Inspection on 21/08/07 for Fairways

This inspection was carried out on 21st August 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Fairways 05/11/09

Fairways 05/11/09

Fairways 23/07/09

Fairways 24/08/06

Fairways 14/09/05

Fairways 10/05/05

Fairways 23/08/04

Fairways 23/06/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Fairways The Fairways Fuller`s Field, Swan Lane Westerfield Ipswich Suffolk IP6 9AX Lead Inspector Julie Small Unannounced Inspection 21st August 2007 10:00 Fairways DS0000058263.V349087.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 DS0000058263.V349087.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 DS0000058263.V349087.R01.S.doc Version 5.2 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 01473 214997 Care Aspirations Limited Marc Morris Hendy Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Fairways DS0000058263.V349087.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st February 2007 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 care 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. During the inspection the inspector was informed that the fees for the home range from £1283 to £2607 per week dependent on the care that each resident required. Fairways DS0000058263.V349087.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on Tuesday 21st August 2007 from 10.45 to 17.25. The inspection was a key inspection which focused on the core standards relating to adults and was undertaken by regulatory inspector Julie Small. The report has been written using accumulated evidence gained prior to and during the inspection. The home had a newly appointed manager who reported that they were awaiting their CRB (Criminal Records Bureau) check to allow them to make a Registered Manager Application with CSCI (Commission for Social Care Inspection). The manager and the home’s area manager were present during the inspection and provided requested information in a prompt and open manner. The manager said that service users were referred to as residents, this term will be used throughout the report. During the inspection a tour of the building and observation of work practice was undertaken. Five residents were met and four staff members were spoken with. Records viewed included three resident, three staff recruitment, training and health and safety records. Further records viewed are detailed in the main body of this report. Prior to the inspection an annual quality assurance assessment (AQAA) questionnaire and staff, visitors and residents surveys were sent to the home. The AQAA and three staff and two relative/visitor surveys were returned to CSCI. Eight resident surveys were returned and the manager explained that staff had assisted the residents in completing them. What the service does well: The home was clean and well maintained. There were comfortable communal areas such as the garden and lounge which residents could use and their bedrooms reflected their individuality. Interaction between staff and residents was observed to be positive, friendly and professional. Discussions with staff evidenced that staff had a good understanding of individual resident’s needs. Staff were provided with regular supervision and reported that they were supported in their role. There were clear guidelines provided for the administration of PRN (as required) medication. Fairways DS0000058263.V349087.R01.S.doc Version 5.2 Page 6 A range of activities were available for residents to participate in and they were observed throughout the inspection participating in their individual choices of activities. Staffing levels were well maintained and the organisation provided a policy that stated that the home must not be short on the staffing provision. There were several notices displayed around the home which provided accessible information about the home to residents. For example the day’s menu was displayed in picture format on the lounge wall. It was noted that the home provided a ‘thoughtful’ service, where various methods of working with residents were explored and clearly documented. What has improved since the last inspection? What they could do better: Fairways DS0000058263.V349087.R01.S.doc Version 5.2 Page 7 It is recommended that the ‘micro’ training which occurs in the home is documented to evidence that staff were provided with training specific to the resident’s disabilities. The home’s Statement of Purpose should be formally amended to show the current management arrangements as pointed out by the manager. It is recommended that an accessible complaints procedure be forwarded to resident’s family members. 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 DS0000058263.V349087.R01.S.doc Version 5.2 Page 8 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.V349087.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents can expect that they are provided with the information they need to make an informed choice about where to live and that their aspirations and needs are assessed. EVIDENCE: The home’s statement of purpose was viewed and included details of the aims and objectives of the home, facilities and services which were provided by the home. There had been an amendment made in ink, which showed the current management arrangements for the home. The manager explained that a copy of the document was in the process of being typed to reflect the identified changes. The home’s service users guide was viewed and was in picture and text format that was accessible to resident’s living at the home. The manager confirmed that the service users guide would be amended to reflect that CSCI was the current regulatory body. Fairways DS0000058263.V349087.R01.S.doc Version 5.2 Page 10 The relative/visitor survey asked if they were provided with enough information about the home to help them make decisions. One answered always and one answered sometimes. The resident survey asked if they had enough information about the home before they moved in. Four