Inspection on 24/08/06 for Fairways

This inspection was carried out on 24th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fairways 05/11/09

Fairways 05/11/09

Fairways 23/07/09

Fairways 21/08/07

Fairways 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 Jane Higham Unannounced Inspection 24th August 2006 10:10 Fairways DS0000058263.V300809.R02.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.V300809.R02.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.V300809.R02.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.V300809.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th September 2005 Brief Description of the Service: Fairways Residential Home is situated in a residential area of the village of Westerfield on the outskirts of the town of Ipswich. The home was first registered in April 2004 and offers care and accommodation for up to eight service users who have a learning disability coupled with challenging behaviour. Fairways is owned and administered by Care Aspirations, a specialist independent healthcare provider, established in 1986, who provide residential 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. Fairways DS0000058263.V300809.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Unannounced Key inspection of Fairways, an eight bedded residential home for adults with learning disabilities coupled with challenging behaviour, sited in a residential area of the village of Westerfield on the outskirts of Ipswich. The home is owned and administered by Care Aspirations Ltd. The inspection was carried out on 24 August 2006 over a period of six and a half hours. The key inspection focused on the care standards relating to Care Homes for Adults. This report has been used using accumulated evidence gathered prior to and during the inspection. In advance of the inspection, the home was provided with both service user and relative/visitors questionnaires for distribution. At the time of writing three relative/visitor questionnaires had been returned as had three service user questionnaires (although these had been completed on behalf of residents by family members.) Comments contained within these questionnaires have been reflected in this report. The National Minimum Standards and Care Homes Regulations 2001 are referred to throughout this report and any non compliance identified. All key standards were assessed as part of this inspection. The registered Manager and Deputy manager were unavailable for the first part of the inspection as they were undertaking an assessment visit to a prospective resident. The inspection was facilitated by a member of the care staff and latterly the registered manager on his return to the service. The Inspector had the opportunity to talk to residents, although due to cognitive impairment it was difficult to gain detailed feedback in relation to the quality of the services provided. On the day of the inspection, there were no visitors to the home. At the time of writing the fees charged for this residential service ranged from £1283 - £2607 per week. What the service does well: The service continues to provide a homely and unrestricted environment for residents who in addition to a diagnosed learning disability exhibit challenging and complex behaviours. The home ensures that residents are provided with information in a format which will aid their cognition. Care Plans are detailed in their content, person centred and place an emphasis on enabling residents to follow their preferred daily routines and chosen activities. Service users are Fairways DS0000058263.V300809.R02.S.doc Version 5.2 Page 6 offered a wide range of activities. The home endeavours to enable residents to access community health services and actively seeks clinical guidance from NHS Learning Disability Services. What has improved since the last inspection? What they could do better: Whilst staff have received training on the Protection of Vulnerable Adults there was evidence to show that the owning organisation had not carried out its responsibilities in ensuring that all reports of suspected abused are reported via the local authorities reporting procedure. On the day of the inspection, the home was left in a vulnerable position with a limited amount of staff due to staff sickness and minimal management support. The home must ensure that at all times there is a sufficient skill and competence mix of staff in sufficient numbers to ensure that the individual of complex and challenging needs of residents are met. Whilst it is appreciated that the behaviour of residents is challenging and therefore the environment faces wear and tear, the owning organisation must ensure that the building is maintained to a good standard of repair and cleanliness. Resident’s access to their own ensuite toilet facilities must not be restricted in any way. Please contact the provider for advice of actions taken in response to this Fairways DS0000058263.V300809.R02.S.doc Version 5.2 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Fairways DS0000058263.V300809.R02.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.V300809.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5 Prospective residents and their representatives can expect to be issued with adequate information on which they can base a decision as to whether they would wish to live at the home. Residents can also expect that they will receive an individual assessment, before admission takes place to ensure that their needs can be met by the home. Residents will be provided with documents in a form which aids their comprehension. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The home has a very detailed and comprehensive Statement of Purpose which provides all the information about the services provided as required by Regulation 4 of the Care Homes Regulations 2001. The home was able to evidence that it also provides residents and their representatives with a Service User Guide which is presented in a pictorial form. This document had recently been revised and the Inspector was advised that keyworkers were due to go through this document with each service user. At the time of the inspection, seven residents were being accommodated. All residents accommodated had been resident at the service for over two years. Pre-admission assessments for all residents had been examined as part of the previous inspections and the home has been able to evidence that prior to admissions taking place a detailed assessment of the individuals needs is Fairways DS0000058263.V300809.R02.S.doc Version 5.2 Page 10 carried out. On the day of the inspection, the Manager and Deputy Manager were on their way to visit a prospective service user for the purposes of carrying out a pre-admission assessment. All admissions are via the local authority and as such community care assessments are carried out by the named assessor and submitted to the service for consideration prior to any admission taking place. As part of the inspection, the Inspector selected two residents for the purposes of care tracking. In both cases, the home was able to evidence that a contract which contained information on terms and conditions had been issued. The home is commended on issuing the contract and terms and conditions in a pictorial form. Fairways DS0000058263.V300809.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Residents living at the home can expect to be provided with an individual plan of care. Residents can also expect to be supported to make decisions around their everyday lives within a framework of risk assessment. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: For the purposes of the inspection, the Inspector examined the care plans of two residents selected for the purposes of care tracking. Both care plans were detailed in their content and were very person centred. Care Plans placed a strong emphasis on ensuring that the preferred daily routines, likes, dislikes and strengths and weaknesses of individual service users are documented. Each care plan identified different areas of assessed need, the interventions and support required to ensure that these needs are met, the evaluation and progress made in relation to the goals set and the outcomes reached ie achieved or not achieved. Areas of need identified in the care plans seen ranged from personal care to self-neglect. The home was able to evidence that both care plans had been reviewed regularly and provided current information. Fairways DS0000058263.V300809.R02.S.doc Version 5.2 Page 12 Whilst in general, the communication abilities of residents is limited, care plans seen identified that they were enabled and supported to make decisions around their daily lives. Staff at the home practice “positive communication” with residents. The Inspector observed one resident handing a staff member a “token” indicating that they wished to have a drink As part of the care planning process, the Inspector was able to examine detailed risk assessments completed for both the service users selected for the purposes of care tracking. These showed that risks associated with their everyday lives within the home had been identified and clear plans set in place to minimise the risks involved. In the case of both residents, who exhibited challenging behaviour, current behaviour modification plans had been put in place. Fairways DS0000058263.V300809.R02.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Residents living at the home can expect to be offered a range of activities and access to community resources. They can also expect to be supported to maintain contact with their families and to be provided with a varied and nutritious diet. The home was unable to evidence that the rights of service users were totally protected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The home was able to evidence that it had a planned programme of activities for residents and on the day of the inspection, these included walking, swimming, cleaning the homes’ minibus, bowling, music group and arts and crafts. Activities are tailored to the individual needs and abilities of each person. The home uses local leisure facilities and learning disabilities day services such as Genesis. The Manager expressed concerns about the recent cutbacks in learning disability community services. The home has its own minibus which is used for accessing local resources or simply for taking Fairways DS0000058263.V300809.R02.S.doc Version 5.2 Page 14 residents out for a drive. One resident was due to go to Ireland for a weeks’ holiday supported by three members of care staff. The home enables residents to maintain contact with family and friends and three of the current service users make regular trips home supported by a member of staff. Residents’ key workers are encouraged to make contact with relatives on a fortnightly basis to update them on the welfare and progress of their family member. The three comment cards submitted by relatives, all confirmed that they felt they were kept informed by staff of their family member’s welfare. Individual care plans seen at the time of the inspection, evidenced that residents are supported to make choices around their life at the home and preferred daily routines, although one of the three relative comment cards returned, indicated that the respondent had a concern about the amount of time their family member spent in bed. Two of the three resident questionnaires (completed on their behalf) indicated that activities were offered at the home, although the third commented that these were never available. All residents have their own bedroom with ensuite facilities, thus ensuring maximum privacy. However it was noted that the ensuite facility in one bedroom had been fitted with a digital lock, preventing the occupant of the room from using the toilet unless supported by a member of staff. Feedback received from one relative indicated that they were dissatisfied with the way in which other residents were freely able to access their family member’s ensuite facilities. The home was able to evidence that meals are prepared from a planned menu with two options being offered for the mid-day meal. The Inspector noted that a notice on the kitchen wall requested that staff take a digital photograph of the dishes being prepared to assist residents in selecting their meal options in the future. The menu was varied in its content and evidenced that there was an intention to ensure that residents were provided with a nutritious and varied diet. A large container of fruit was stored in the kitchen and available to residents. Fairways DS0000058263.V300809.R02.