CARE HOME ADULTS 18-65
Fairways 119 Cardigan Road Bridlington East Yorkshire YO15 3LP Lead Inspector
John Trainor Unannounced 23 August 2005 09:30
rd 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 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 Stationary 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 J04 J53 Fairways S63612 V232365 190705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Fairways Address 119 Cardigan Road Bridlington East Yorkshire YO15 3LP 01262 676804 01262 676804 john@franklinhomes.co.uk Franklin Homes Ltd Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) N/A Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Fairways J04 J53 Fairways S63612 V232365 190705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection N/A Brief Description of the Service: The Fairways is a home registered for twelve service users of either gender with a learning disability who present as a challenge. It is situated on the outskirts of Bridlington and the accommodation is contained within one large house. The accommodation in the home is on 2 floors, and residents’ bedrooms are on both floors. There are 2 lounge areas on the ground floor, one of which also serves as a dining room. The service users tend to congregate in the latter facility. Service users have access to the home’s garden. The home has a mini-bus to enable service users to access the local community and take part in outings. Fairways J04 J53 Fairways S63612 V232365 190705 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over 6 hours. Several of the people living in the home were in during the inspection and the care provided to three of them was inspected in detail to establish whether the home was meeting the national minimum standards. Documents inspected included care plans, policies and procedures safety certificates and insurance documents. What the service does well: What has improved since the last inspection? What they could do better:
The information provided to people before they move into the home needed improvement to accurately reflect the current situation as it was at the time of inspection and so the statement of purpose and service user guide needed to be updated. The home would benefit from a more robust risk assessment and risk management process particularly with reference to documenting peoples needs so all staff are aware of risk management strategies for managing peoples behaviour. The environment needed to be risk assessed with a view to maintaining people’s safety in the least restrictive way possible so people could have the maximum access to all parts of the home that their needs would allow. Fairways J04 J53 Fairways S63612 V232365 190705 Stage 4.doc Version 1.30 Page 6 Some improvement to managing and recording health and safety issues was necessary. In particular a fire risk assessment and management plan was needed in conjunction with the local fire officer. An electrical hard wiring certificate was also needed to ensure the installation was safe. The dining area in the home had floor tiling which was unsafe when wet and staff expressed concerns about its safety. There had been recent improvements to the management structure of the company and a quality assurance tool was being developed to enable the home to assess its performance in meeting the needs of the people resident. However other areas of the management of the home needed to be improved. The manager needed to register with the Commission for Social Care Inspection and staff recruitment and supervision needed to be more robust to ensure people living in the home got the best possible service from the staff. The provider was instructed to take action to make these things better for the 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. Fairways J04 J53 Fairways S63612 V232365 190705 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Fairways J04 J53 Fairways S63612 V232365 190705 Stage 4.doc Version 1.30 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 2 Though all people had assessments by care managers prior to admission in order to assess their needs, improvements to the home’s information describing the service were necessary in order to ensure people had all the information to make an informed choice. EVIDENCE: The statement of purpose needed review to reflect the service as currently provided including the fact that the lift did not work so people in wheelchairs couldn’t be accommodated. The service user guide needed development to ensure it provided all the information people needed to make a decision to live in the home. Guidance on what to include in this can be found in regulation 5 of the Care Homes Regulations 2001. Discussions were held about how to present in appropriate formats for the people resident in the home. In one home in the group a care worker goes through the service user guide on an individual basis with each person living in the home and explains in a way most appropriate for that individual. This is then recorded in care diaries and this was accepted as a model for ensuring a satisfactory outcome for the individual person. Though all of those files inspected had copies of care management assessments the home is in the process of developing their own pre admission assessment format.
Fairways J04 J53 Fairways S63612 V232365 190705 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 and 9. People had their care needs recorded in plans and though people were encouraged and supported to be as independent as possible improvements were needed to the risk assessment and risk management process to ensure peoples safety. EVIDENCE: Families of service users were involved in the planning process and had copies of care plans. They were invited to reviews. Where people did not have families the home needed to develop contacts with an independent advocacy service to provide people with independent scrutiny of their care needs and represent their individual wishes. Risk assessments were included in care files though some people who went out unsupervised and who present with challenging behaviour as part of their condition did not have risk management plans and strategies for this activity. Environmental risk assessments needed development and recording particularly where they present with a risk management strategy which impacts on the freedoms of the individual.
