Inspection on 14/09/05 for Fairways

This inspection was carried out on 14th September 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

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 10/05/05

Fairways 23/08/04

Fairways 23/06/04

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Coopers Mill Ltd

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Paradise Lodge

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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 The Fairways Fuller`s Field, Swan Lane Westerfield Ipswich Suffolk IP6 9AX Lead Inspector Jane Higham Announced Inspection 14th September 2005 12:00 Fairways DS0000058263.V257865.R01.S.doc Version 5.0 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 Fairways DS0000058263.V257865.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Fairways DS0000058263.V257865.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Fairways Address 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) The Fairways Fuller`s Field, Swan Lane Westerfield Ipswich Suffolk IP6 9AX 01473 214966 Care Aspirations Limited Marc Morris Hendy Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Fairways DS0000058263.V257865.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th May 2005 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 disability 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 building became unviable. Fairways DS0000058263.V257865.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Announced Inspection of Fairways, an eight bedded residential home for adults with learning disabilities, coupled with challenging behaviour. This was the second inspection in the inspection year 2005/2006.This report should be read in conjunction with the Unannounced Inspection report of 10 May 2005. All key standards have been assessed over the two inspections. The inspection was carried out on 14 September 2005 over a period of 6 hours. Information contained within this report was derived from the submitted pre-inspection questionnaire, five comment cards returned by family members, discussions with staff members, service users and the Manager of the home. What the service does well: What has improved since the last inspection? There have been significant improvements in the service since the last inspection. There is a much more planned and structured approach to the provision of meaningful activity for residents which has, in turn, produced a calmer atmosphere within the home. Since the previous inspection, the home has ensured that all residents have been assessed by a psychologist in relation to their individual behaviours and detailed behaviour management plans have been produced. Fairways DS0000058263.V257865.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Fairways DS0000058263.V257865.R01.S.doc Version 5.0 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 Fairways DS0000058263.V257865.R01.S.doc Version 5.0 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 the following standard(s): 1 and 3 Prospective residents and their families can expect to be provided with sufficient information to enable them to make a choice about whether they wish to live at the home. Service users can expect to have their individual specialist needs met by the home. EVIDENCE: Since the previous inspection all residents have been re-assessed in relation to their specialist needs. A psychologist employed by the owning organisation has been involved in these assessments and Behaviour Management Guidelines have now been produced for each person. Those assessments seen at the time of the inspection were detailed in their content and provided clear guidelines to staff on the level of required support and interventions. At the time of the inspection, individual behaviour management guidelines were waiting to be included in resident’s life plans (care plans). The home was able to evidence that it has produced a Statement of Purpose which complies with Regulation 4 and Schedule 1 of the Care Homes Regulations 2001 and sets out in detail the services which it intends to provide. This document is available to all residents and their family members or advocates. Fairways DS0000058263.V257865.R01.S.doc Version 5.0 Page 9 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 the following standard(s): 6, 7 and 10 Residents living at the home can expect that their individual care plan will be reviewed on a regular basis and that their preferences and choices will be recorded as part of that plan. Residents can also expect that personal information in relation to their care is maintained in a confidential manner. EVIDENCE: The home was able to evidence that since the previous inspection resident care plans are reviewed on a regular basis and amended where required. Residents are encouraged and enabled to make choices around their daily living routines. One care plan seen evidenced that a pen picture is produced for each resident which indicates, for example, the preferred time and way that they would like to get up in the morning and what they would like for breakfast. During the inspection, the home was able to evidence that confidential information concerning residents is stored securely. Fairways DS0000058263.V257865.R01.S.doc Version 5.0 Page 10 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 the following standard(s): 14, 15, 16 and 17 Residents living at the home can expect to be provided with a range of activities which are appropriate to their needs and capabilities and to be supported to maintain contact with their families and friends. Additionally residents can expect that their rights are protected and promoted and