Inspection on 14/10/04 for Fairways

Care Homes For Adults (18 ­ 65)Fairways7 Elvetham Road Fleet Hampshire GU51 4QLUnannounced Inspection14th October 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Fairways Address 7 Elvetham Road, Fleet, Hampshire, GU51 4QL Email address j.deeley@seeability.org Name of registered provider(s)/company (if applicable) SeeAbility Name of registered manager (if applicable) Mr Marcus Wayne Shepperdson Type of registration Care Home No. of places registered (if applicable) 7 Tel No: 01372 755 044 Fax No:Category(ies) of registration, with (number of places) Learning disability (7), Physical disability (7), Sensory impairment (7) Registration number H030001108 Date first registered 5th September 2003 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 5th September 2003 NO NO 9-7-04 If Yes refer to Part CFairwaysPage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 314th October 2004 10:00 am Sue MaynardID Code108413Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionFairwaysPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Providers Response Providers Comments Action Plan Providers AgreementFairwaysPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Fairways. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.FairwaysPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Fairways is a large family home located in a quiet residential area. Previously part of the School For The Blind, it is now Registered by SeeAbility. It is close to shops and local amenities. Accommodation is provided in single rooms, the majority of which have en suite facilities. There is a communal lounge, kitchen and dining room on the ground floor and a large enclosed garden and patio area to the rear of the property. The aims and objectives of the home are to provide care for service users aged 18 to 65 with visual impairments and learning disabilities. The home is also registered to provide care for service users with visual impairments and physical disabilities.FairwaysPage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This inspection was the second inspection for the year 2004/5. The inspection was unannounced and was conducted by one inspector. Of the seven service users for whom the home is registered, five where in the home during the inspection. The inspector was able to speak to these service users, who expressed their satisfaction with the care that they were receiving. The service users spoke very highly of the staff and the way they were always treated with respect and kindness at all times. Service users are encouraged and supported to be as independent as possible in all aspects of their daily lives. All standards assessed during this inspection are those that were not assessed at the previous inspection. Requirements and recommendations have been made as a result of this inspection. The issues around these are addressed in the main body of the report. Choice of Home (Standards1-5) 3 standards were assessed and were met. All prospective new service users are able to visit the home and spend time with service users who are already resident in the home. A full needs assessment for service users would be undertaken prior to admission to the home. Individual Needs and Choices (Standards 6-10) 3 standards were assessed and were met. All records relating to service users are kept secure in locked cupboards. Staff are made aware of the homes policy on confidentiality during their induction programme. Service users were supported to take risks as part of an independent lifestyle. Lifestyle (Standards11-17) 1 standard was assessed and was met. Service users were involved in the planning of their meals and given a choice of when and where to eat. The meal that was served during the inspection was a popular choice with all the service users. On the day of the inspection all the service users had chosen to eat their meal in the Fairways Page 6 dining room. Personal and Healthcare Support (Standards18-21) 2 standards were assessed. 1 was not met. Requirements have been made around issues raised about administration, recording and storage of medications and lotions. Staff have not received appropriate training concerning medications with result that inaccuracies have occurred. Concerns, Complaints and Protection (Standards 22-23) 2 standards were assessed. I was not fully met. The home does not have a copy of the Department of Health guidance No Secrets. No complaints have been received by the Commission concerning this service. Environment (Standards 24-30) 2 standards were assessed. 1 was not fully met. On the day of the inspection the home was found to be very clean and tidy. The home does not have an alarm call system that is available for service users enabling them to alert staff in an emergency, especially at night. Staffing (Standards 31-36) 4 standards were assessed and were met. The home has a strict recruitment procedure. Staff records seen by the inspector confirmed that all new staff members have been interviewed and references obtained. All staff members attend regular training sessions that are relevant to the care provided for this client group. Conduct and Management of the Home (Standards 37- 43) 4 standards were assessed. 1 was not fully met. Service users confirmed with the inspector that they are always made aware of any changes that occur in the home. The manager facilitates regular meetings between staff members. Minutes for these meetings are recorded. Meetings with service users are also held every month. Records of these meetings are also kept. The home has very comprehensive policies and procedures. These are regularly reviewed and updated. Records were seen by the inspector that confirmed that all fire safety equipment is regularly checked and that all staff receive fire safety training. A requirement has been made all detergent products that were found in the laundry area must be stored securely.FairwaysPage 7 Requirements from last Inspection visit fully actioned?YESSTATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action The registered person must ensure that all medications, including lotions and creams are stored appropriately. Lotions such as those used for the irrigation of the eyes of service users must not be stored along side foodstuffs in the domestic fridge. All medications, lotions etc for service users that are required to be refrigerated must be secured in individually named and locked boxes before being stored in the refrigerator. 