answered yes and four did not answer, comments included ‘a brochure was given to me’ and ‘I was told about Fairways by the staff at (a previous home)’. Three resident’s records were viewed and each contained a detailed needs assessment which had been undertaken prior to the resident moving into the home. The needs assessment detailed the support that the individual required in their daily living. The AQAA stated that an employee of the organisation undertook comprehensive assessments and that visits were arranged to allow the prospective residents to get to know staff, peers and the environment. Fairways DS0000058263.V349087.R01.S.doc Version 5.2 Page 11 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, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that their assessed and changing needs are reflected in their individual plan, that they are supported to make decisions about their lives and that they are supported to take risks as part of an independent lifestyle. EVIDENCE: Three resident’s records were viewed and each contained a detailed care plan, which identified the support they required with their daily living such as with behaviour, communication and personal care. The care plans were updated and identified where there had been changes in the care provision due to resident’s changing needs and wishes. For example, one care plan included how they required support with meal times, they had previously taken food from their peers. The care plans reflected the various support that they had Fairways DS0000058263.V349087.R01.S.doc Version 5.2 Page 12 provided to the resident until the behaviour had ceased. All resident’s records viewed were regularly updated. Resident’s care plans included behaviour management plans and there were records of incidents. The behaviour and care plans clearly identified actions that should be taken by staff in the case of aggressive and self-harming behaviours. There were details included in the care plans which identified the support that residents were to be provided with regarding the ways that they had displayed sexualised behaviours. There was clear reference to ensuring that their dignity and privacy was maintained. Care plans included details of regular care reviews, including input from the resident, their families and their placing authorities. Two relative/visitor surveys said that the home met the resident’s needs and that the home provided the support to the resident that they expected or agreed. The manager explained that they were in the process of reviewing resident’s records and improving the content. Two resident’s records viewed had been reviewed and included increased detail. One had not yet been updated and the manager explained how it would be improved, for example in identifying the resident’s specific skin and hair care needs. The manager explained that the staff team were consulted with regarding the care that residents were provided with. A staff member spoken with confirmed this and detailed how they had contributed to the support that one resident was provided with regarding their food consumption. The staff survey asked how they were given up to date information about the needs of the residents. Comments made in the returned surveys included ‘Via the line manager, team meetings, care plans, other healthcare professionals’ and ‘the manager gives the information before it is written in the care plan’. Records were viewed which evidenced that a local advocacy group had been sought to provide an advocacy service to each resident. The AQAA stated that the home had a named advocate. Each resident was provided with a key worker group, which consisted if either the manager or the deputy manager who was the named care manager, an allocated senior worker, key worker and associated workers which included members of the night waking staff. The AQAA stated that key workers were allocated to match with the resident’s culture and gender. Daily records viewed were cross-referenced to the care plans which they related to. Fairways DS0000058263.V349087.R01.S.doc Version 5.2 Page 13 The daily records viewed evidenced the choices that residents had made in their lives including what they wanted to eat, wear and activities they participated in. The records viewed included details of their likes and dislikes with regards to food, clothing, routines and their interests. Residents were observed to be provided with choices throughout the day, such as where in the home they wanted to be and activities that they wished to participate in. A resident’s bedroom had a notice board with pictures of items such as drink, shower and bath. A staff member said that they could use them to communicate their choices to staff. The resident survey asked if they could do what they wanted each day. Three answered always, four answered sometimes and one did not answer’. The survey asked if staff listened and acted on what they said. Seven answered always and one did not answer. Two relative/visitor surveys said that they home supported the residents to live the life they choose. Each resident’s records viewed included risk assessments, which were included in their care plans and they identified the risks in their daily living and the environment and methods of minimising the risks. Fairways DS0000058263.V349087.R01.S.doc Version 5.2 Page 14 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, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that they are supported to participate in appropriate activities, that they are supported to maintain relationships, that their rights are respected and that they are provided with a healthy diet. EVIDENCE: The daily records viewed identified activities which residents participated in, which included shopping, swimming, day trips, horse riding and eating out. There was a notice board near to the entrance of the lounge which had pictures of activities which were provided and attached were photographs of residents who were participating