that they are provided with a healthy diet which takes account of their tastes and preferences. EVIDENCE: The home was able to evidence that it has made significant progress in the provision of an appropriate programme of activities for residents which is now offered on a more structured basis. On the day of the inspection some of the residents were occupied in an art session led by a member of staff. The Manager reported that progress was still being made in investigating the availability and appropriateness of some community resources and residents had recently been able to access trampolining sessions. The Manager also reported that all residents had either been on holiday this year or a holiday had been booked for them. Two service users were due to go to Disneyland in Paris with the support of care staff. The owning organisation employs an Occupational Therapist who visits the home on a Tuesday morning. A social Fairways DS0000058263.V257865.R01.S.doc Version 5.0 Page 11 worker was due to visit the home in the near future to carry out “fair access” assessments for each resident in relation to the availability and appropriateness of day service provision. Residents are supported and encouraged to maintain contact with families and friends. Each resident is allocated a keyworker who acts as a link person between the service user and their family. The keyworker will, amongst other things, ensure that the resident remembers family birthdays and other such occasions. The home was able to evidence that some residents are enabled to visit their family homes with the support of staff members. It was reported that one resident continued to have contact with their peers from school and the home had held a tea party where families were invited to attend. The home was able to evidence that the preferred daily routines of residents are recorded and facilitated wherever possible. The privacy and dignity of residents is protected wherever possible. Staff ensure that they knock on residents doors before entering and all bathrooms are fitted with privacy locks. The Manager reported that the Occupational Therapist had been asked to carry out some work with residents in relation to their capabilities to use a key to access their own rooms. Residents are assisted to open their own personal mail with the assistance of staff members. Resident meals are prepared by staff in the home’s domestic style kitchen. On the day of the inspection, the home was providing meals from a planned sixweek summer menu. Staff had a good knowledge of the dietary needs, likes and dislikes of each resident and the home’s menus seen evidenced that residents were provided with a varied menu of meals which were both varied and nutritious. The kitchen itself was maintained to a good standard of hygiene and cleanliness and a cleaning rota evidenced that daily cleaning tasks were carried out by staff members. Fairways DS0000058263.V257865.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 18 Residents can expect to be supported to maintain their personal care in a manner which takes account of their preferred routines and preferences. EVIDENCE: Individual care plans for residents reflect the level of personal support that they require and identify the way in which this should be provided. Individual pen pictures produced for each resident identify preferred daily routines which include the provision of personal care. Fairways DS0000058263.V257865.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 23 Residents can expect that the home’s policies and procedures protect them from abuse, self neglect and self-harm. However at the time of the inspection residents could not be assured that the levels of training provided to staff in relation to the use of physical intervention ensure their safety EVIDENCE: The home was able to evidence that all newly employed staff are provided with information on the recognition and reporting of abuse. Training in relation to this area is also provided as part of the Care Aspirations Induction training package. The Manager of the home is awaiting a place on the next available POVA (Protection of Vulnerable Adults) trainers course. Comments contained within relative comment cards indicated that some family members felt unsure of how to lodge a complaint about the service. The home was able to evidence that appropriate documentation is completed when any physical intervention is used in the care of residents who exhibit challenging behaviour. The home was also able to evidence that staff receive training in the use of physical intervention which includes the employment of de-escalation and breakaway techniques. Records examined evidenced that in some instances practices of control and restraint have been employed. Whilst these are recorded appropriately the home must ensure that the level of training provided to staff members is sufficient to ensure that residents are not at risk of physical injury and that their well-being is protected. Since the previous inspection the Commission has received no complaints in relation to this service. Fairways DS0000058263.V257865.R01.S.doc Version 5.0 Page 14 Fairways DS0000058263.V257865.R01.S.doc Version 5.0 Page 15 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 the following standard(s): 24-30 Residents can expect to be provided with pleasant and spacious accommodation which is fit for purpose and provides a homely, safe and well maintained environment. EVIDENCE: The home consists of spacious single storey accommodation situated in a quiet cul-de-sac in a 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. There is a large centrally sited