17(1)(a) Schedule 3(k) The registered person must ensure that a record of all medicines is kept in the home for service users, and the date on which they were administered to the service user. The registered person must ensure that a policy and staff adhere to the procedure for the administration of medications that are administered as required. Records of the date and times that these medications are administered must be kept.113(2)YA 20.11-11-042YA 20.916-10-04313(2)YA 20.931-10-04FairwaysPage 8 Designated and appropriately trained staff must only administer all medicines, including Controlled drugs. The registered manager must ensure that staff in the home who are to be designated to administered medicines attend a training programme which includes 4 13(2) YA 20.10 · Basic knowledge of how medicines are used and how to recognise and deal with problems when they are in use The principles behind all aspects of the homes policy on the handling and recording of all medications. 30-11-04·516(1)(2)(c)YA 29.2Risk assessments must be undertaken to address the possible needs of the service users in the home in the likely event that they may have to summon assistance at night or 1-12-04 to a part of the home that staff are not present at all times and any identified remedial action must be taken. The registered person must ensure that all chemical substances hazardous to health, COSHH, are stored appropriately in a locked cupboard. This includes the detergent tablets and fabric conditioners used in the laundry.613(4)(a)YA 42.3(i)1-11-04RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * A current copy of The British National Formulary should be obtained and be available as a reference tool to ensure best practice for all staff members who are responsible for the administration of medications.1YA 20.6FairwaysPage 9 * Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Fairways YES YES NA YES YES YES NO NA YES YES YES NO NO YES NA NA NA YES NO YES 5 0 0 NO NO YES NO 8 0 Page 10 Date of inspection Time of inspection Duration of inspection (hrs)14-10-04 10.00 5.5The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.FairwaysPage 11 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. 44,991.00 To £ 51,100.00 Range of fees charged From £ (per week) YES Any charges for extras If yes, please state what the extras are Hairdressing Chiropody Aromatherapy 3 Key findings/Evidence Standard met? At the last inspection a service user guide was not available. The document was available at this inspection and is also available to service users in a Braille format.Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? All the service users at Fairways have been resident in the home for some years prior to the implementation of the Care Standards Act 2000 and therefore do not have a pre-admission assessment as required by this standard. The assessments seen by the inspector that had been completed prior to the service users admission to Fairways were very detailed and included most of the information required in this standard. The assessments had been undertaken by the service users care managers and representatives from their funding authorities.FairwaysPage 12 Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 3 Key findings/Evidence Standard met? Prospective service users have the chance to visit the home with relatives, friends or an advocate before admission. They are able to stay for a day to meet other service users, staff, view the premises and have a meal. A three-month trial period is offered to new service users and this is followed up by a review. The existing service users are consulted about the placements of the prospective service user. Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 3 Key findings/Evidence Standard met? All service users have a written contract or statement of terms and conditions. The service users are involved in the in the drawing up of the contract. A copy is kept in the service users file.FairwaysPage 13 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.FairwaysPage 14 Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 3 Key findings/Evidence Standard met? SeeAbility is a large organisation the service users have limited involvement in the development and review of policies and procedures but appropriate service users are involved in decisions that affect them directly. They attended regular meetings each month and are given feedback in regard to their participation during their Key-worker reviews. Service users are involved in the selection of new staff members.Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 3 Key findings/Evidence Standard met? Service users are involved in the development of the risk assessments and are given education about personal safety. The risk assessments enable service users to make an informed choice about any activity that may involve some form of risk. The service user is encouraged to discuss the undertaking with their key worker but ultimately the choice is that of the service user.Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 3 Key findings/Evidence Standard met? Records relating to the service users were accurate, confidential and stored in a lockable cabinet. The policy on confidentiality is available to service users, their families and staff members. The importance of confidentiality is discussed with staff during their induction training in the home.FairwaysPage 15 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.FairwaysPage 16 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. Key findings/Evidence Standard met? This standard was not assessed at this inspection.0Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.FairwaysPage 17 Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? The menus for the home are planned on a weekly basis with the full involvement of the service users. Each service user will choose the meals for one day each week. Alternative meals are arranged if any of the service users do not like what has been chosen. The mid-day meal is the main meal of the day and the inspector was able to observe service users eating their lunch in the dining room. The meal looked very appetising and nutritious and included a variety of fresh vegetables. The service users all commented how good the food was and how much they enjoyed being able to choose their favourite meals every week. Two service users were out of the home at centres for special activities, they would be given a meal at the centre.FairwaysPage 18 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes 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.