Fairways J04 J53 Fairways S63612 V232365 190705 Stage 4.doc Version 1.30 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15, 16, and 17. People were supported into a lifestyle which attempted to reflect individual preference and support inclusion. EVIDENCE: Some people were out at the time of inspection as they go out unaccompanied and visit local shops or go to town. Most people go out most days even if accompanied. The home had a mini bus which enabled people to have outings. Family and friends were encouraged to visit and be involved. Staff were observed to treat people with dignity and respect. People were supplied with a varied diet with alternatives for those who did not want what was on offer.
Fairways J04 J53 Fairways S63612 V232365 190705 Stage 4.doc Version 1.30 Page 11 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 and 20 People had their health and personal care needs met though more attention to individual preference would improve personal care provision. EVIDENCE: People had full access to primary and secondary health services. Care plans included some recording of preference with regard to personal care though this could be improved. There was evidence of communal toiletries in bathrooms and razors were left in unlocked bathroom cupboards unlabelled. The home needed to develop its environmental risk assessment processes to ensure the environment is maintained safely in a manner which is least restrictive on the freedom of the individual to move around their home. Fairways J04 J53 Fairways S63612 V232365 190705 Stage 4.doc Version 1.30 Page 12 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 Though procedures are in place to protect people from the risks of abuse, people are not guaranteed a timely response to any concerns or complaints. EVIDENCE: The home had an adult abuse policy and copy of the multi agency procedure. The complaints procedure needed review to include timescales though no complaints were recorded in the last year. Fairways J04 J53 Fairways S63612 V232365 190705 Stage 4.doc Version 1.30 Page 13 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26 and 30. The environment was clean and hygienic, though more attention to safety needs to be considered to ensure people would be safe in any eventuality. EVIDENCE: The home was clean and some improvement to the general décor had taken place. Individual rooms were tailored to individual needs. Tiles in the dining area were unsafe with a raised edge where they joined the carpet causing a trip hazard and feedback from staff that when wet they were unsafe. Some furniture needed replacing or having covers provided. At the time of inspection there were simply blankets thrown over couch frames, which did not create a very nice, relaxing area. The home needs to identify and prioritise those areas of the home and fittings in need of refurbishment. Fairways J04 J53 Fairways S63612 V232365 190705 Stage 4.doc Version 1.30 Page 14 Risk assessments to the environment need to be completed and recorded to enable people maximum freedom of movement around the house in a safe way. There was no fire risk assessment available for inspection. This needs to be completed in conjunction with the fire officer to ensure the home is safe and risks are managed. In particular the locks on doors were Yale and so would default to a locked position and so must be reviewed to ensure people can get through them in an emergency. Fire doors were wedged open and must not be, unless by a device approved by the fire officer, which will enable the door to close in the event of a fire. Fairways J04 J53 Fairways S63612 V232365 190705 Stage 4.doc Version 1.30 Page 15 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 35 and 36 People had sufficient trained staff available in the home to help them with their care needs. EVIDENCE: The company was committed to training care staff with programmes in place to ensure all staff would be trained through induction to foundation level. Their training programme was in the process of being accredited by Learning Disability Awards Framework. Staff had received training in managing challenging behaviour. Five staff were on duty on the morning of inspection and sufficient staff were generally deployed to meet the needs of the people resident. Staff recruitment files did not all have two written references despite previous requirements and discussions were held with the manager about recording references for those staff employed and deployed. Fairways J04 J53 Fairways S63612 V232365 190705 Stage 4.doc Version 1.30 Page 16 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39 and 42 Though the management at the home was improving because of better support from the company and the development of management systems there was insufficient evidence to support the home being managed and maintained safely. EVIDENCE: Insurances were in place for the home and mini bus. The Manager has received line management supervision and feels better supported by the company. Staff were trained in food hygiene and first aid and there was an infection control policy. The general manager is completing regulation 26 visits and a quality assurance methodology is being developed.
