Inspection on 10/05/05 for Fairways

This inspection was carried out on 10th May 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

Fairways 05/11/09

Fairways 05/11/09

Fairways 23/07/09

Fairways 21/08/07

Fairways 24/08/06

Fairways 14/09/05

Fairways 23/08/04

Fairways 23/06/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Fairways Fullers Field Swan Lane, Westerfield Ipswich IP6 9AX Lead Inspector Jane Higham Unannounced 10 May 2005 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 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 Stationary 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. Fairways I54-I04 S58263 Fairways V231051 050510 Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Fairways Address The Fairways, Fullers Field Swan Lane Westerfield Ipswich IP6 9AX 01473 214966 None None Care Aspirations Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Stephen Green Care Home 8 Category(ies) of LD Learning Disability registration, with number of places Fairways I54-I04 S58263 Fairways V231051 050510 Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 23/08/04 Brief Description of the Service: Fairways Residential Home is situated in a residential area of the village of Westerfield on the outskirts of the town of Ipswich. The home was first registered in April 2004 and offers care and accommodation for up to eight service users who have a learning dsiability coupled with challenging behaviour. Fairways is owned and administered by Care Aspirations, a specialist independent healthcare provider, established in 1986, who provide residential and private hospital services for adults within this service user group. This residential resource originally existed in Colchester, Essex but moved to Suffolk when the original buildings became unviable. Fairways I54-I04 S58263 Fairways V231051 050510 Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Unannounced Inspection of Fairways, an eight bedded residential home for adults with learning disabilities, coupled with challenging behaviour. This was the first inspection in the inspection year 2005/2006. The inspection was carried out by two inspectors on the 10 May 2005 over a period of 5 hours and 10 minutes. A number of service users were spoken with as part of the inspection process, although it was difficult to gain feedback in relation to the quality of the service provided due to impaired cognitive ability. A selection of resident care plans, risk assessments, pre-admission assessments, daily records and policies and procedures required by regulation were examined. Both inspectors undertook an environmental tour of the building. What the service does well: What has improved since the last inspection? It was noted that on this occasion the atmosphere within the home was much calmer and residents were involved in individual activities. The range of activities provided to residents has increased and the service is providing residents with new experiences on a trial basis and intends to provide each person with an individual activities care plan. Since the previous inspection a new manager has been appointed who is ensuring that all residents receive a multi-disciplinary assessment in order that the services response to the behavioural needs of individuals can be improved. Fairways I54-I04 S58263 Fairways V231051 050510 Stage4.doc Version 1.30 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. Fairways I54-I04 S58263 Fairways V231051 050510 Stage4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Fairways I54-I04 S58263 Fairways V231051 050510 Stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 and 3 People who move into this home can be sure their general care needs will be assessed but at present can not be assured that their specialist needs will be adequately assessed. EVIDENCE: There have been no new residents admitted to the home for some time. However, it was clear from the current residents care plans that since the appointment of the new manager these have been reviewed and partially rewritten. The manager of the home had referred residents to health professional such as a psychiatrist and speech language therapist in order to obtain an assessment and agree a way of working with each individual. Following discussion it was agreed that the home would ensure that all the current residents would be re-assessed using a multi-disciplinary approach. The primary reason for this is that the specialist care needs of the individuals at this home need to be determined by appropriate professionals particularly in relation to their individual challenging behaviour and not rely upon myth and hearsay that may be known. Two needs assessments completed before the residents moved in were examined. These were general assessments based on activities of daily living. These have been found to be inadequate in detail around the behavioural Fairways I54-I04 S58263 Fairways V231051 050510 Stage4.doc Version 1.30 Page 9 assessments and do not contain enough information to facilitate the development of a meaningful and detailed care plan. Fairways I54-I04 S58263 Fairways V231051 050510 Stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 and 9 People who use this service can expect to have a care plan in place that is accessible to staff. However, they can not be assured that specialist care plans in relation to individual challenging behaviour are available and up to date. EVIDENCE: Two resident care plans and associated documentation were examined as part of the inspection process. These included all personal details as required by the Care Homes Regulations 2001 and a recent photograph. One care plan contained core information which enabled staff to offer the individual resident appropriate care. The second care plan was more holistic and contained information such as a pen portrait of the individual, their likes and dislikes and strengths and weaknesses. This second care plan followed more closely the care plan format provided by the owning organisation. The daily statements written by staff were well written and based on description and factual accounts. Risk assessments were in place and found to be comprehensive and far reaching. The risk assessments informed staff of situations where individual residents could make decisions for themselves; for example in relation to Fairways I54-I04 S58263 Fairways V231051 050510 Stage4.doc Version 1.30 Page 11 finances and consent to treatment. In one file, a risk assessment was being developed in relation to an individual’s safe travel using public transport. In one care plan there was a “behavioural programme”. This document was intended to describe