Inspection on 22/05/07 for Fairways

This inspection was carried out on 22nd May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 09/11/05

Fairways 06/04/05

Fairways 14/10/04

Fairways 09/07/04

Fairways 15/03/04

Fairways 16/09/03

Similar services:

Flint House

Hillview Farm

Dalewood Respite Care

Orchard,The

Heather House Nursing Home

REACH Upton Court Road

The Cotswold Home

Treloar College

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

CARE HOME ADULTS 18-65 Fairways 7 Elvetham Road Fleet Hampshire GU51 4QL Lead Inspector Tracey Horne Unannounced Inspection 22nd May 2007 09:30 Fairways DS0000039631.V335780.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 DS0000039631.V335780.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 DS0000039631.V335780.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fairways Address 7 Elvetham Road Fleet Hampshire GU51 4QL 01252 815256 01252 815579 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of Manager (if applicable) Type of registration No. of places registered (if applicable) SeeAbility Patricia Batterham Care Home 7 Category(ies) of Learning disability (7), Physical disability (7), registration, with number Sensory impairment (7) of places Fairways DS0000039631.V335780.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents in the PD category must not be wheelchair users as the home is not able to meet their needs. 9th November 2005 Date of last inspection Brief Description of the Service: Fairways is a large detached family home located in a quiet residential area. Previously part of the School For The Blind, it is now registered by SeeAbility. It is close to shops and local amenities. Accommodation is provided in single bedrooms (five of which are en-suite) situated on the ground and first floor. Most bedrooms are spacious, all have been personalised to each residents own preference. Access to the first floor can be gained by one flight of stairs. There is a communal lounge, kitchen and dining room on the ground floor and a large enclosed garden and patio area to the rear of the property. The aims and objectives of the home are to provide twenty four hour care for residents aged 18 to 65 with visual impairments and learning disabilities. The home is also registered to provide care for residents with visual impairments and physical disabilities. The fees range are £1,103.92 per week. Fairways DS0000039631.V335780.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the inspection was to assess how well the home is doing in meeting the key National Minimum Standards (NMS) and Regulations. The findings of this report are based on several different sources of evidence. These included: an unannounced visit to the home, which was carried out on the 22nd May 2007 between 09.30 and 14.30, during which Mrs Tracey Horne, Inspector had the opportunity to speak to residents and staff, look at records and observe interaction between people living and working at the home. The people living in the home prefer to be referred to as residents, therefore the rest of this report will reflect this. We received an Annual Quality Assurance Assessment (AQAA) from Patricia Batterham, Registered Manager prior to this visit, which provided further evidence of how the service is meeting the Key National Minimum Standards. The Commission for Social Care Inspection (CSCI) sent feedback forms to the home prior to this site visit, six residents forms were completed and returned and one relative returned their comment card to the CSCI prior to this site visit. All regulatory activity since the last inspection was reviewed and taken into account including notifications sent to the CSCI. What the service does well: The staff are caring, respectful and are mindful of peoples need for privacy and dignity. They encourage individuality and independence within the limits dictated by the resident’s needs. Residents feel supported to make decisions about their lives and are fully involved in planning what happens in their lives. Residents enjoy living in their home which is clean and has a relaxed, homely atmosphere. Residents are encouraged to participate in the local community as they wish. Staff time is organised so that residents may go out on trips on an individual basis or spend time doing activities with staff support in the home. The home has an open and good process in place for dealing with complaints, concerns and compliments. One resident said, “I would tell my keyworker if I was not happy.” The home has a process for recruiting new staff which safeguards the people living in the home. Staff said that they felt very supported by the manager and other team members, are encouraged to obtain qualifications (75 of staff are working Fairways DS0000039631.V335780.R01.S.doc Version 5.2 Page 6 towards, or have achieved a National Vocational Qualification (NVQ) this exceeds the NMS.) and said communication is very good. All residents spoken with said they feel safe and comfortable at the home. Patricia Batterham has provided strong leadership and developed a team that work well together to support residents to achieve their individual goals and aspirations. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Fairways DS0000039631.V335780.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 DS0000039631.V335780.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. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. A comprehensive procedure for assessing the needs and aspirations of potential new residents is in place to ensure the residents and the homes needs are met prior to admission. EVIDENCE: The Statement Of Purpose and Service Users Guide is available in audio or Braille formats upon request. One resident confirmed they received documents in Braille. One resident has been admitted since the last inspection and said they had relevant information about the home, remembered speaking to Patricia Batterham before they moved in and have been supported settled in well. Comprehensive Records were seen and content was used to create the individuals care plan. Patricia Batterham confirmed that she or an appropriate person completes the assessments. The service has one vacancy and is actively pursuing referrals. Fairways DS0000039631.V335780.