it has been discussed, that some of the rooms are being re-arranged. The manager confirmed that this will be discussed again with people at the next house meeting. The main kitchen was clean. It has a larder attached to it. The manager wishes to keep it locked and this was discussed, and must be kept under review. There is another kitchen with seating area for people to use at any time. There is a fridge, oven and microwave in there and people can make snacks and drinks at any point. This was observed. People’s bedrooms were personalised and had pictures and personal effects making the rooms more homely. The maintenance book shows that the manager and team leader have gone through the whole home and written a list of all the things which need to be done. An action plan needs to be written to ensure that the list is completed. This will be followed up the next inspection. The home was generally clean and tidy on the day of inspection. The AQAA stated that the previously employed domestic no longer works in the home and it was decided that the post would not be filled as people living in the home are becoming more involved in cleaning their home. People do clean their own rooms but from discussions with people and reading minutes from the house meetings, it was clear that there have been issues about the cleaning of the shared areas. People spoken with said that they do they ‘chores’ but some people do not pull their weight. All 6 of the surveys returned stated that the home is ‘always’ fresh and clean. The manager is reviewing this situation. Fairview House DS0000028080.V350050.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in the home are supported by an effective staff team who are qualified and are supported by their manager. Training is needed to ensure that all people’s needs are met fully. People are protected by the organisation’s recruitment practices; however, full documentation needs to be available at all times. EVIDENCE: The inspector met a number of staff, and the team leader during the inspection and also spoke to some members of staff over the phone prior to the inspection. From the 6 surveys returned from people living in the home, 4 stated that the staff ‘always’ treat them well, and 2 people ticked ‘sometimes’. It was observed during the inspection that people felt comfortable with approaching staff and staff responded appropriately. It was nice to see staff and people spending time together and laughing, as well as people talking to staff about their concerns and issues. Fairview House DS0000028080.V350050.R01.S.doc Version 5.2 Page 21 The rota and staffing levels were discussed with the manager and a separate letter has been written to the manager regarding this. The manager is currently looking at how to best meet the needs of the people living in the house and how different shift times could better support people. The manager has found that people are not accessing activities in the evening and weekends due to staffing numbers. It has already been discussed in the last staff meeting and staff have welcomed the idea. It was stated that there must be sufficient numbers of staff to meet the assessed needs of the people living there. Once a decision has been made, it would be good practice for the manager to inform the Commission of the changes to the rota. There were concerns from staff and relatives about the level of agency staff being used. 2 full time workers are due to start in the near future, once all the recruitment documents have been returned. Staff recruitment records are held in the office in a secure filing cabinet, which only the manager and the deputy have access to. 3 staff files were checked and contained most of the required documents (application form, references). 2 of the 3 people did not have Criminal Record Bureau checks. The manager took immediate action and evidenced that checks had been carried out or were in the process of being sent though. The manager has since sent further evidence to confirm that all staff have these checks in place. Due to the missing CRBs, all the other staff’s CRBs were checked and were on file. It was discussed with the manager that guidance from CRB states that it is good practice to renew these checks every 3 years. There was one person who would need a new CRB according to the guidance. 5 staff’s training files were read and varied in evidence of mandatory training. Some people had nothing in their file but verbally told the inspector what training they have done; some people had a complete file, and some had only completed one course. The manager must ensure that copies of staff’s training certificates are held on file to evidence that staff have undertaken the necessary training. Currently the team are completing a distance-learning course in Infection Control. There was no evidence of manual handling training which is necessary. A requirement has been made regarding this. Some staff have completed their National Vocational Qualification in Health and Social Care, certificates were on some people’s files and the last monthly report (regulation 26 visit) stated that 43 of the staff had completed their NVQ. The previous inspection report stated that the newer staff will have specific mental health training. Some certificates were seen showing that staff have undertaken Mental Health Awareness training. This will be followed up at the next inspection. Staff told the inspector that over the past year, supervisions have not been regular. Since the new manager starting, this has improved. Supervision Fairview House DS0000028080.V350050.R01.S.doc Version 5.2 Page 22 notes were read and each member of staff now has a new ‘supervision contract’ and all have had their first supervision with the manager. The manager said that these will be monthly until she and the team have settled. Staff meetings have also resumed under the new manager. These are occurring on a weekly basis at the moment until the team and issues have settled, then they will be monthly. Fairview House DS0000028080.V350050.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. People in the home are benefiting from a new manager who is settling in and running the home well. People in the home benefit from a good internal quality assurance system. People living in the home are protected by the health and safety measures in place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Fairview house has a new manager in post. Ms Beaven appears to have settled in and is still gaining specific service knowledge. She was welcoming and open to the inspection process. Ms Beaven needs to apply for her registration with the Commission and is in the process of doing this. Fairview House DS0000028080.V350050.R01.S.doc Version 5.2 Page 24 Ms Beaven is fully aware of the needs of the home. She has been realistic about what can be achieved and has prioritised areas to work on. Requirements from this visit have been proportionate to the needs of the home and reflect the fact that Ms Beaven was aware of the areas for improvement. Rethink have a comprehensive internal quality assurance system. The manager must ensure that the annual report be sent to the Commission under Regulation 24 of The Care Standards Act. This will be followed up at the next inspection. Monthly visits from the provider are carried out and the last 3 reports were read during the visit. A requirement has been made for these to be sent to the Commission until the home has improved and the manager has settled. The fire safety records were read and records showed that external contractors are employed and visit the home to ensure that it is safe. The generic fire risk assessment is up to date and the home conducts regular fire drills to ensure people know what to do. The outcome from the evacuations are recorded. Those people who do not respond to the alarm are risk assessed individually. There will be one member of staff who will be the designated fire warden who will be responsible for the fire safety checks within the home. They will receive specific training. Currently, the manager has obtained a fire safety DVD to show people in the next staff meeting. Other heath and safety checks (e.g. gas safety; water systems; electrical tests) are carried out and are updated within the legal time frames. Fairview House DS0000028080.V350050.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 3 29 2 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X 3 X 2 X X 3 X Fairview House DS0000028080.V350050.R01.S.doc Version 5.2 Page 26 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA5 Regulation 5(b,c) Requirement Each person living in the home must have an up to date contract. Each person living in the home must have a working support plan which meets the National Minimum Standards. Staff to have training in the Protection of Vulnerable Adults. All staff must receive regular training updates. (outstanding requirement, previous timescale 18/11/06) Timescale for action 31/03/08 2. YA6 15 31/05/08 3. 4. YA23 YA35 13(6) 18(1ci) 30/04/08 31/05/08 5. 6. YA35 YA39 18(1a,c) 26 Certificates must be held on file to evidence the training. Staff to receive training in Manual Handling. The registered provider shall supply a copy of the report from the monthly visit to the Commission. 31/05/08 30/03/08 Fairview House DS0000028080.V350050.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA22 Good Practice Recommendations Remind relatives and people living in the home of the complaints procedure. Fairview House DS0000028080.V350050.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Regional Office Colston 33 33 Colston Avenue Bristol BS1 4UA 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. 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