the potential challenging behaviour of a resident and to offer an outline of interventions for staff to follow. It was noted that this care plan was out of date and had not been reviewed since December 2003. However, the new Manager explained the limitations in relation to this document and was able to provide a new format based upon a “script” for staff to follow. The example seen was comprehensive and gave clear instructions on the sequence of interventions to be followed. This was in the development stage and had only been completed for one resident. The involvement of relatives in resident care planning was variable and the manager explained that some family members were more involved than others. The home runs a keyworker system and a recent review of an individual care plan in March 2005 by the keyworker evidenced a good understanding of the individual resident and the report was written in a way that demonstrated respect for the individual. Fairways I54-I04 S58263 Fairways V231051 050510 Stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13 and 14 Residents are provided with a range of activities which are appropriate to their special needs. Residents are not enabled to make the most of local community facilities at the present time. EVIDENCE: Members of staff working within the home are in the process of producing an individual activities plan for each resident. At the time of the inspection a seven week activities plan had been produced for all residents on a trial basis. Care Plans seen evidenced that activities included watching TV, a walk in Felixstowe, a trip to Tesco for a drink and shopping, a walk in the garden a visit from a relative, use of the snoozlem and a walk in Woodbridge. A record of which activities were enjoyed by which resident is then maintained from which it is envisaged an individual activities plan can be compiled. As far as possible residents are involved in daily living tasks and supported by staff where appropriate. On the morning of the inspection residents were occupied in an activities session in the dining room. Specialist sensory equipment had been purchased for use by residents. At the time of the inspection staff members were compiling a list of local resources which may be appropriate for use by residents. It is noted however, that the home has been operational Fairways I54-I04 S58263 Fairways V231051 050510 Stage4.doc Version 1.30 Page 13 since April 2004 and to date only a limited amount of local resources are in use. On the day of the inspection it was noted that two residents were enjoying a short holiday at Centre Parcs. Fairways I54-I04 S58263 Fairways V231051 050510 Stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 20 Residents living at the home can expect to have their health needs met and to be assisted to access local community health resources. The homes policies and procedures ensure that the systems used for the administration of medication are both safe and secure. EVIDENCE: Care plans examined evidenced that residents are enabled to access community health facilities such as GPs, asthma clinics and dentists. All visits by community health services are recorded. During the inspection, a Senior Support Worker was observed issuing medication to residents. Medication is administered from pre-dispensed blister packs in an appropriate and safe manner and medication records which were examined had been completed at the time that individual medication was dispensed. Due to impaired cognitive ability none of the residents administered their own medication. Fairways I54-I04 S58263 Fairways V231051 050510 Stage4.doc Version 1.30 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and23 The home has appropriate procedures in relation to the protection of vulnerable adults and the reporting of suspected abuse. However, the service can not wholly ensure that residents are protected from abuse due to the fact that staff members have not received training. The fact that not all staff members have received training in the use of control and restraint places residents at risk of injury. Whilst residents have limited communication skills, procedures are in place to ensure that both they and family members are able to make a complaint either to the owning organisation or to other agencies. EVIDENCE: A very clear and detailed complaints procedure is provided within the home’s Service User Guide which is presented in a pictorial format appropriate for use by residents. It was noted that the procedure did not provide the contact details for the local CSCI area office. At the time of the inspection, the home had a copy of the local authority procedure on the protection of vulnerable adults which contained information on what to do in the event of any suspicion of abuse. Whilst staff working within the home receive information in relation to the protection of vulnerable adults, no staff members have received training in this area. Taking into consideration the vulnerability of residents accommodated at the home it is necessary that staff receive adequate training in this area as required by the Care Homes Regulations 2001. At the time of the inspection, many staff members had not received training in the use of Control and Restraint, although records evidenced that this practice was used. The CSCI confirms that it is appropriate to use physical intervention where appropriate or where de-escalation techniques have failed. However, Fairways I54-I04 S58263 Fairways V231051 050510 Stage4.doc Version 1.30 Page 16 physical intervention must only be used following an appropriate individual risk assessment and as part of the care planning process. No member of staff should participate in the control and restraint of a resident unless he or she has received appropriate and formal training in this type of intervention. Procedures employed for the administration and safe keeping of resident finances were examined and found to be both appropriate and secure. Since the previous inspection three complaints were received by the Commission in October 2004 in relation to two incidents which had occurred at the home. The complaints were investigated by the Commission and found to be substantiated. Fairways I54-I04 S58263 Fairways V231051 050510 Stage4.doc Version 1.30 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24-28 and 30 Residents live in accommodation which is appropriate to their needs, comfortable and spacious. Residents are enabled to furnish their own rooms in a way which expresses their preferences and interests. On the day of the inspection certain concerns in relation to cleanliness and hygiene procedures needed