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) Key findings/Evidence This standard was not assessed at this inspection. Standard met? XX 0FairwaysPage 19 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 1 Key findings/Evidence Standard met?FairwaysPage 20 The inspector examined medication administration records for service users. Some of the medical administration recording sheets were found to have gaps. On examining the medication storage box for the service users the tablets appeared to have been administered. These omissions were brought to the attention of the manager who stated that staff sometimes forgot to sign the MAR sheets. The inspector explained the importance of accurate recording of medication administration and that the manager had the responsibility as part of her duty of care to ensure that her staff adhered to the homes policy for drug administration. Whilst checking food storage in the kitchen refrigerator the inspector found two bottles of an un-named liquid being stored in a compartment of the fridge door. When asked what these were the manager explained that it was a Soda Bicarbonate solution that the staff made up for use as an eye irrigation solution for two service users. Only one bottle had a label on which was, supposedly with the service users name, but was illegible the other bottle was un-named. The manager explained that staff made up this solution and stored in the fridge to use as required. There was no record of when these solutions had been made or how long they had been in the fridge. The solution was made up from a packet of Soda Bicarbonate that was stored in a kitchen cupboard. The packet was open, the lid was not covering the powder and there appeared to be particles of dirt in the powder. The inspector advised the manager, to destroy both the powder and the solutions immediately as there was a high risk of contamination and cross infection risk to the service user. The manager was not able to provide evidence of guidance for the dilution of the solution of Soda Bicarbonate for use as eye irrigation. The inspector advised the manager that any eye irrigation solution should only be prepared and used and then destroyed as when it is required and never stored as a bulk solution. The inspector suggested to the manager that she took advice from the supplying pharmacy to the home. The manager brought to the attention of the inspector that some service users occasionally required medications on an as required basis. The home has no protocol for the administration of these medicines and the inspector could find no record of when these were administered. The inspector brought to the attention of the manager the importance of accurate recording of all medicines to ensure that possible duplication of administration does not occur. The staff in the home does not appear to have an up to date knowledge concerning medication. The staff has received no guidance for the safe administration of drugs, their possible interactions with other drugs and some food stuffs or whether it is necessary to administer some drugs before or after food. Medication administration record keeping is poor. The staff current reference manual such as the British National Formulary. The one seen in the home was dated 1999. The inspector has made requirements and recommendations for the homes manager to address these areas of concern.FairwaysPage 21 Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 3 Key findings/Evidence Standard met? The home has a policy to address ageing and death. In the event of a service user becoming terminally ill the manager of the home would seek advise and guidance from the service users doctor regarding the management of the care of the service user.FairwaysPage 22 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 0 X X X X 0 X 3Key findings/Evidence Standard met? The home has a complaints procedure. The manager of the home investigates all complaints.FairwaysPage 23 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists NO02 Key findings/Evidence Standard met? The home has an adult protection policy and procedure and was able to evidence a copy of the Hampshire Protection of Vulnerable Adults procedure. The manager did not have a copy of the Dept of Health guidance document No Secrets. The manager is advised to obtains a copy of this document and make it available for reference by all staff. Staff are made aware of the homes whistle blowing policy as part of their induction training programme. The manager has recently attended a study day for the prevention of abuse in a residential setting. The knowledge and information obtained will be cascaded to other staff working in the home as part of the in-house training programme. The home looks after pocket money for one service user. The records for this money were seen by the inspector and were found to be accurate. The money is stored securely in a locked safe.FairwaysPage 24 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.FairwaysPage 25 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite Key findings/Evidence YES NO NO 7 5 0 0 Standard met? 3 7 00 0 0 0All bedrooms provided for service users are single occupancy. Five of the rooms provide en-suite facilities.FairwaysPage 26 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. Key findings/Evidence This standard was not assessed at this inspection. Standard met? 0Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.FairwaysPage 27 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 2 Key findings/Evidence Standard met? A speaking sign was prominently located in the hallway to give the service users information about the meals and staff on duty for two consecutive days. The dining room was spacious and contained a speaking microwave. Shower seats, grab-rails and non-slip floors were available in the bathrooms. The inspector noted that no call bell system is available in any of the service users rooms to enable service users to alert staff especially, at night, that they are in need of assistance. The inspector asked the manager why there was no call system for service user and was informed that it had never been raised as an issue before. The home employs one key worker at night that is on a sleep in shift and the inspector was informed that all the service users are aware of this and would go to the worker if they were in need of assistance. The inspector raised concerns of how a service user would alert the person on the sleep in shift if they were unable to get out of bed or were taken ill in a toilet or bathroom? One service user is soon to undergo major surgery on their knee. The inspector questions as to how this service user will be able to alert care staff on their return from hospital when they will have limited mobility. The sleep in room is on the first floor. This particular service users room is on the ground floor. No satisfactory answer was given. A requirement has been made that risk assessments must be undertaken for all service users in the event of that they may require assistance at night.