Fairways J04 J53 Fairways S63612 V232365 190705 Stage 4.doc Version 1.30 Page 17 Though portable appliance testing was evidenced the electrical hard wiring safety certificate was not available for inspection so the safety of the installation could not be proven. There was no fire risk assessment for inspection. The current manager had not yet made application to the Commission for Social Care Inspection to register to be manager. Fairways J04 J53 Fairways S63612 V232365 190705 Stage 4.doc Version 1.30 Page 18 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 1 3 x x x Standard No 22 23
ENVIRONMENT Score 1 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 2 2 x 1 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 1 x 3 x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x 2 1 3 1 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Fairways Score 2 3 3 x Standard No 37 38 39 40 41 42 43 Score 1 x 1 2 x 1 x J04 J53 Fairways S63612 V232365 190705 Stage 4.doc Version 1.30 Page 19 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA 1 Regulation 4 and 5 Requirement The Registered Person must ensure that the home’s statement of purpose is updated to reflect that the homes lift is out of commission. The Registered Person must ensure that this document is regularly reviewed to reflect any changes to the service. (Previous timescale of 1st June 2005 not met.) The Registered Person must ensure that risk assessment and management plans are developed and that any restrictions on choice and freedoms on the part of the service user are made explicit, together with information and background history for staff in order to assist them in taking appropriate action if necessary. The Registered Person must ensure that the practice of risk assessment is developed in the home in order to protect the health and safety of service users and staff. (Previous timescale of 16th May 2005 not met.)
Fairways J04 J53 Fairways S63612 V232365 190705 Stage 4.doc Version 1.30 Page 20 Timescale for action 30th November 2005. 2. YA9 13 30th November 2005. 3. YA 22 22 4. YA 34 18 (1(a)), schedule 2. 5. YA 36 18(2) 6. YA 37 8 and 9 7. YA 39 24 8. YA24, YA 42 13 (4) The Registered Person must update the home’s complaints policy and procedure to give timescales for action and details of how to contact the local office of the Commission for Social Care Inspection. (Previous timescale of 1st June 2005 not met.) The registered person must ensure that the home strengthens its recruitment procedures and that the required information specified by regulation is obtained for staff employed in the care home. (Previous timescale of 16th May 2005 Not met) The registered person must ensure that persons working at the care home are appropriately supervised. People should be supervised six times per year and a programme to commence this must be implemented before 30th November 2005. (Previous timescale of 2nd May 2005 not met.) The manager should make application to register with the Commission for Social Care Inspection Before 30th November 2005. The registered person must ensure an effective quality assurance and qualitymonitoring system is implemented for the home and that the results of service user and associated stakeholder surveys are published and made available to interested parties including the CSCI. (Previous timescale of 1st July 2005 not met.) Fixed Wiring Electrical Safety Certificates were not available for inspection. These certificates 30th November 2005. 30th November 2005. 30th November 2005. 30th November 2005. 31st December 2005. 31st August 2005.
Page 21 Fairways J04 J53 Fairways S63612 V232365 190705 Stage 4.doc Version 1.30 must be made available to the Commission for Social Care Inspection before the 31st August 2005 to evidence that the health and safety of people is being protected. There was no fire risk assessment available for inspection. This needs to be completed in conjunction with the fire officer to ensure the home is safe and risks are managed. In particular the locks on doors which are Yale and so will default to a locked position must be reviewed to ensure people can get through them in an emergency. Fire doors must not be wedged open unless by a device approved by the fire officer which will enable the door to close in the event of a fire. The floor tiled dining area poses a risk to both staff and service users especially when wet and should be reviewed and made safe before 30th September 200s. 30th November 2005. From the day of inspection and to be maintained thereafter. 30th September 2005. 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 YA6 and YA7 YA18 Good Practice Recommendations The home needs to develop contacts with an independent advocacy service to provide people with independent scrutiny of their care needs and represent their individual wishes. People should have individual toiletries clearly identified as
J04 J53 Fairways S63612 V232365 190705 Stage 4.doc Version 1.30 Page 22 2.
Fairways 3. 4. YA 33 YA40 their own so staff do not use communal toiletries when helping people with personal care. The Registered Person should ensure that a minimum of 6 staff meetings are held annually. The Manager should review all policies and procedures in use at the home and ensure they are specific to the identified needs at Fairways and should sign and date them to evidence this review. Fairways J04 J53 Fairways S63612 V232365 190705 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection York Area Office Unit4, Triune Court Monks Cross York, YO32 9GZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Fairways J04 J53 Fairways S63612 V232365 190705 Stage 4.doc Version 1.30 Page 24 - 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!