to be addressed. EVIDENCE: The home consists of spacious single storey accommodation situated in a quiet residential area of the village of Westerfield. The accommodation is domestic in style and all residents are provided with a single room with ensuite shower and toilet facilities. Several resident rooms seen at the time of the inspection had been made to look very homely with the addition of personal belongings such as music centres and televisions. However, some rooms were found to be rather bare but this was in the main due to the challenging behaviour of particular residents. It was noted that some resident rooms did not have curtains and the manager was reminded that this had been highlighted as part Fairways I54-I04 S58263 Fairways V231051 050510 Stage4.doc Version 1.30 Page 18 of the Unannounced Inspection which took place on 23 August 2005. The home has a large lounge which is sited centrally within the building and divided into two distinct areas. It was comfortably furnished with armchairs and settees and had benefited from redecoration since the previous inspection. In addition to the showers provided in ensuite facilities, the home has one communal bathroom with a “walk in” style bath. There is a domestic style kitchen where residents meals are prepared and a laundry room. In general the home was maintained to a good standard of decorative order and repair. However, solid bodily waste was found in the ensuite of one service users room and is was also noted that a staff member who was moving soiled clothing from one room to the laundry did not adopt standard infection control procedures. The home has very pleasant secure gardens which are well used by residents. Fairways I54-I04 S58263 Fairways V231051 050510 Stage4.doc Version 1.30 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 People living at the home are provided with support and care from a level of staffing which is appropriate to meet their individual needs which are both complex and challenging. EVIDENCE: Staffing rotas seen at the time of the inspection, evidenced that residents were supported by a level of staffing which was appropriate to ensure their health, safety and well-being. During the day the home is staffed by the Manager (in a supernumerary capacity) who is supported by seven support workers. During the night period, the home is staffed by two support workers on an “awake” basis. On the day of the inspection a slightly lower level of staffing was provided as two residents were away on holiday. Fairways I54-I04 S58263 Fairways V231051 050510 Stage4.doc Version 1.30 Page 20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,39, 40,41and 42 Residents can benefit from a home that is well managed and from clearly defined staff roles. Residents rights and best interests are safeguarded by records, policies and procedures which are required by regulation and a quality assurance process which reports to the CSCI. Residents can expect to live in a safe and well-maintained building. EVIDENCE: Since the previous inspection, a new manager had been appointed to the home and an application for his registration with the Commission for Social Care Inspection has been submitted. On the day of the inspection, the home was well run and staff carried out their roles in a confident and responsible manner. Records and policies and procedures required by regulation were referred to throughout the inspection and were maintained and available. The home was able to evidence that quality monitoring visits are carried out by a representative of the owning organisation on a monthly basis and reports of such visits are submitted to the Commission as required by Regulation 26 of Fairways I54-I04 S58263 Fairways V231051 050510 Stage4.doc Version 1.30 Page 21 the Care Homes Regulations 2001. The home provides a safe environment for both service users and staff. Fire safety records examined as part of the inspection, evidenced that fire alarm systems are tested on a weekly basis and emergency lighting on a monthly basis in line with guidance provided by the Suffolk Fire and Rescue Service. Fairways I54-I04 S58263 Fairways V231051 050510 Stage4.doc Version 1.30 Page 22 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 2 x x Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 2 3 3 3 x 2 Standard No 11 12 13 14 15 16 17 x 3 2 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x 3 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Fairways Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 3 3 3 3 x I54-I04 S58263 Fairways V231051 050510 Stage4.doc Version 1.30 Page 23 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 3 Regulation 4(1)(a) Requirement The Registered Persons must ensure that the needs of each resident are assessed using a multi-discplinary approach and including assessment of need in relation to behavioural problems. The Registered Persons must ensure that the individual care plans of residents are kept under review at a minimum frequency of every six months. The Registered Persons must ensure that residents are enabled to access facilities and resources within the local community. The Registered Persons must ensure that the homes complaints procedure contains the contact details for the Commission for Social Care Inspection. The Registered Persons must ensure that staff working within the care home receive training in the Protection of Vulnerable Adults. The Registered Persons must ensure that all staff members involved in the use of Control and Restraint measures receive Timescale for action 18/07/05 2. 6 15(2)(b) Immediate 3. 13 16(2)(m) 02/08/05 4. 22 22(7)(a) Immediate 5. 23 13(6) 01/09/05 6. 23 13(6) 02/08/05 Fairways I54-I04 S58263 Fairways V231051 050510 Stage4.doc Version 1.30 Page 24 and accredited training. 7. 24 16(1) The Registered Persons must 02/08/05 ensure that all residents bedrooms are provided with either curtains of blinds in order to protect the privacy and dignity of the occupant. This is a repeat requirement. The Registered Persons must Immediate ensure that all staff use appropriate infection control procedures when transferring soiled articles of clothing or linen to the laundry facility. 8. 30 13(3) 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 NA Good Practice Recommendations None Fairways I54-I04 S58263 Fairways V231051 050510 Stage4.doc Version 1.30 Page 25 Commission for Social Care Inspection 5th Floor St Vincent House Cutler Street Ipswich IP1 1UQ 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 Fairways I54-I04 S58263 Fairways V231051 050510 Stage4.doc Version 1.30 Page 26 - 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!