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): Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Residents’ individual plans reflect their assessed and changing needs and personal goals. Practices within the home demonstrate that residents are encouraged to make decisions about their lives and to take risks as part of an independent lifestyle. EVIDENCE: The inspector looked at two essential life and support plans that had been being developed and reviewed in a person centred way and are designed in line with the individual’s needs and are outcome focussed. One resident’s care plan is being transported into DVD format to meet the individual’s needs. Residents said they receive the support they need and that staff ‘always help’ them. The staff said they knew residents very well and were able to describe the support that individuals needed. Information such as photographs of people who are important to the individual and places of interest, likes and dislikes, dreams and aspirations, how to Fairways DS0000039631.V335780.R01.S.doc Version 5.2 Page 10 communicate with individuals and how to interpret their actions were clearly written in the plans. Residents confirmed they were aware of their plans and were involved in developing and reviewing them. Through observation it was evident that residents are able to make decisions about their lives. Residents said they are able to choose how they spend their time, when they get up, go to bed and when they want to eat. One person expressed a wish to move to a bedroom on the ground floor due to their changing personal needs, this was agreed and implemented. The resident said they were much happier in their new room. Staff were observed knocking on bedroom doors before entering. They address residents by the name the individual prefers, as stated in their care plan. Risk assessments seen were drawn up on an individual basis and the emphasis on independence and positive outcomes supports residents to achieve their goals and aspirations. Fairways DS0000039631.V335780.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 & 17 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Residents feel able to make choices about their life style, and are supported to develop their life skills. Social, cultural and recreational activities are being improved to meet individual’s expectations. EVIDENCE: CSCI surveys completed by two residents stated they would like to do more activities’. The home are addressing this by employing volunteers to improve the provision for activities. The AQAA stated that the range of activities pursued are recorded in daily records and activity programmes/reports, these records were seen. Two staff have completed the provider’s social inclusion training programme and there has been improved focus on enabling residents to develop skills, choice and community inclusion e.g. supporting people in planning & preparing their own evening meal, undertaking mobility training to independently access a local gym. Certificates confirmed this training and a volunteer supported a Fairways DS0000039631.V335780.R01.S.doc Version 5.2 Page 12 resident to access the community where they went shopping and had lunch out. Goals and aspirations are recorded in individuals plans and records showed how these are being met. One resident went on a mini cruise holiday and one resident is having piano lesions. The home have introduced an in house activity co-ordinator to plan and review with residents a four weekly activity programme. Residents are supported to access a range of leisure and educational activities where they have the opportunity to develop friendships. Each resident has an activities chart which includes details of what activities the individual will be doing each day. There was evidence that annual reviews take place. Residents said they felt that staff understood them and listened to their views and opinions. This was also evident through discussion with staff who were allocated as the resident’s key worker. Residents felt able to pursue their hobbies and interests. One resident was supported by a volunteer to go out for lunch and shopping and told the inspector she spends time with the volunteer once a fortnight to go out, and she can pursue her hobby of collecting buttons. Equality and diversity is promoted in the home and good examples of this were available. Residents are supported to express their individuality through a range of social activities and are members of specific interest groups such as Blind club. Residents are active in their local community and attend local groups, clubs and use the local shops, pubs and restaurants. Residents are encouraged to maintain relationships that are important to them. Records showed residents being supported to maintain links with families and friends. One resident had been on holiday recently with staff from the home and a resident who used to live with them at the home. The Patricia Batterham said that relatives were invited to attend annual reviews so they could be involved in care planning if the resident wants. Support is given to residents to take responsibility for household tasks and be involved in all aspects of running the home. Healthy and varied meals are provided and residents said they enjoyed helping with the cooking. Details of specific dietary needs (such as soft diet) need to be recorded in care plans. Patricia Batterham acknowledged this and confirmed the day after this visit that it had been completed. Residents spoken to said they liked the food and found that meal times are flexible to fit around their activities. One resident confirmed residents take it in turns to plan the weekly menu and devise a shopping list. Four staff are currently undertaking a level 2 certificate in nutrition & health and Patricia said they are working with residents to promote and educate healthy eating. The service use adapted equipment such as talking microwave, talking sign to explain what is on the menu for the next 2 days, liquid level indicators and talking scales to promote independence. Fairways DS0000039631.V335780.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 & 20. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents receive health & personal care on an individual basis. The home practices the principles of respect, dignity and privacy. EVIDENCE: The AQAA states that records of health action plans demonstrate how the service is supporting people to meet their care needs, records seen confirmed this and showed that emotional needs are considered individually and strategies for support are in place for those who need it. Each resident is supported to maintain their health and well being by having their own General Practitioner (GP). Support is given to keep GP’s appointments as well as dental and podiatry appointments. Specialist healthcare professionals are involved when necessary for residents with specific health needs, records showed visits to a diabetic nurse and faith healer. Systems are in place to monitor and review these to ensure follow up appointments are maintained. One resident said ‘I see my doctor and dentist.’ The care plan included a picture of a doctor but it was not one of the residents doctor. Patricia Fairways DS0000039631.V335780.R01.S.doc Version 5.2 Page 14 Batterham said she hopes to improve this as part of developing all the care plans. One relative stated in the CSCI survey ‘I am always advised of medical treatment as required and am advised personally by the doctor before any action taken. Always with a member of the residential home in attendance.’ The requirement made at the last inspection has been met, all staff who administer medication do so only after being assessed as competent by the Patricia Batterham. The AQAA stated that all current staff had completed this process. The inspector saw records of this assessment that had been completed with staff this year. The manager said she will be arranging safe administration of medication training as well. The home do not stock controlled drugs (instead of individually prescribed drugs for named residents.). The home has an arrangement with the local pharmacist for medication to be supplied in a monitored dosage system. Individual’s medication, together with any creams and lotions are stored in a lockable cupboard in the resident’s bedrooms. One resident confirmed they prefer staff to administer their medication. The medication administration record (MAR) had been completed for the morning’s medication but a gap in the MAR sheet was noted from two evenings ago for one resident. Patricia Batterham acknowledged this and confirmed the day after this visit that the MAR sheet had been signed. Staff confirmed the medication had been checked and had been administered correctly. Fairways DS0000039631.V335780.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 & 23. Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Residents feel able to air their views and make complaints. The policies and procedures used in the home, and the training staff have received protect residents from the risk of abuse. EVIDENCE: The homes satisfaction survey resulted in 100 of respondents knew how to address concerns & complaints. All who responded to the CSCI survey were are aware of how to raise concerns; one relative stated they have never had to. Residents stated that staff usually or sometimes listen and act on what they say. Two residents said that staff always listen to them, they have the opportunity to air their views or choices via their keyworker, resident meetings or they can request a meeting to discuss any issues or concerns they may have. Patricia Batterham confirmed no complaints have been made to the home. During the visit residents spoke openly with staff about any questions or concerns they had, staff were quick to respond, and explained most of the time residents need reassure about what is happening during the day. Staff acting promptly and consistently elevated any anxieties. The AQAA stated that records show staff have attended AP training. Minutes of residents meetings demonstrate that residents are reminded of and encouraged to raise concerns and complaints. Records seen and one resident confirmed this. Fairways DS0000039631.V335780.R01.S.doc Version 5.2 Page 16 Staff said they were familiar with the home’s adult protection and whistle blowing policy as well as Hampshire County Council’s policy on safeguarding adults. Staff said they were aware of their responsibilities within them. Patricia Batterham said that staff have attended training regarding adult protection issues, records seen confirmed this. Care plans; risk assessments and intervention plans are in place for managing challenging behaviour. Staff and residents were aware of them. Records showed staff has received appropriate training to carry out such interventions and the homes policy had clear guidelines. One resident is supported with their finances, they can have access to their money when they wish. Receipts and written records of transactions are kept. Monies held on behalf of the resident were sampled and were accurate. Patricia Batterham said an audit was carried out recently by an external auditing company and found records of residents and household moneys to be satisfactory Fairways DS0000039631.V335780.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 & 30. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe, well maintained and comfortable environment, which encourages independence. EVIDENCE: The home provide spacious and homely accommodation which have been adapted through the use of contrasting textures and colours to enhance orientation for people with visual impairment. Residents were seen to be able to move freely round the home and the garden and use adapted equipment such as a talking sign to explain who is on duty and what is on the menu for the next two days. Equipment has been adapted to promote independence, such as raised markings on the programme dial of the washing machine. The home was found to be comfortable, clean and safe. A system is in place to report repairs and improvements needed. Bedrooms seen were suitably decorated with adequate furniture and personalised to reflect the preferences and needs of the people living there. Fairways DS0000039631.V335780.R01.S.doc Version 5.2 Page 18 There was adequate communal space and these areas were clean and comfortable. The annual development plan includes during 2007-08 a new kitchen will be fitted, boiler will be replaced and three bedrooms will be re decorated. The AQAA stated that the home have a policy for preventing infection & managing infection control. Certificated confirmed that staff have received training in the prevention of infection & management of Infection Control and were aware of the home’s policies and procedures of hygiene issues. The last Environmental Health Officer inspection in March 2006 confirmed ‘a good standard of food safety & cleanliness’ no recommendations were made. 100 of people who responded to the home’s satisfaction survey last year were satisfied that the home was kept clean & comfortable. Residents do not use hoists, stair/chair lifts or emergency call equipment. Fairways DS0000039631.V335780.