Inspection on 19/09/07 for Fairways

This inspection was carried out on 19th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fairways 04/10/06

Fairways 03/01/06

Fairways 23/08/05

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Fairways 119 Cardigan Road Bridlington East Yorkshire YO15 3LP Lead Inspector Rob Padwick Key Unannounced Inspection 19th September 2007 1:30 Fairways DS0000063612.V351021.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Fairways DS0000063612.V351021.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Fairways DS0000063612.V351021.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fairways Address 119 Cardigan Road Bridlington East Yorkshire YO15 3LP 01262 676804 01262 676804 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) Franklin Homes Limited Mrs Anne Hall Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Fairways DS0000063612.V351021.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th October 2006 Brief Description of the Service: Fairways is a home registered for twelve people with a learning disability, some of whom have complex needs. The home is situated on the outskirts of Bridlington and consists of a large house with accommodation provided on two floors. There are two lounge areas on the ground floor, one of which also serves as a dining room. The home has a dedicated arts and crafts activity room and people living in the home have access to the home’s garden. The service has its own minibus to enable people living in the home to get out into the local community and for going out on trips. The manager indicated that the current scale of charges range from £750 to £1,000 with extra charges for things like holidays and magazines. Fairways provides information about the home to service users in its Statement of Purpose and Service User Guide. Fairways DS0000063612.V351021.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) since the last key inspection of the home on 4th October 2006, including information gathered during a site visit to the home A questionnaire asking for information about the service was sent to the provider before the inspection visit and information from this was included as part of the inspection process. Other information used, included feedback from people living in the home and from questionnaires sent to relatives and professional staff who know the home well well, together with official notifications received by the Commission for Social Care Inspection about the service. The inspection visit for this service lasted for 6 hours and during this period, time was spent talking with people living in the home and observing their daily lives. Other time was spent looking at their care plans and other records and talking to staff. The inspection visit also included a tour of the properties. What the service does well: What has improved since the last inspection? What they could do better: Staff must always be properly checked before they start work to make sure they are safe to work with people living in the home. Staff should be provided Fairways DS0000063612.V351021.R01.S.doc Version 5.2 Page 6 with clearer information about what to look out for and do to make sure that risks to people living in the home are managed well. More activities should be provided for people living in the home so that that their individual lifestyles can be enhanced. Some of the home’s main policies (including complaints) should be developed into a format that is more accessible to people living in the home, so they can understand their rights better. Systems should be further developed so that the manager can monitor and check that the service is meeting the wants and needs of people living in the home. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Fairways DS0000063612.V351021.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fairways DS0000063612.V351021.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4 People who use this service experience good outcomes in this area. People living in the home are able to be involved in the process of moving into the home and their needs are assessed to ensure the service is suitable to meet them appropriately. This judgement has been made using available evidence including a visit to this service EVIDENCE: The case records of the person most recently admitted to the home contained a Local Authority Care Plan and a Community Care Assessment of their needs, together a further assessment that the manager had completed in order to confirm that the home was suitable for them. People living in the home indicated they had been able to visit, so they could try it first and be involved in making decisions about moving into the home. Fairways DS0000063612.V351021.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 People who use this service experience good outcomes in this area. People living in the home were involved in making decisions about their lives and information about their needs and wishes were included in their care plans to ensure staff could support these. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The case files belonging to three people living in the home that we inspected all contained comprehensive information about a range of their individual health, emotional, psychological and social needs. The provider organisation had recently implemented a “Circle of Life” Personal Centred Planning system that focussed on the individual strengths of people living in the home, together with strategies aimed at developing and maximising their opportunities for independence. The group of the people living at Fairways have a wide range needs and abilities, with ages varying from the mid twenties to the early seventies and information provided by the manager indicated that staff had received training in relation to these. People living in the home that confirmed they were aware of their care plans and that staff supported them to make decisions about their lives. Documentation contained in the case files detailed Fairways DS0000063612.V351021.R01.S.doc Version 5.2 Page 10 regular meetings with people living in the home and their key workers, to enable them to have input into their care plans and ensure that the support provided was right for them. Up to date information relating to the management of risks to people living in the home were included in the case files and observation and discussion with them indicated they were included in decisions and choices about these which were appropriate to their levels of understanding. Evidence was seen that requirements made at the last inspection about assessments of people living in the home visit had been complied with, although the information to staff about what actions to take in relation to some risk assessments were not always clear and a recommendation is made about this. Fairways DS0000063612.V351021.