in the activities. During the inspection one resident was observed going out for a drive in the home’s mini bus. Residents were observed to participate in a music making activity, where they played instruments. Further activities observed during the Fairways DS0000058263.V349087.R01.S.doc Version 5.2 Page 15 inspection included a resident was observed to carry their music player around the home with them and listen to their music, one cycled around the garden, some watched television and residents were observed playing with a giant connect four game in the garden. It was noted that there was a range of DVD films and board games in the home, which residents could use. There were a range of musical instruments which included a drum and large xylophone. There was a snoozelem room in a summerhouse in the garden, which was in the process of being made available for use. The manager confirmed that they were undertaking risk assessments prior to the use of the room. Each resident’s bedroom contained a range of their personal chosen activities, such as a train set and DVD films. The manager explained that at the time of the inspection no residents attended day services and that they were attempting to find some structured service which they could attend outside the home. They explained that issues with their attention and behaviours did affect their participation in day services. The manager was observed speaking to the local authority with a view to find an art therapist to provide a service to the residents at the home. The AQAA stated that the manager planned to contact the local authority to seek sexual education support for residents living at the home. Resident’s records viewed evidenced when they had maintained contact with their family members. There were records which showed that staff members regularly updated family members regarding the resident’s well being. The relative/visitor survey asked if the home helped the resident to keep in touch with them and one answered always and one answered sometimes. The survey asked if they were kept up to date with important issues affecting the resident and two answered always. Two resident’s records viewed included details of their birth name and their preferred from of address, which was an abbreviation of their name. Staff were observed to use the resident’s preferred form of address during the inspection. Interaction between staff and residents was observed to be friendly, positive and professional. Staff included residents in their discussions. Bedroom doors were lockable and a staff member explained that residents were provided with keys to their bedroom. It was noted that two bedrooms had the locking facility taped, the manager and a staff member explained that the resident had mislaid the key and that there was an order to replace the locking mechanism. The manager said that there would be a store of spare keys to prevent the issue occurring again. Fairways DS0000058263.V349087.R01.S.doc Version 5.2 Page 16 The menu was viewed and evidenced that residents were provided with a healthy diet. There were a range of culturally diverse meals provided which included Asian and Italian. There was a notice board in the lounge which displayed pictures of the choices of meals for that day. The cook was spoken with and said that they taken pictures of the meals that they prepared and changed the notice board to meet with the day’s menu. They said that the menu was changed seasonally. Resident’s records identified specific dietary requirements and their likes and dislikes and specific support they required at meal times. For example one resident had taken food from their peer’s plates and the records clearly identified actions taken to prevent the issue. A resident’s records identified that they should be provided with softer foods because their lack of teeth. The manager explained how a resident had been supported to choose their meal times. The manager said that they had requested support from a dietary professional regarding one resident’s specific dietary needs. The AQAA stated that the employment of the full time cook was an improvement made during the last twelve months and that a dietician had been consulted with regarding the menu. It was noted that there was a range of fresh vegetables and fruit. Foodstuffs, which had been opened, were labelled with the date of opening and the use by date. Fairways DS0000058263.V349087.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that they are provided with the personal support which they prefer and require, that their health needs are met and that they are protected by the home’s medication procedures. EVIDENCE: Three resident’s records viewed detailed the personal care and continence needs that each individual had, and included regular reviews and updates when their needs had changed. The records detailed their preferences regarding how they dressed and the specific support they required when bathing. There were records which identified the health care appointments which residents had attended such as dental, chiropody, doctor, optical and psychiatric. Resident’s records viewed included details of their behaviour management and that they had been prescribed with PRN medication. There were clear PRN Fairways DS0000058263.V349087.R01.S.doc Version 5.2 Page 18 protocols for each resident and identified at what points of their behaviours the medication was to be administered. Resident’s records viewed identified the support that they required with the administration of their medication. A staff member spoken with confirmed that no residents at the home administered their medication themselves. Staff spoken with and staff surveys confirmed that they were provided with medication training prior to administering medication. A staff member said that they also shadowed staff administering medication and that they were observed prior to undertaking a lead role in the process. Training records viewed evidenced that staff were provided with medication training. The MAR (medication administration records) were viewed and there were no gaps identified. The medication storage was viewed and medication was stored in MDS (monitored dosage system) blister packs in a secure cabinet in the office. The lunchtime medication round was partially observed. Two staff members undertook it and they carried each resident’s medication with them, along with their photograph taken from the MAR charts. A staff member explained that the practice was undertaken to ensure that each resident was provided with the correct medication. The MAR charts were signed when the resident had taken the medication. A staff member explained the procedure if a resident refused medication or if medication was disposed of. Records were maintained to evidence when medication had been returned to the pharmacy. Fairways DS0000058263.V349087.