Inspection on 04/10/06 for Fairways

This inspection was carried out on 4th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fairways 19/09/07

Fairways 03/01/06

Fairways 23/08/05

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Fairways 119 Cardigan Road Bridlington East Yorkshire YO15 3LP Lead Inspector David White Key Unannounced Inspection 4th October 2006 09:00 Fairways DS0000063612.V311794.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 DS0000063612.V311794.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 DS0000063612.V311794.R01.S.doc Version 5.2 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 Mrs Anne Hall Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Fairways DS0000063612.V311794.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd January 2006 Brief Description of the Service: Fairways is a home registered for twelve service users with a learning disability. 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 and a dedicated arts and crafts activity 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.V311794.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report follows an unannounced site visit undertaken on the 4th October 2006. This visit was carried out by one Regulation Inspector and took 8.5 hours with 6 hours preparation time. The home was able to return the requested information before this site visit. Surveys were sent out to service users, relatives and health and social care professionals and three surveys had been returned. Information was used from the Regulation Inspector’s inspection record, which detailed the history of the home and relevant information about what had been happening in the home since the previous inspection visit. The site visit comprised of an inspection of the premises. The care records of four service users were looked at which included service users assessments, care plans and medication records. Staff rotas and health and safety documentation were inspected. Time was spent talking to two service users, three members of care staff and the manager of the home. The activity in the home and the interaction between service users and staff was observed. The focus of the inspection was on a number of key standards and inspecting the case records of a number of service users to establish whether they corresponded with their experiences of life in the home. The manager of the home was available throughout the inspection and the findings were discussed at the end of the inspection. What the service does well: The home provides good standards of care to the service users whose needs were well met. The service users who were able to communicate said they were encouraged to make their own choices and this helped to maintain their independence. The home provided opportunities for service users to participate in a range of activities to enable them to be able to pursue their leisure interests. Service users could see visitors at any reasonable time enabling them to maintain relationships with their family and friends. Staff receive a range of training which equips them with a good understanding of the rights of the service users. Fairways DS0000063612.V311794.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: A thorough assessment of prospective service users must be done before admission to ensure the home is able to meet their needs. The recently admitted service user must have a care plan explaining what care they need and a risk assessment must be carried out on this service user to prevent harm to them from poor practice. Urgent action needs to be taken to ensure that a review of one service user’s care needs is undertaken within 14 days from the time of the site visit in order to protect the interests and safety of the service user and others. Also a review of the service user’s current risk assessment must immediately be undertaken in order to minimise risks to the service user and others from the behaviour. A formal letter was left at the site visit requiring the registered person to deal with these issues. Healthcare services must be provided in private areas in the home in order to maintain the privacy and dignity of the service users. Fairways DS0000063612.V311794.R01.S.doc Version 5.2 Page 7 Proper pre-employment checks must be made on all staff prior to them taking up their post so that service users are not put at risk of potential harm. Staff need updated training in health and safety, fire safety, moving and handling, infection control and food hygiene so that service users are not at risk from poor working practices and staff should have dementia training to help them in meeting the specific needs of one of the service users who has dementia. Staff meetings and formal supervision sessions need to be held on a more regular basis in order to support staff and to enable the management to be aware of issues concerning staff. Improvements are needed to aspects of the record keeping to safeguard the interests of the service users. 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.V311794.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fairways DS0000063612.V311794.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4 Quality in this outcome area was poor. This judgement had been made using available evidence including a visit to this service. The care records of the most recently admitted service user showed that the home had not carried out their own pre-admission assessment of the service user’s needs and therefore they could not ensure that they were able to meet the person’s needs. EVIDENCE: The home had admitted one service user in mid-August 2006 since the previous inspection visit. The manager said that she had carried out the preadmission assessment for this service user although there was no documentation within the service user’s care records to show this. The records showed that an initial assessment and care plan had been obtained from the placing authority which clearly detailed the specific needs of the individual and this information included risk assessments that had been carried out on the service user to promote their independence and safety. However there was no evidence that the home had carried out their own needs assessment to ensure that they were able to meet the service user’s needs. No risk assessments had been undertaken on the service user in order to safeguard their interests and the service user did not have a care plan to say how their needs would be addressed. Prospective service users and their relatives were invited to visit the home and spend time there before making any decision about moving into the home. Fairways DS0000063612.V311794.R01.S.doc Version 5.2 Page 10 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 Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to this service. Although overall the individual needs of the service users were met, improvements were needed to the way in which the home responded to service user’s changing needs in order to protect service users interests and to ensure the safety of