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, and 17 People who use this service experience good outcomes in this area. People living in the home were being supported to make decisions and choices about their lives to ensure their lifestyle needs were met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Owing to the variety and complexity of need experienced by people living in the home, some of them are more able to actively participate in community activities than others. A specialist worker frequently visits the home to support arts and crafts activities and items of these were on display in the home. People living at Fairways talked about regular things that they enjoyed doing such as attending “aqua tone” and a fitness club, whilst the case files contained evidence of others attending day centres during the week. The manager indicated that trips out were made to places such as local pubs and restaurants and a number of people living in the home were observed going for a walk with staff during this inspection visit. Staff were observed interacting with people living in the home in a friendly and sensitive manner, although some of those with more complex needs were choosing to sit quietly on their Fairways DS0000063612.V351021.R01.S.doc Version 5.2 Page 12 own. Comments received from relatives were generally satisfactory and stated “staff genuinely care about people looked after and encourage life opportunities”. However, some relative comments indicated a desire for further activities to be provided and a recommendation is made about this. The parent organisation employs a psychologist to provide advice to staff about the individual needs of people living in the home and evidence of this was contained in the case files inspected. People living in the home talked about their involvement in domestic tasks such as helping to clean their rooms in order to develop their independent living skills and ensure that their rights and responsibilities towards each other were met. People confirmed they enjoyed the food in the home and evidence was seen in the case files inspected and home’s menus that nutritional needs were being appropriately monitored. Fairways DS0000063612.V351021.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People who use this service experience good outcomes in this area. People living in the home were being treated with dignity and respect and staff had been provided with information and training about their individual needs, in order that their health and personal care was appropriately met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living in the home indicated they were they were happy with the way their health and personal care needs were delivered and observation indicated that they were being treated with dignity and respect by a caring staff team. Information about these were included in the case files inspected together with guidance to staff on the way people living in the home liked their support to be given. Feedback received from professionals associated with the service was generally satisfactory and evidence was seen of close working with them to ensure that the needs of the people living in the home continue to be appropriately met. The case files inspected contained evidence of input from a psychologist in order that staff had guidance about the specialist needs of the people living in the home. Evidence of staff training in the safe use and handling of medicine was seen in the staff files inspected and all medication Fairways DS0000063612.V351021.R01.S.doc Version 5.2 Page 14 kept in the home was securely stored with records for these being accurately maintained. Fairways DS0000063612.V351021.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use this service experience good outcomes in this area. Staff had received training to ensure people living in the home were safeguarded from harm although the operation of the home’s complaints policy needed strengthening to ensure that their concerns were taken seriously. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Policies and procedures were available to ensure people living in the home were protected from abuse and that their concerns were taken seriously. The policies however, were not in a format that was easily understandable to them and it is recommended these be developed to help with this. The Commission for Social Care Inspection had not received any complaints about the service since the last inspection visit and the home’s book for these contained evidence of actions taken by the manager, to resolve one of the two complaint that been received by the service but not for the other. Comments received from relatives were generally satisfactory, although some indicated that they felt the way their concerns were dealt with could be improved. A recommendation is made that the operation of the complaints policy is developed to ensure that concerns are actively welcomed and that the outcomes for these are shared with the person making the complaint, in order that their rights are protected. Information provided by the manger, indicated that staff had received training on the protection of Vulnerable Adults and confirmation of this was seen in the staff files inspected. Staff were observed having positive relationships with the people living in the home and discussion with them indicated they would act appropriately if they suspected any abuse. The records of money held on behalf of people living in the home indicated that Fairways DS0000063612.V351021.R01.S.doc Version 5.2 Page 16 appropriate procedures were being followed to ensure their financial interests were being safeguarded. Fairways DS0000063612.V351021.