lounge which is divided into two distinct sitting areas with a dining room and domestic style kitchen leading off. In addition to the ensuite facilities, the home has a communal bathroom which is provided with a “walk-in” bath and toilet. The home also provides very pleasant secure gardens which are well used by residents and on the day of the inspection were provided with a gazebo and garden swing. Since the previous inspection all communal areas have been redecorated and the television provided in one of the lounges has been set into the wall and screened with safety glass. Communal areas were comfortably furnished and maintained to a good standard of decorative order and repair. Colourful and Fairways DS0000058263.V257865.R01.S.doc Version 5.0 Page 16 attractive murals had been painted at various points around the building. Several resident’s rooms were seen during the inspection. Some of these had been made to look very homely with the addition of personal belongings which reflected the tastes and interests of the occupant. All bedrooms were provided with a good standard of furnishings. The home has a laundry room which is provided with appropriate equipment and fit for purpose. The home’s kitchen is also well equipped and maintained to a good standard of cleanliness and hygiene. In general the environment is maintained to a good standard, despite the complex and challenging behaviours of individual residents. The accommodation is appropriate for use and provides residents with an unrestricted and spacious home. Fairways DS0000058263.V257865.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Residents can expect to be supported by a level of staffing sufficient to ensure that their needs are met. In general residents can expect to be supported by staff who have received appropriate training, although a shortfall was identified in this inspection. Residents can be assured that staff members receive both support and supervision. EVIDENCE: On the day of the inspection, the home was being staffed by the Registered Manager and seven support workers. This staffing level included one member of agency staff who had been acquired to provide one to one support for a particular resident. During the night the home is staffed by two support workers on an “awake “ basis. The staffing rota correctly reflected the number of staff on duty. Since the previous inspection, five staff had left the employ of the home. Information received via relative comment cards indicated that some residents’ families expressed concern about what they perceived to be a relatively high staff turnover. Information gained from the pre-inspection questionnaire confirmed that whilst only 20 of the current care staff had gained NVQ qualifications, 10 were in the process of undertaking either level 2 or 3. Fairways DS0000058263.V257865.R01.S.doc Version 5.0 Page 18 During the inspection, two staff personnel files were examined and evidenced that the home has robust recruitment procedures which seek to protect service users. Personnel files were well organised and contained the required documentation, inclusive of two written references taken up before the prospective staff member commenced duties. The two personnel files examined evidenced that both staff members had completed an Induction training package which complied with TOPPS standards. A high percentage of staff had attained a first aid qualification and health and safety training had been provided as part of the Induction package. One of the two staff members had been booked to attend a training programme on challenging behaviour which was specific to the current service provision. It was noted during the inspection that despite the fact that the registered manager of the home is an accredited moving and handling trainer, two support workers had not completed this training. In both cases the home was able to evidence that staff members are provided with formal one to one supervision, the contents of which is documented. Fairways DS0000058263.V257865.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not applicable EVIDENCE: Not assessed as part of this inspection. Please see Unannounced Inspection report dated 10 May 2005. Fairways DS0000058263.V257865.R01.S.doc Version 5.0 Page 20 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 3 x 3 x x Standard No 22 23 Score x 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 x x x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 x 12 x 13 x 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x 3 3 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Fairways Score 3 x x x Standard No 37 38 39 40 41 42 43 Score x x x x x x x DS0000058263.V257865.R01.S.doc Version 5.0 Page 21 NO 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 YA23 Regulation 13(6)&(7) 18(1)©(i) Requirement Timescale for action 04/01/06 2 YA42 13(5) The Registered Persons must ensure that staff receive the appropriate training to reflect the level of physical intervention/control and restraint employed at the home. The Registered Persons must 04/01/06 ensure that all staff receive accredited training in moving and handling. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 3 Refer to Standard YA22 Good Practice Recommendations The Registered Persons should ensure that all family members are made aware of the home’s complaints procedure. Fairways DS0000058263.V257865.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk 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 DS0000058263.V257865.R01.S.doc Version 5.0 Page 23 - 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. 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