the service users’ and other people. EVIDENCE: A number of the service users had complex needs and some had communication difficulties. However two service users’ were able to say that they felt they were “well cared for” and were encouraged to make their own decisions about their daily routines. Both service users commented that they found staff “helpful and supportive”. The care plans of four service users were looked at including those of the most recently admitted service user. Three of the care plans were informative and detailed the personal care needs of the service users and how these were to be met. However the care records of the most recently admitted service user only had limited information so that staff did not have clear guidance about the needs of this person and the actions they were to take to meet any needs Fairways DS0000063612.V311794.R01.S.doc Version 5.2 Page 11 identified. In the other three care records individual risk assessments had been carried out in relation to moving and handling, management of physical aggression and aspects of daily living to promote independence and safety. The care records included information about services provided by healthcare specialists and actions taken by them. One service user had developed dementia and had swallowing difficulties. The care records showed that a dietician was involved in the service user’s care to provide specific guidance to enable the service user’s nutritional needs to be met and the service user’s weight was regularly monitored. The service user also had regular involvement with a member of the Community Team for Learning Disability and his General Practitioner (GP) who were monitoring the service user’s health and staff had been provided with some information on dementia to support them in meeting the needs of the service user. The care records showed that the service user’s health had been deteriorating for some time, however despite this a care review of the service user’s needs had not taken place since November 2005 although a review was planned for next month. A number of service users’ could exhibit challenging behaviour and the records showed that there had been a recent incident on 30th September 2006 in which a service user had acted inappropriately towards a member of the public whilst out in the local community and this had been reported to the police. Although the police had visited the service user at the home no further action was taken at the request of the member of public. Following the incident the manager had notified the service user’s Care Manager and a member of the Community Team for Learning Disabilities had arranged to visit the service user. The care records showed that the Care Manager had advised that the service user should not leave the home without a member of staff present until a meeting had been organised to review the situation. Since that time the Care Manager had been absent from work through sickness and so at the time of the site visit on 4th October 2006 no meeting had been arranged to review the service user’s needs. The individual care records showed that the service user had exhibited inappropriate behaviours in the past and a risk assessment was in place for this, however since the recent incident the risk assessment had not been reviewed to look at ways of minimising risks from the service user’s behaviour. The manager stated that the service user was being accompanied by a member of staff when leaving the home and was currently agreeable to this, however the manager felt that due to the unpredictability of the service user’s behaviour this could change at any time. Due to the serious concerns about the service user’s and other peoples’ wellbeing and safety an immediate requirement was issued at the time of the site visit in relation to this matter. Staff spoken to were able to demonstrate a good understanding of the needs of the service users and a recently appointed member of staff felt that the care plans were “easy to follow and understand”. Fairways DS0000063612.V311794.R01.S.doc Version 5.2 Page 12 The home had managed to arrange for one of the service user’s without family to have access to an advocacy agent from Mencap and the manager commented that the service user had benefited from the advocate’s involvement. Fairways DS0000063612.V311794.R01.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, 15, 16 and 17 Quality in this outcome area was good. This judgement has been made using available information including a visit to this service. Service users were able to enjoy a lifestyle to suit their individual preferences. EVIDENCE: Some service users had difficulty in communicating their needs and wishes, however staff had attended communication training to assist them in communicating with the service users. One service user used Makaton to communicate their needs and some of the staff had undertaken Makaton training in order to enhance their communication skills with the service user. Three of the service users were capable of leaving the home without needing a staff member with them. Two service users who were able to communicate verbally did say that they enjoyed going for walks in the local areas and liked shopping. One service user was visiting the local swimming baths for aqua fit sessions at the time of the site visit and some of the service users attended the local Gateway social club. One service user said that he enjoyed going to the local church service every week and trips out in the home’s minibus and five of the service users had recently been on a holiday to Disneyland in Paris. Fairways DS0000063612.V311794.R01.S.doc Version 5.2 Page 14 There was also an activity room in the home where a weekly arts and crafts class was held. The room contained an exercise bike and some computers had been acquired for the use of the service users. Some service users preferred not to participate in activities and enjoyed watching television and it was observed that both the lounges in the home had a television. Service users were observed to be getting on well together and both service users’ spoken to were able to confirm this. Visiting arrangements were flexible and service users could see family and friends whenever they wanted and one of the service users’ had planned a holiday with their family. Service users were complimentary about the standard of the food at the home and advice and guidance had been sought from a dietician on how the service users nutritional requirements could be best met and food supplements were available. Fairways DS0000063612.V311794.R01.