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by staff that are trained, skilled and in sufficient numbers to meet individuals and group needs. Staff support the smooth running of the home in line with their terms and conditions of employment. EVIDENCE: The staff spoken to during the inspection were confident and competent, were clear about their roles and responsibilities and stated Patricia Batterham provides clear direction. They said they enjoyed their work and showed an in depth knowledge of the individual needs of residents and spoke about residents in a sensitive and positive manner and were seen interacting in this way. The training co-ordinator has been supported to complete a distance-learning programme on activities provision. The staff undertake the cooking and cleaning with the residents assisting where possible. No separate ancillary staff are employed at the home. Staff said that a minimum of two staff are on duty. The rotas showed that a minimum of two staff were on duty that day. This did not include Patricia Batterham who does work with staff to provide supervision and support, and Fairways DS0000039631.V335780.R01.S.doc Version 5.2 Page 20 enables staff to spend one to one time with residents. One member of staff provides sleep-in cover during each night shift. Patricia Batterham stated that the home have not been successful in recruiting male staff to work with male residents, which is something she is keen to improve upon to enable the choice of having a same gender carer. The AQAA stated that the home operate a robust recruitment and selection process and all relevant safety checks are completed prior to employment but one staff record seen did not include copies of the individual’s identification Patricia Batterham said she has seen copies which may be at Head Office. The day after this visit Patricia Batterham confirmed the paperwork was now on file. Residents have been involved in recruiting volunteers, which has enabled residents to attend more activities. Staff training incorporates Common Induction Standards, in line with national guidelines for good practice that include elements relating to values, individuality and courses in disability, equality, human rights, values and positive lifestyles and anti-discriminatory practices. Specialist training is provided to meet individuals needs such as visual impairment and learning disability. The training programme equips staff to work with individuals and the local community to promote access to services and facilities and challenge barriers in society that disable people. Staff have a development programme which shows training completed and when it is due. 75 of staff are qualified to NVQ level 2 or above this exceeds the NMS of 50 of staff being qualified to an NVQ. Certificates showed staff are trained in all mandatory training such as Health and Safety, Fire and First Aid. Staff spoke highly of the training they receive that they felt enables them to do their job. One member of staff stated they receive support from the manager and their colleagues via meetings, training and supervisions. Fairways DS0000039631.V335780.R01.S.doc Version 5.2 Page 21 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 excellent This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect, has effective quality assurance systems developed by a qualified, competent manager. EVIDENCE: Although predominantly a younger adults service, three of the current residents are now over 65. Mrs Batterham has been able to reflect and utilise her previous experience with older people to ensure that the service continues to meet people’s needs. AQAA states Mrs Batterham has completed her Registered Managers Award (RMA) and NVQ level 4 in management and has undertaken training in learning disabilities and visual impairment, and is currently undertaking a leadership development programme. Residents expressed confidence in the manager and Fairways DS0000039631.V335780.R01.S.doc Version 5.2 Page 22 felt able to talk to her, found her approachable and supportive. Residents said they are consulted on a daily basis and at house meetings where their views are listened to and acted on. Residents are able to contribute to the planning and review of the service via annual satisfaction surveys, during six monthly reviews (attended by residents, their keyworker, the home manager, residents relatives and care managers) who are all able to contribute to the evaluation of care provision, during monthly Regulation 26 visits by a responsible person to evidence how the service is performing and via the concern/complaints procedure. A recent decision regarding staff having keys to the home was over turned by the residents’ views, as they wanted staff to have keys to the home to let themselves in. As a result of a satisfaction survey completed during February-march ’07, volunteers have been recruited to enhance the level of 1-1 support available to residents to go out at weekends. The resident who requested more activities at weekends was involved in the process of distributing leaflets in appropriate local establishments, such as library, volunteer bureau. The AQAA stated that appliances and equipment were serviced regularly. A number of records and certificates were checked at the visit and were found to be in order. In addition, staff completed their own in-house checks on equipment. For example, staff checked that fire alarms were working on a weekly basis and completed a visual check of fire extinguishers every month. Staff records showed that staff were able to complete health and safety training such as first aid, moving and handling and food hygiene on a rolling programme. Their individual training needs were identified through monitoring, supervision and appraisal. Regulation 37 forms are sent to the commission to inform us of events detrimental to the well being of residents. The home has policies, procedures and risk assessments in place to promote the health and safety of residents and staff. Fairways DS0000039631.V335780.R01.S.doc Version 5.2 Page 23 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 X 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 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 3 35 4 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 x LIFESTYLES Standard No Score 11 X 12 3 13 4 14 X 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 x 4 X 4 X X 4 x Fairways DS0000039631.V335780.R01.S.doc Version 5.2 Page 24 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. Refer to Standard Good Practice Recommendations Fairways DS0000039631.V335780.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 DS0000039631.V335780.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!