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that their views are listened to and acted upon and that they are protected from abuse. EVIDENCE: On arrival at the home staff asked to see the inspector’s identification and they were asked to sign the visitor’s book. Staff training records were viewed and evidenced that staff were provided with POVA (protection of vulnerable adults) training. The AQAA stated that the POVA training was accessed through the local authority. Staff spoken with had a clear understanding of the protection of residents living at the home. A staff member spoken with explained how one resident displayed self-harming behaviours and the actions that the home took to minimise the behaviours. The details were recorded in their care plan, which was viewed. The home had the Suffolk guidelines for the protection of vulnerable adults, which was available for staff reference in the office. There was a flow chart which clearly explained the whistle blowing procedure. Fairways DS0000058263.V349087.R01.S.doc Version 5.2 Page 20 Training records viewed and discussions with staff evidenced that they were provided with training on working with individuals who displayed aggressive behaviours. Records viewed and discussions with staff stated that physical intervention must be used as a last resort and diversion techniques must be used. The AQAA stated that staff were provided with de-briefing sessions following issues of challenging behaviours. There was a suggestion made that male staff were targeted to undertake physical interventions. The manager was asked if specific staff members were identified to undertake physical intervention and they said that three people on each shift were identified at the handover meeting, who would co-ordinate any issues with physical intervention during the shift. The complaints procedure was viewed. Records of complaints and actions taken by the home were clearly documented. There was a recent complaint made by a family member and there was documentary evidence in the resident’s records which identified that staff had supported them in the process. A complaint had been made by a neighbour regarding the noise in the garden and actions had been taken to minimise the noise. There were complaints forms, which were in picture and text format, which residents could complete if they were unhappy about any issues in the home or with their care. Two staff surveys said that they knew how to support a resident or a relative if they wished to make a complaint about the home. Staff spoken with were aware of the complaints and whistle blowing procedure. The resident survey asked if they knew who to speak to if they were not happy. Five answered yes and one did not answer. The survey asked if they knew how to make a complaint. One answered always, four answered sometimes and one did not answer. The relative/visitor survey asked if they knew how to make a complaint. One answered no and one answered that they could not remember. The survey asked if the home responded appropriately if they had raised concerns. One answered always and one answered usually. The manager was spoken with about if the complaints procedure was provided to family members. The area manager said that there were quarterly meetings, where families and representatives were invited to and that they could discuss any concerns they had about the service. Families and representatives were advised verbally of how they could raise complaints. The manager said that there had been discussions about how the complaints procedure was distributed to resident’s families in managers meetings. They Fairways DS0000058263.V349087.R01.S.doc Version 5.2 Page 21 said that they would raise the issue at the next meeting with a view to action it. Fairways DS0000058263.V349087.R01.S.doc Version 5.2 Page 22 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, 25, 26, 27, 28, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to live in a homely, safe and clean environment. EVIDENCE: Maintenance records were viewed, which evidenced that reported repairs were actioned. Since the last inspection laminate flooring had been laid in the office, hallways, lounge, dining room and two bedrooms. The removal of carpet and laying of easy to clean flooring had improved the smell in one bedroom. Some bedrooms had been repainted and recarpeted since the last inspection. The lounge had comfortable seating and residents were observed using it to watch the television and listen to music during the inspection. The Fairways DS0000058263.V349087.R01.S.doc Version 5.2 Page 23 entertainment equipment, such as the television were secured in a display case. The dining room had attractive dining tables and chairs, which provided sufficient seating for the residents living in the home. During the inspection residents were observed using the room to participate in a music making activity. Resident’s bedrooms viewed during a tour of the building were clean and well maintained. One resident showed the inspector their bedroom. The bedrooms held their personal possessions