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 Quality in this outcome area was good. This judgement has been made using available evidence including a site visit to this service. Service users personal and healthcare needs were generally well met although the arrangements for providing one aspect of healthcare needed to be reviewed in order to ensure that the privacy and dignity of the service users was maintained. EVIDENCE: Service users who were able to communicate said that they felt they were supported well by the staff team who were “helpful and kind”. The care records of the service users described what level of support was needed to meet their needs and to ensure their safety. Staff said that they felt the care standards in the home were good and they had a good understanding of the rights of the service users. Each service user was registered with a GP and specialist health professionals were accessed for specific needs. Service users were supported and assisted by staff when attending dental, optician and hospital appointments and one service user received visits from a physiotherapy to the home. At the time of the site visit a chiropodist was visiting the home and was observed to be attending to service user’s foot care in the lounge of the home where a number of service users were sat. This was discussed with the manager who will be reviewing these arrangements in order to promote more privacy and dignity for Fairways DS0000063612.V311794.R01.S.doc Version 5.2 Page 16 the service users. A survey received from a health professional indicated that the care at the home was good and that the home was “welcoming”. All the service users required assistance with the taking of medication and the medication systems and arrangements were found to be satisfactory overall although in one instance for one particular type of medication, whilst the correct dosage of medication was being administered the Medication Administration Record had not been signed in the right place. Medications were safely stored and staff responsible for administering medications had received some training. A member of the care staff carried out weekly audits of the medication records and procedures. Fairways DS0000063612.V311794.R01.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 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Clear complaints and adult protection policies were in place and understood by staff to safeguard service users from abuse. EVIDENCE: The home had a complaints procedure that was on display in the home and had been updated to include information about the timescales for the completion of complaints and contact details of other agencies where concerns may be raised. Whilst the service users might not use the formal procedure due to the complexity of their needs service users did say they would raise concerns with the manager of the home. Service users were observed to have good relationships with the staff and staff indicated that they would not hesitate in immediately raising any concerns on behalf of the service users and were aware of the home’s complaints procedure. The home had an adult protection policy and procedure and all the staff had received abuse awareness training and this was also included as part of the NVQ training programme which the majority of the staff had either completed or were doing. Staff were clear about their roles and responsibilities in relation to protecting the service users’ from abuse and knew who they would need to report any concerns to. Fairways DS0000063612.V311794.R01.S.doc Version 5.2 Page 18 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 and 30 Quality in this outcome area was good. This judgement has been made using available evidence including a site visit. Service users live in a comfortable and homely environment. EVIDENCE: On the day of the site visit the home was warm and bright and free from offensive odours. The home had an ongoing refurbishment programme to try to keep up to the maintenance of the environment and there was a new settee in one of the lounge areas that promoted the comfort of the home for the service users. The bedrooms were located on two floors which could be accessed by a passenger lift, however there was no ramped access to and from the home and so this meant the home was unsuitable for people with mobility difficulties. Bedrooms and communal areas were clean and tidy and both service users spoken to said that they were pleased with their bedrooms that were observed to be personalised. Service users looked comfortable and could sit in lounge areas if they chose to do so and there was also a patio area in the garden where service users could sit. A survey had been returned in which a relative had described the atmosphere in the environment as “homely and loving”. Fairways DS0000063612.V311794.R01.S.doc Version 5.2 Page 19 At the previous inspection visit a requirement had been made about the lounge fire doors being wedged open and since that time some automatic door closures had been fitted to both lounge doors so that service users could have the doors open as they liked, however in the event of the alarm being activated the fire doors would automatically close. The home had also carried out a fire safety risk assessment on the premises to safeguard service users from the risk of fire. There were systems in place to monitor and test the hot water temperatures and a random check of the hot water from a shower area was found to be within safe limits. At the time of the site visit an electrician was carrying out some ongoing work to fully re-wire the home and this was being completed in phased stages so that the daily routines of the service users were not affected. The home had a separate utility room where laundry was attended to and chemical agents were stored securely. The home had an infection control policy, however a number of the staff were in need of updated infection control training. Fairways DS0000063612.V311794.R01.S.doc Version 5.2 Page 20 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, 34, 35 and 36 Quality in this outcome area was adequate. This judgement has been made using available evidence including a site visit. Staffing levels ensured that service users needs could be met, however improvements were needed in recruitment practices and some areas of staff training to ensure that service users were not put at risk. EVIDENCE: The duty rotas showed that up until 4pm there were usually six members of staff on duty, and following that there were three members of staff on duty until 10pm. At night there was one waking member of night staff and another staff member sleeping in on the premises. Staff could be seen supporting the service users in an unhurried manner and there was good banter between the service users and the staff. Staff commented that the home “was a good place to work” and said that they particularly enjoyed working with the service user group. Some of the staff had attained NVQ level 2 or above and others were doing the NVQ training. A range of training had been provided to staff and this included training specific to the needs of people with a learning disability and guidance on how to manage challenging behaviours. However staff had not attended recent training in health and safety, fire safety, moving and handling, food hygiene and infection control and it was recommended that staff should have some dementia training Fairways DS0000063612.V311794.R01.S.doc Version 5.2 Page 21 to