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Residents living at the home can expect to be assisted with their personal care in a manner which takes account of their wishes and preferences. Residents can also expect that both their physical and emotional health needs will be monitored and that where appropriate they will be supported to access community health services. Residents were not protected by the homes procedures for the administration of medication. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Care Plans selected for the purposes of care tracking evidenced that residents preferred daily routines and preferences in relation to personal hygiene and dressing etc. were taken into account and as far as possible accommodated. Care Plans also evidenced that both the physical and emotional health needs of residents were monitored and addressed as and where required. All interventions by health professionals such as social workers, chiropodists, consultant psychiatrists and GPs were documented as part of the care planning process. As part of the inspection process, the Inspector examined the systems and procedures used for the safe storage and administration of resident Fairways DS0000058263.V300809.R02.S.doc Version 5.2 Page 16 medication. On the day of the Inspection resident medication was administered by a member of care staff who was “acting up” as a senior due to staff shortages. The member of care staff reported that they had undertaken training in the administration of medication but this was under a previous employer. Training records seen for this member of staff did not evidence that they had undertaken training in this area. On the arrival of the Inspector, the member of care staff was completing the administration of the morning medication. It was noted that the medication administration records were completed for all residents at the conclusion of the medication round, instead of after administration to each resident. However, medication administration records for the two service users selected for the purposes of care tracking were completed appropriately with no gaps in recording. Medication was administered from pre-dispensed blister packs which were stored in a fit-forpurpose medication cabinet sited in the secure office. Fairways DS0000058263.V300809.R02.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The home provides sufficient information to service users and their representatives to enable them to make a complaint or raise any concern they may have. Procedures used by the owning organisation have not ensured that residents are appropriately protected from abuse. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The home was able to evidence that it has a detailed complaints procedure which is contained within the Statement of Purpose and also the Service User Guide using a pictorial format. The home was able to evidence that it maintains a log of all complaints received. Whilst no copy of the complaints procedure is available within the building comment cards are available in a box outside the building and visitors are encouraged to provide their comments on eleven areas of the service provided. Since the previous inspection, the Commission has received no complaints in relation to this service. Two of the three relative comment cards indicated that family members were aware of the home’s complaints procedure. The home was able to evidence that all staff members receive training on the recognition and reporting of abuse and that staff are aware of both the home’s procedure on the Protection of Vulnerable Adults and that of the local authority. Since the previous inspection, the Manager of the home has completed the POVA “Training for Trainers” course. Where staff members are required to use physical interventions for the protection of residents, these are documented and provide information in Fairways DS0000058263.V300809.R02.S.doc Version 5.2 Page 18 relation to the details of the restraint, the staff members involved and the duration. The log of received complaints evidenced that since the previous inspection, several allegations of suspected abuse had been documented but had not been referred to social care services in line with the local authority Protection of Vulnerable Adults procedure. Whilst the owning organisation had been informed of these allegations, they were investigated internally and not referred via the appropriate agency. Fairways DS0000058263.V300809.R02.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 and 30 Residents living at the home can expect to be provided with accommodation which is suitable for use, homely and maintained to a good standard of decorative order. Residents can also expect to be provided with appropriate and domestic style furniture. However, residents could not necessarily expect to live in an environment which is maintained to a good standard of hygiene and cleanliness. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Fairways consists of a large single storey detached bungalow which has eight bedrooms, seven with ensuite shower and toilet facilities and one with ensuite bath and toilet facilities. In addition to the ensuite facilities the home has a communal bathroom with a “walk-in” bath, toilet and wash handbasin. In addition to the bedroom accommodation there are two lounges, a dining room, fitted kitchen and an office and laundry. The home is set in a quiet cul-de-sac and has secure spacious rear gardens with a summer house. Fairways DS0000058263.V300809.R02.S.doc Version 5.2 Page 20 As part of the inspection process, the Inspector looked at a selection of resident rooms. These varied in that some had been made to look very homely with the addition of personal items which reflected the preferences, hobbies and interests of the occupant, whilst others were somewhat bare although it is acknowledged that this is related to the complex and challenging behaviours exhibited by some service users. One bedroom had been furnished to a good standard and the occupant had bought a music centre. Another occupant had bought a billiard table, which they had put in their room. The two living rooms were appropriately furnished with settees and armchairs and a large television which had been mounted in a secure unit behind glass. Some of the sofas and armchairs in this room had sustained some damage. The main kitchen was well equipped with fridges and freezers, the temperatures of which were recorded on a daily basis. A kitchen cleaning rota was maintained and the kitchen had adequate storage space and a separate handwashing sink. During the inspection, some observations were made by the inspector in relation to the cleanliness, hygiene of the building and provision of fixtures and fittings. * An unpleasant odour was detected in the hallway of the building. * There were no curtains in the lounge or in several residents’ bedrooms * Whilst there was a hand-washing sink in the laundry room, no liquid soap had been provided. Liquid soap was also not provided in the communal bathroom and toilet. * A damp smell was detected in room 7. * An unpleasant odour was detected in room 7 * Three ensuite toilets were in a unhygienic and soiled state. * The resident accommodated in Room 8 had been provided with an unsuitable pillow. * Loud banging noises were coming from the pipe work in an ensuite toilet. * A resident was observed bringing laundry to the laundry room in an inappropriate manner. Laundry should be transferred from bedrooms to the laundry room either in a linen basket with a lid or a sealed plastic bag. * A digital lock had been fitted to the ensuite facility in Room 5. Fairways DS0000058263.V300809.R02.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Whilst residents living at the home can normally expect to be supported by competent and qualified staff, in sufficient numbers to ensure that there needs were met, this was not the case on the day of the inspection. Staff do not receive all the training they require to ensure that they are able to carry out their roles effectively. Residents could however expect to be protected by the homes recruitment procedures and that staff receive appropriate supervision. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. EVIDENCE: On the day of the inspection, the Manager and Deputy Manager were both away from the service, carrying out an assessment visit with a prospective resident. The Senior Carer who was rostered to be on duty had called in sick that morning and subsequently the home was being run by a member of care staff on an “acting up” basis. The member of staff left in charge of the home did not have any qualifications ie NVQ. The usual staffing level during the waking day is the Manager plus seven members of care staff. On the morning of the inspection, only four members of staff were on duty (inclusive of the member of staff who was “acting up” as a Senior and a member of agency staff). An additional member of agency staff arrived at the home at about 11.30 am but due to the high needs of service users and the shortage of staff, Fairways DS0000058263.V300809.R02.S.doc Version 5.2 Page 22 there was little time to provide them with an adequate breakdown of the needs of individual residents and routines of the home. It was evident that on the morning of the inspection, residents had been left in a vulnerable position with limited staffing to meet their needs and insufficient management. For the purposes of the inspection, the Inspector examined the recruitment records for two members of care staff. In both cases the home was able to evidence that it has a clear recruitment procedure which includes the gaining of two written references before any prospective staff member commences duties. Evidence was also available to confirm that an Enhanced Disclosure had been gained via the Criminal Records Bureau for both employees. The home was able to evidence that it had very formalised and detailed staff training records. The Inspector examined the training undertaken by two members of care staff. Both staff members had undertaken an induction training package and had received training on the Protection of Vulnerable Adults, Control and Restraint and Total Communication. However, the records did show that one of the staff members had not undertaken Moving and Handling training and neither had received training on Fire Safety. It was noted from the records that staff members had not received training in infection control, although the Inspector was advised that it was the intention of the organisation to enable one member of staff to qualify as a trainer in this subject. Both staff personnel records evidenced that staff receive regular one to one supervision sessions. One of the relative comment cards submitted and one of the resident questionnaires (completed on their behalf) indicated that there was some concern as to the high turnover of staff. All three resident questionnaires (completed on their behalf) indicated that residents always received the care and support they needed and that in the main staff listened to service users and acted up what they had to say. Fairways DS0000058263.V300809.R02.