CARE HOME ADULTS 18-65
Fairways 119 Cardigan Road Bridlington East Yorkshire YO15 3LP Lead Inspector
Brian Hallgate Unannounced Inspection 3rd January 2005 1:30 Fairways DS0000063612.V256539.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Fairways DS0000063612.V256539.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Fairways DS0000063612.V256539.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Fairways Address 119 Cardigan Road Bridlington East Yorkshire YO15 3LP 01262 676804 01262 676804 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Franklin Homes Limited *** Post Vacant *** Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Fairways DS0000063612.V256539.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 23rd August 2005 Brief Description of the Service: Fairways is a home registered for twelve service users with a learning disability who present as a challenge to the service. It is situated on the outskirts of Bridlington and the accommodation is contained within one large house. The accommodation in the home is on two floors, and residents’ bedrooms are on both floors. There are two lounge areas on the ground floor, one of which also serves as a dining room. Service users have access to the home’s garden. The home has a minibus to enable service users to access the local community and take part in outings. Fairways DS0000063612.V256539.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was an unannounced inspection and took place over three and a half hours, including preparation time. A tour of the building was made with the manager of the home and a number of records were inspected. One service user and three members of staff were spoken to. The staff were observed interacting with other service users. Key standards not inspected on this occasion were inspected on the previous inspection held on the 23rd August 2005. What the service does well: What has improved since the last inspection?
The statement of purpose has been updated. Risk assessments on service users have been completed to enable staff to take appropriate action as necessary. The recruitment process has been improved and ensures that two written references and a Criminal Record check are completed before staff are employed. A quality monitoring system has been commenced with questionnaires given to those service users who are able to participate and to relatives. The floor in the dining area has been improved. Fairways DS0000063612.V256539.R01.S.doc Version 5.0 Page 6 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. Fairways DS0000063612.V256539.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fairways DS0000063612.V256539.R01.S.doc Version 5.0 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 the following standard(s): 1 The homes Statement of Purpose has been updated to reflect the need for the majority of service users to be able to negotiate stairs. EVIDENCE: The statement of purpose has been updated to show that the lift is not operational and people with mobility problems may not be able to be admitted to the home if the bedrooms available are on the first floor. There are four single bedrooms at ground floor level but the other eight bedrooms are on the first floor accessed by stairs. Fairways DS0000063612.V256539.R01.S.doc Version 5.0 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 the following standard(s): 6, 7 and 9 There is a planning system in place to provide staff with the information needed to care for the service uses. A number of service users may benefit from contact with an independent advocate. EVIDENCE: Three service users are able to participate in their own reviews and provide input into the care planning process. Eight service users are unable to participate in decisions about their lives due to their complex needs and lack of verbal skills, although they all attend their reviews. Four service users have regular contact with their relatives and one service user told me how she enjoyed going home and staying with her mother. A recommendation at the previous review was for staff to approach an advocacy agency to provide independent contact for those service users without family contact. This has not taken place. Risk assessments are completed on aspects of their lives. Three service users are able to go out of the home independently following risk assessments. Fairways DS0000063612.V256539.R01.S.doc Version 5.0 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 the following standard(s): None EVIDENCE: Fairways DS0000063612.V256539.R01.S.doc Version 5.0 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 the following standard(s): 18 Service users now have their own toiletries and no longer use communal toiletries. EVIDENCE: Service users now have their own toiletries as a result of a recommendation at the previous inspection. These are clearly identified to ensure staff use the correct toiletries when assisting any service user with personal care tasks. Fairways DS0000063612.V256539.R01.S.doc Version 5.0 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 the following standard(s): 22 The complaints procedure needs updating. EVIDENCE: The complaints procedure needs updating to give time scales for the investigation of complaints and the address and telephone number of the Commission for Social Care Inspection. This was a requirement of the previous inspection that has not been complied with Fairways DS0000063612.V256539.R01.S.doc Version 5.0 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 the following standard(s): 24 The standard of care within the home is good providing service users with a homely place in which to live. Some lounge furniture needs replacing. EVIDENCE: The