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? On the day of the inspection the home was found to be clean and tidy. Relevant literature and procedures were in place to control infection and gloves and aprons were available in the home. The laundry was domestic in size and had an impermeable floor. It was also found to be clean.FairwaysPage 28 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 3 Key findings/Evidence Standard met? The home has recruited new staff and now has a full compliment of staff. It was reported that the staff do read the policies and procedures and they have to sign to say that they have done so. SeeAbility provides the staff with information of their key-worker role. Several volunteers were used in the home on a supernumerary basis. They were involved in the gardening, home maintenance and support of the service users.Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 3 Key findings/Evidence Standard met? Two staff members have achieved NVQ3 and two more are working towards NVQ2. SeeAbility provides a comprehensive training programme for staff which enables them to address the specific individual needs of the service users in this home.FairwaysPage 29 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme X X X X X No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X XXX3 Key findings/Evidence Standard met? An appropriate roster was in place to indicate who actually worked. Over night a member of staff is on sleep in duty. The staffs in the home undertake all domestic duties. Agency staff are only used in the home in the event of the home not being able to provide cover for sickness or annual leave.Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? The inspector examined samples of staff recruitment records. These were found be comprehensive and contained two written references. The recruitment procedure of the home involves the applicant having a formal interview with a senior member of staff and the manager, followed by an informal interview with the service users.FairwaysPage 30 Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 3 Key findings/Evidence Standard met? Staff receive formal supervision sessions every month from the manager or a senior member of staff. Records of these sessions were viewed in the staff files and they covered appropriate areas, including the service users, support and training needs. The manager has attended a supervision and appraisal study course, which has enabled her to undertake supervision of her staff more objectively.FairwaysPage 31 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. Key findings/Evidence This standard was not assessed at this inspection. NO 0Standard met?Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The home has an open culture to promote involvement of both staff and service users. Staff meetings were held every fortnight and service users had monthly meetings, both of which were minuted. Other strategies to communicate with staff include their supervision sessions, appraisals and informally. Monthly key-worker meetings and a satisfaction survey facilitated communication with service users.FairwaysPage 32 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 3 Key findings/Evidence Standard met? The inspector viewed relevant policies and procedures implemented by the home. These were available to service users and staff, and were found to be reviewed and dated. One specific procedure is of note. This particular policy covers the homes strategy for Disaster and Crisis management. This document covers the procedure that staff must follow when the service users must be evacuated from the building in the event of a major incident. A place of safety is already designated. Personal details of all service users, including next of kin contact details, doctors contact details and a list of the individual service users current medication is ready to go with the service users to the place of safety. All policies and procedures for the home are regularly reviewed and up dated. Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met Service users records are available to them and securely stored in a lockable cabinet. The manager reported that some records were kept on the computer, but access to them was restricted to select members of staff. Notification of Regulation 37 incidences had been forwarded to the Commission and a record of visitors to the home was available.FairwaysPage 33 Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? The fire officer visited the home after the last inspection. Recommendations were made and these have been complied with. The manager ensures that fire safety training and drills are undertaken regularly. The inspector saw records of this training. All staff has undertaken training for safe moving and handling, first aid, food hygiene, and infection control. Whilst touring the building the inspector noted that in the laundry room detergent tablets and bottles of fabric conditioners were being stored openly on worktops. Other cleaning materials were securely stored in a locked cupboard next to the laundry room. A requirement has been made that all detergent products are stored securely together with all other cleaning materials.Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 0 Key findings/Evidence Standard met ? This standard was not assessed at this inspection.FairwaysPage 34 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateSignature Signature SignatureFairwaysPage 35 Public reports It should be noted that all CSCI inspection reports are public documents.FairwaysPage 36 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 5th October 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleAction taken by the CSCI in response to provider comments: Fairways Page 37 Amendments to the report were necessaryComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONONONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 8 December 2004, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationNOAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action plan YESOther: enter details here FairwaysPage 38 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of Fairways confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of Fairways am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.FairwaysPage 39 Fairways / 14th October 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000039631.V190874.R01© This report may only be used in its entirety. 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