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Residents can expect to live in a home which is appropriately and affectively managed. They can also expect that the service will be carried out in their best interests and that feedback is actively sought from their advocates and families as to the quality of the service. Residents are provided with a safe environment in which to live. Quality is this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The home is managed by Mr. Marc Hendy who has been in post since January 2005. Mr. Hendy is registered with the Commission and is currently undertaking the Registered Manager’s Award. The home was able to evidence that a representative of the owning organisation visits the home on a monthly basis for the purposes of quality assurance in line with Regulation 26 of the Care Homes Regulations 2001. Fairways DS0000058263.V300809.R02.S.doc Version 5.2 Page 24 Whilst it is difficult for the home to hold resident meetings due to the complex and challenging behaviour of residents, an Investors in People questionnaire had recently been distributed to both purchasers of care and residents’ families. Every six months the home holds a social function to which families and advocates are invited and staff are available to discuss the welfare and progress of individual residents. In general the home provides a safe environment for both service users and staff. Evidence was available to confirm that fire alarms were tested on a weekly basis and that a fire risk assessment had been completed in relation to the building. A valid electrical certificate and portable appliance test certificate were available for inspection. It was identified during the inspection that two staff members had not received training in fire safety and one had not undertaken moving and handling training (please see comments under “Staffing”). The home was able to evidence that it had a clear and detailed risk assessment process in relation the challenging behaviour of residents. All accidents occurring in the home and involving residents had been appropriately recorded on incident recording sheets. Fairways DS0000058263.V300809.R02.S.doc Version 5.2 Page 25 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 4 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 2 25 3 26 2 27 3 28 3 29 x 30 2 STAFFING Standard No Score 31 x 32 2 33 2 34 3 35 2 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 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 2 x 3 x x 2 x Fairways DS0000058263.V300809.R02.S.doc Version 5.2 Page 26 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 YA16 Regulation 12(2)&(3) Requirement The Registered Persons must ensure that the digital lock fitted to the ensuite facility in a resident’s room is removed. The Registered Persons must ensure that staff responsible for the administration of medication have received appropriate training. The Registered Persons must ensure that Medication Administration Records are completed directly following the administration of prescribed medication to individual service users. The Registered Persons must ensure that any allegation of suspected abuse is reported in line with the local authority Protection of Vulnerable Adults Procedure. The Registered Persons must ensure that all windows located in resident bedrooms and shared spaces used by residents are fitted with blinds or curtains. The Registered Persons must ensure that the loud banging noise coming from the pipe work DS0000058263.V300809.R02.S.doc Timescale for action 04/10/06 2 YA20 13(2) 25/10/06 3 YA20 13(2) 25/08/06 4 YA23 13(6) 25/08/06 5 YA24 16(c) 25/10/06 6 YA24 23(2) (b)&(c) 18/10/06 Fairways Version 5.2 Page 27 7 YA24 23(2) (b)&(c) 16(2)(k) 8 YA30 9 YA30 23(2)(d) 10 YA30 13(3) 11 YA30 13(3) 12 YA30 13(3) 18(c)(i) 13 YA32 YA33 18(1)(a) 14 YA42 23(4)(d) 15. YA42 13(5) in an ensuite facility is located and addressed. The Registered Persons must ensure that the source of a damp smell located in Room 7 is identified and eliminated. The Registered Persons must ensure that the unpleasant odours located in the hallway of the building and in room 7 are identified and eliminated. The Registered Persons must ensure that all toilets are maintained to a satisfactory standard of cleanliness and hygiene. The Registered Persons must ensure that liquid soap is provided for the handwashing sink sited in the laundry room and also in communal bathrooms and toilets. The Registered Persons must ensure that soiled laundry is transferred from residents’ bedrooms to the laundry room, either in a cleanable linen basket with lid or a sealed plastic bag. The Registered Person must ensure that appropriate infection control procedures are in place and fully understood and practiced by staff members. The Registered Persons must ensure that at all times service users are supported by a skill and competency mix of staff in sufficient numbers to ensure that the individual needs of service users are met. The Registered Persons must ensure that all staff employed at the home receive regular training in fire safety. The Registered Persons must ensure that all staff receive accredited training in moving and handling. DS0000058263.V300809.R02.S.doc 18/10/06 04/10/06 25/08/06 04/10/06 25/08/06 18/10/06 25/08/06 04/10/06 18/10/06 Fairways Version 5.2 Page 28 This is a repeat requirement from the previous inspection dated 14 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. Refer to Standard Good Practice Recommendations Fairways DS0000058263.V300809.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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