home has two large lounges, one of which is also used as a dining room, a large kitchen and single bedrooms for each service user. The home is clean and hygienic and provides good accommodation for the needs of the service users. There is a large garden to the rear of the property that service users use when they wish. The seating in one of the lounges needs replacing. Throws had been purchased to put over two settees that were in need of replacement. Fairways DS0000063612.V256539.R01.S.doc Version 5.0 Page 14 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): 33, 34, 35 and 36 The service users receive a good standard of care from the well-prepared and motivated staff. EVIDENCE: All staff spoken to were committed to providing good quality care to the service users. The duty rota showed that there were sufficient staff on duty to meet the needs of the service users. The rota showed six staff on duty in a morning, three in an evening and one waking night staff with one member of staff sleeping in on the premises. The latest member of staffs personnel file was inspected. It showed that the recruitment procedure was effective and protected the service users. Three members of staff have obtained an NVQ Level 2 in care or above and three members of staff are undertaking NVQ Level 3 in care at the present time. Other training undertaken includes risk management, induction and foundation training, anti-oppressive behaviour, abuse awareness, food hygiene, medication management, epilepsy, challenging behaviour and communication. Staff meetings are held on a monthly basis and minutes of the meetings are recorded. There is no formal supervision of staff at the present time. Fairways DS0000063612.V256539.R01.S.doc Version 5.0 Page 15 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, 40 and 42 The management of this home is satisfactory overall but there are outstanding health and safety issues that need resolving. EVIDENCE: There is no registered manager of the home at the present time. The manager stated that she had completed an application form in December 2005 to become the registered manager and had forwarded it to her line manager. Questionnaires had been designed and sent to those service users who could respond and to parents to provide a quality monitoring system. The results of this survey have not yet been published. In addition to the manager of the home there are three senior care officers on a rota to supervise the work of the staff. The senior staff work alongside the care officers and observe their practice. A number of outstanding health and safety issues gives cause for concern as they were clearly identified at previous inspections and no action has been taken to resolve them. The fixed wiring electrical safety certificate must be obtained and a copy forwarded to the Commission for Social Care Inspection. A fire risk assessment on the building must be undertaken and a
Fairways DS0000063612.V256539.R01.S.doc Version 5.0 Page 16 copy of this forwarded to the Commission for Social Care Inspection. The fire doors must not be wedged open unless by a device approved by the Chief Fire and Rescue Officer. Fairways DS0000063612.V256539.R01.S.doc Version 5.0 Page 17 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 3 x x x X Standard No 22 23 Score 1 x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 x 3 x Standard No 24 25 26 27 28 29 30
STAFFING Score 2 x x x x x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x x 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Fairways Score 3 x x x Standard No 37 38 39 40 41 42 43 Score 1 x 3 3 x 1 x DS0000063612.V256539.R01.S.doc Version 5.0 Page 18 YES Are there any outstanding requirements from the last inspection? Fairways DS0000063612.V256539.R01.S.doc Version 5.0 Page 19 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 YA22 Regulation 22 Requirement The registered person must update the home’s complaints policy to give timescales for action and details of how to contact the local office of the Commission for Social Care Inspection (Previous timescales of 1st June 2005 and 30th November 2005 not met) The manager should make application to register with the Commission for Social Care Inspection before the 31st January 2006 (Previous timescale of 30th November 2005 not met) A fixed wire electrical safety certificate must be obtained and a copy forwarded to the Commission for Social Care Inspection (Previous timescale of 31 August 2005 nor met.) A fire risk assessment for the premises must be completed to ensure that the home is safe and that risks are managed (Previous timescale of 30 November 2005 not met) Fire doors must not be wedged open unless by a devise approved by the Chief Fire and Rescue Officer that will enable the door to close in the event of a fire (Previous timescale of 23 August 2005 not met)
DS0000063612.V256539.R01.S.doc Timescale for action 15/01/06 2 YA37 8 31/01/06 3 YA42 13 15/01/06 4 YA42 13 31/01/06 5 YA42 13 03/01/06 Fairways Version 5.0 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA36 YA6 Good Practice Recommendations All staff should receive formal supervision at least six times each year and a record kept of the supervision sessions. The registered person needs to develop contact with an independent advocacy service to provide people, without contact with relatives, independent scrutiny of their care needs and to represent the wishes of the individuals. Fairways DS0000063612.V256539.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection York Area Office Unit 4 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 DS0000063612.V256539.R01.S.doc Version 5.0 Page 22 - 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!