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People who use this service experience good outcomes in this area. People living in the home were provided with an environment that was clean, comfortable and safely meeting their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living in the home indicated they liked living at Fairways, which was warm and clean on the day of this inspection visit. The provider organisation had implemented plans to improve the property, which had recently involved a rewiring of the building with other work being carried out to upgrade a downstairs bedroom with an ensuite toilet. The lounge areas were comfortable and bright with newly fitted carpets and other plans were in place to improve the building further. People living in the home confirmed that they were able to choose the decorations for their bedrooms and those that were seen had been personalised with belongings and items of equipment that reflected their individual tastes and personalities. Regular checks of equipment were being carried out and a random inspection of the home’s maintenance certificates confirmed these were being kept up to date to ensure the safety of people living in the home. Fairways DS0000063612.V351021.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 People who use this service experience adequate outcomes in this area. Staff had been provided with training to ensure they could do their jobs although better recruitment checks were needed to ensure people living in the home were safeguarded from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living in the home we spoke with indicated they felt safe with the staff and trusted them and observation of the interactions in the home indicated that staff were committed to doing their jobs in a friendly and sensitive manner. Evidence of NVQ training and specialist courses was contained in the staff files inspected together with regular professional supervision to ensure that career development needs were met. An appropriate induction and foundation training programme was in place to ensure staff were equipped with the skills needed to meet the needs of the people living in the home and discussion with staff members on duty indicated they were knowledgeable about the individual needs of the people living at Fairways. The home had a recruitment policy and procedure to ensure staff were safe to work with people living in the home and evidence of this being adhered to were contained in two of the three staff files inspected. The file of another staff member however, whilst containing references and other pre employment checks, indicated that Fairways DS0000063612.V351021.R01.S.doc Version 5.2 Page 19 they had started work in the home the day before their Protection of Vulnerable Adults (PoVA First) check had been returned. This potentially places people living in the home at risk of harm and a requirement is therefore made about this. Fairways DS0000063612.V351021.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 People who use this service experience good outcomes in this area. Management and administrative systems were in place to ensure the welfare of people living in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager is registered with the Commission for Social Care Inspection and qualified to manage the service. Staff and people living in the home confirmed they had confidence in her and indicated that they felt the home was being well run. Evidence of communication was seen in the minutes of meetings held with staff and people living in the home in order to ensure that they were consulted about developments in the home. A business plan had been developed and a Quality Assurance system was in place to monitor the effectiveness of the home against its stated aims and objectives. The manager indicated this system had not yet been fully developed, and in the light of comments received as part of the inspection process, it is recommended that Fairways DS0000063612.V351021.R01.S.doc Version 5.2 Page 21 consultation with those connected with the home be further developed so that feedback obtained from them, can be considered as part of the home’s monitoring process. Regular checks of equipment were being carried out and a random inspection of the maintenance certificates confirmed these were up to date in order to ensure the health and safety of people living in the home. Fairways DS0000063612.V351021.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X 3 3 X Fairways DS0000063612.V351021.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA34YA34 Regulation 19 Requirement The registered person must ensure that all the necessary pre-employment checks have been carried out and the required records are in place prior to the employment of new staff. Previous timescale of 04/11/06 not met Timescale for action 19/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA9YA9 Good Practice Recommendations The registered person should develop the risk assessments of people living in the home in order that staff are provided with clear information about what action they should take to ensure people living in the home are safeguarded from harm The registered person should develop the provision of further activities for people living in the home to ensure that their lifestyle opportunities are maximised The registered person should develop the home’s key policies (including complaints) into a format that is more DS0000063612.V351021.R01.S.doc Version 5.2 Page 24 2 3 YA12YA12 YA22YA22 Fairways 4 YA22YA22 5 YA39YA39 accessible to people living in the home, in order that they can understand their rights better The registered person should ensure the operation of the home’s complaints policy is developed further to ensure that concerns are actively welcomed and that outcomes for these are openly shared in order that the rights of complainants are protected The quality assurance system should be developed to ensure the views of those connected with the service can be considered as part of the home’s monitoring of its aims and objectives Fairways DS0000063612.V351021.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Fairways DS0000063612.V351021.R01.S.doc Version 5.2 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!