equip them better in understanding and meeting the specific needs of one of the service user’s. Three staff files were looked at including those of the most recently employed members of staff. In one file there was only a record of the Criminal Record Bureau (CRB) check from a new member of staff’s previous employment and this practice could not ensure that service users were protected from harm. The home had supervision systems in place but staff supervision was not taking place on a regular basis and staff were able to confirm this. Fairways DS0000063612.V311794.R01.S.doc Version 5.2 Page 22 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, 41 and 42 Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to this service. Improvements were needed in the management of the home to make sure that the home was run in the best interests of service users so that their needs were met and their safety protected. EVIDENCE: Since the previous inspection visit the manager had been successful in her application to register with the Commission. The manager had recently completed NVQ level 4 to enhance her management skills and was nearing completion of the Registered Manager’s Award. Three senior care officers in providing leadership at the home supported the manager. Service users and staff commented that the manager was “approachable and supportive”. The home had systems in place to seek the views of service users and relatives about the care and services provided. Service users where possible and relatives were given questionnaires in order to seek their views. Records of the findings from these questionnaires were seen and generally provided positive Fairways DS0000063612.V311794.R01.S.doc Version 5.2 Page 23 feedback about the care and services at the home. The manager had produced a business plan outlining improvement plans for coming year. However staff said that staff meetings were not held on a regular basis and this together with the lack of consistent staff supervision arrangements did not ensure that staff were involved in the running of the home and that management were aware of issues concerning the staff. Appropriate arrangements had been made to keep records secure however some aspects of record keeping were in need of improvement. The records showed that a serious incident had occurred involving a service user but this had not been reported to the Commission and a risk assessment had not been updated following the serious incident to promote the service user’s and others interests and safety. The home had not carried out their own assessment of a service user’s needs before admitting them into the home and so could not be sure that they were able to meet the person’s needs and there was no care plan in place for this service user to say what care was needed. Although the manager had addressed all but one of the requirements from the previous inspection visit in a satisfactory manner some concerns existed about some aspects of health and safety. A number of health and safety certificates were looked at and were satisfactory although the home had still not obtained a fixed electrical wiring certificate. However the home was in the process of being fully re-wired and it was expected that the work would be completed by the end of October 2006 when a certificate would be provided to confirm that the electrical wiring in the home was safe. A fire risk assessment had been completed for the premises and the fire equipment had been recently checked and automatic door closures had been fitted to the lounge doors so that they were no longer wedged open. Hot water temperatures were regularly monitored to prevent risks to service users from scalding. However staff were in need of updated training in a range of safe working practices. Fairways DS0000063612.V311794.R01.S.doc Version 5.2 Page 24 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 X 3 1 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 1 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 3 3 X 2 X 2 X 2 1 X Fairways DS0000063612.V311794.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 YA3 Regulation 14 Requirement Timescale for action 04/11/06 2. YA6 12, 14 The registered person must undertake pre-admission assessments on all prospective service users in order to ensure that the home is able to meet the service user’s needs. 06/10/06 • The registered person must make immediate arrangements for an urgent review of the care needs of the service user who had recently behaved inappropriately towards a member of the public whilst in the local community. • A review of the service user’s current risk assessment must immediately be undertaken in order to minimise risks to the service user and others from the behaviour. An immediate requirement was issued. 3. YA6 15 • The registered person must have a care plan in place for the most recently 04/11/06 Fairways DS0000063612.V311794.R01.S.doc Version 5.2 Page 26 4. YA18 12 5. YA34 19 6. YA35 18 7. YA37 13 8. 9. YA41 13 13 YA42 admitted service user including up to date risk assessments to ensure that staff are clear about the service user’s needs and the actions they are to take to meet these needs • Care plans must be reviewed on a regular basis to address changing needs so that appropriate actions can be taken to meet service users’ needs. The registered person must make arrangements so that chiropody services are provided in areas of the home that offer service users privacy. The registered person must ensure that all the necessary pre-employment checks have been carried out and the required records are in place prior to the employment of new staff. The registered person must make arrangements for all staff to attend up to date training in health and safety, fire safety, moving and handling, food hygiene and infection control. The registered person must notify the Commission of occurrences in the home in accordance with Regulation 37 of the Care Homes Regulations 2001 and recent guidance issued by the Commission. The registered person must make arrangements to improve record keeping at the home. A fixed wire electrical safety certificate must be obtained and a copy forwarded to the Commission for Social Care Inspection (previous timescale of 15/01/06 not met). 04/11/06 04/11/06 04/12/06 04/10/06 04/11/06 30/11/06 Fairways DS0000063612.V311794.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA35 YA36 YA39 Good Practice Recommendations Staff should have dementia training to equip them with additional knowledge and skills in meeting the needs of one of the service users who has dementia. All staff should receive more regular formal supervision in order to support staff in meeting service users needs and so that management are aware of any staffing issues. Staff meetings should be held on a more regular basis to encourage staff to voice their views and opinions about the home. Fairways DS0000063612.V311794.R01.S.doc Version 5.2 Page 28 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. 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