and memorabilia and reflected their individuality. Each bedroom provided an en-suite facility which included a toilet, hand washbasin and shower. The AQAA stated that residents chose their bedding and curtains and that the home had purchased water proof mattress’ since the last inspection. Some bedrooms and the lounge had been supplied with magnetic curtain rails, which allowed easy to replace curtains, when residents had pulled them down. It was noted that one bedroom did not hold the curtain rail and the manager confirmed that they were awaiting delivery of the curtain rails for the remaining windows in the home. A digital lock to an en-suite facility had been removed, which was a requirement from the last inspection. There was a communal bathroom which provided a toilet, hand washbasin and assisted bath, which provided residents with a choice of using the shower in their en-suite facility or bath. A staff member confirmed that residents could choose which bathing facility they used. There was an attractive garden, with seating and residents were observed using the area by playing with the giant connect four game and riding a bicycle. There was a shed in the garden, which was used as a staff room, it held seating, refrigerator and hot drink making facilities. The room was used by the inspector to speak to staff during the inspection. Staff spoken with reported that they cleaned the home regularly and attempted to ensure that it was as homely as possible. Staff spoken with had a good understanding of infection control. Staff were observed to wear disposable gloves and aprons when undertaking tasks throughout inspection. A staff member explained that each staff member was provided with a personal bottle of hand wash liquid. Staff were observed cleansing their hands prior to administering the lunchtime medication. The AQAA stated that the home had improved the infection control training and that they purchased disposable mops, which were replaced on a weekly basis. The laundry was viewed and had a large washing machine and drying machine. There were hand washing facilities and a stock of disposable gloves. Laundry Fairways DS0000058263.V349087.R01.S.doc Version 5.2 Page 24 baskets which had lids and were labelled with individual resident’s names were provided to transport soiled laundry from their bedroom to the laundry room. The kitchen was viewed and was clean, the cook explained methods of infection control in the kitchen area, which included the use of colour coded chopping boards and the storing of foodstuffs. The kitchen provided hand washing facilities. The laundry and bathrooms provided hand drying machines. Hand wash liquid was provided in the staff toilet and the laundry. The resident survey asked if the home was fresh and clean. Five answered always, two answered sometimes and one did not answer. Fairways DS0000058263.V349087.R01.S.doc Version 5.2 Page 25 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that they are supported by qualified, trained and supported staff and that they are protected by the home’s recruitment procedures. EVIDENCE: Nineteen staff worked at the home and ten staff had achieved an NVQ (National Vocational Qualification) level 2 or 3, three staff were working on their award and six staff had not yet achieved their award. The home had met the target in the National Minimum Standards relating to adults that 50 of staff had achieved a minimum of NVQ level 2 by 2005. Two staff members spoken with confirmed that they had achieved both NVQ levels 2 and 3 since they had been employed at the home. One newly employed staff member was spoken with and confirmed that they would undertake their award when they had completed their probation and induction period. Fairways DS0000058263.V349087.R01.S.doc Version 5.2 Page 26 The AQAA stated that the deputy manager was working on the NVQ Registered Managers Award (RMA). Induction records were viewed and evidenced that the induction period was provided over a six week period and included details of the building, such as fire safety, health and safety, medication, communication, quality procedures, employment, use of appliance, finances and personal development. The area manager confirmed that when staff had completed their induction they would be supported to undertake their NVA award as soon as possible. Three staff member’s recruitment records were viewed and included an application form, CRB (criminal records bureau) check, POVA first check, interview notes, identification and two written references. Staff records viewed evidenced that staff were provided with regular supervision and appraisal meetings. Staff spoken with and staff surveys confirmed that they were provided with regular supervision and team meetings and that they were supported in their work role. On arrival at the inspection it was noted that one staff member and the manager was in a supervision meeting. Training records viewed evidenced that staff were provided with training such as POVA, medication, health and safety, first aid, food hygiene, managing challenging behaviour, fire safety communication, manual handling and equal opportunities. Staff reported that they were provided with training which enabled them to support the residents at the home. The manager was asked if staff were provided with specific training on disabilities, such as autism and epilepsy. The manager confirmed that they provided in house ‘micro training’. However, this had not been recorded, the manager showed the inspector individual training needs records for each staff member and agreed that the ‘micro training’ and in house activities could be recorded to evidence further informal training that staff were provided with. The rota was viewed and there was a minimum of six staff on each day shift and two waking night staff member. The manager confirmed that they maintained the staffing levels at all times to ensure that the resident’s needs were met. The manager said that there was one vacancy at the home, and they were observed talking to an applicant for the post on the telephone during the inspection. The manager reported that they had an agreement with an agency, that in the event that agency staff were required they would be provided with regular staff who were known to the residents. Three staff surveys answered yes to the question ‘do the staffing levels on each shift give you enough time to meet the assessed needs of the residents?’ Fairways DS0000058263.V349087.R01.S.doc Version 5.2 Page 27 The AQAA stated that staff were provided with the opportunity to earn financial bonuses and achieve pay rises, by, for example not taking sick leave, for achieving their NVQ award and completing their development programme. The manager explained that staff development was provided by asking staff to study areas of good practice, legislation or issues relating to the residents living at the home and presenting their knowledge to the staff team. This was confirmed in the AQAA. Fairways DS0000058263.V349087.R01.S.doc Version 5.2 Page 28 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that they benefit from a well run home, that their views underpin self monitoring of the home and that their health, safety and welfare is promoted. EVIDENCE: The registered manager at the home had left. An application had been received from a manager who had also left. The current manager at the home had been employed since April 2007. They had advised CSCI of the management change and were awaiting their CRB check. When their check was received then they would submit their registered manager application to CSCI. The manager was spoken with during the inspection and had several years experience in a caring and management role. They had achieved a nursing qualification. The manager Fairways DS0000058263.V349087.R01.S.doc Version 5.2 Page 29 had made several positive changes in the home, including in the environment, reviewing resident’s records and consultation with staff. They explained further positive changes they were hoping to action in the future. Staff spoken with were complimentary about the management of the home. The area manager confirmed that staff, resident and family satisfaction were regularly undertaken and the organisation assessed the outcomes and identified methods of improving the service. There were quarterly meetings where resident’s families were invited to. The director of the organisation and senior management attended the meetings and they provided the attendees to discuss issues with the home and the organisation. The AQAA stated that there was a comments and suggestions box at the home and that staff undertook management 360-degree questionnaires. This identified the staff satisfaction with the management support they were provided with. Regular Regulation 26 meetings were undertaken and the reports were forwarded to CSCI. Copies of the reports were not stored in the home, following discussion with the area manager and the home’s manager the reports were accessed and stored in the home during the inspection. The home’s fire risk assessment and regular fire safety checks were viewed. Fire drills were regularly undertaken and included the date and time of the drill, who was involved and the evacuation time scales. Maintenance records viewed evidenced that reported repairs were actioned and that water temperature and portable electrical appliance checks were regularly undertaken. There was documentary evidence to show that legionella checks and weekly health and safety checks had been undertaken. The home had environmental and COSHH (control of substances hazardous to health) risk assessments. The secured COSHH cupboard was viewed and a staff member explained that each resident’s bedroom was provided with individual cleaning materials which prevented cross contamination. COSHH guidelines were displayed in the COSHH cupboard and in the laundry. In the kitchen the sharp knives were stored in a secured drawer. Food was stored appropriately and opened foods were labelled to show the opening date. The previous inspection noted that there were offensive smells in one bedroom. During this inspection the carpeting had been replaced with laminate flooring and staff explained that regular cleaning had eliminated the smell. The tour of the building was undertaken in the morning and there was a faint smell of urine detected in the bedroom which was eliminated when the windows were opened. Fairways DS0000058263.V349087.R01.S.doc Version 5.2 Page 30 Staff training records viewed evidenced that staff were provided with food hygiene, first aid, manual handling, health and safety and medication training. Fairways DS0000058263.V349087.R01.S.doc Version 5.2 Page 31 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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 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 3 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 X 3 X Fairways DS0000058263.V349087.R01.S.doc Version 5.2 Page 32 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. Standard Regulation Requirement Timescale for action 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. 2. 3. Refer to Standard YA22 YA35 YA35 Good Practice Recommendations It is recommended that a copy of the complaints procedure be forwarded to resident’s family members It is recommended that informal training provided to staff is recorded to provide evidence that staff have been provided with specific training It is recommended that training be provided regarding the specific issues related to learning disabilities. Fairways DS0000058263.V349087.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Colchester Local Office 1st Floor Fairfax House Causton Road Colchester CO1 1RJ 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 DS0000058263.V349087.R01.S.doc Version 5.2 Page 34 - 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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