Inspection on 01/12/06 for Fairways, The

This inspection was carried out on 1st December 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Fairways, The 22/11/07

Fairways, The 07/02/06

Fairways, The 06/10/05

Fairways, The 02/09/04

Fairways, The 05/04/04

Fairways, The 27/10/03

Fairways, The 31/07/03

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Fairways, The 64 Ickenham Road Ruislip Middlesex HA4 7DQ Lead Inspector Ms Jean Bovell Key Unannounced Inspection 11:00 1st December 2006 X10015.doc Version 1.40 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, The DS0000044518.V308016.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 Older People. 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, The DS0000044518.V308016.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fairways, The Address 64 Ickenham Road Ruislip Middlesex HA4 7DQ 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) 01895 675885 Farrington Care Homes Ltd Mrs Julia Ann Palmer Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Fairways, The DS0000044518.V308016.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. As agreed on 27th February 2006, 12 named service users with Dementia can be accommodated within the home. This is approved for as long as there is no deterioration of a service user(s) that affects the well-being of any other person living in the home. The home must advise the CSCI when a service user(s) no longer resides at the home. 7th February 2006 Date of last inspection Brief Description of the Service: The Fairways is an established residential home. The proprietors are Farrington Care Homes Limited who own three other homes within the Ruislip/Ickenham area. The Fairways is a converted Edwardian house in Ruislip. There is good parking at the front of the home and it is easily accessed by tube, train and bus routes. Ruislip shopping centre is a short distance away. The Home is registered for 27 older people and there are currently three vacancies. The Home consists of two separate houses, the main House and the smaller Feather House. The Main House has six bedrooms on the ground floor and an assisted shower/bathroom/toilet and a separate toilet. There is a small kitchen to the rear of the House on the ground floor and small office, which the Manager uses. The ground floor also houses the day lounge that has a quite area and rear conservatory where meals are served overlooking the garden. The first floor is accessed by both stairs and lift and has nine bedrooms and a bathroom and two toilets. The second floor which can be accessed by stairs or stair-lift, has a seating area, one double bedroom, a bathroom/toilet, staff sleepover room and staff toilet. Feather House is located at the end of the garden set at the edge of the golf course. Feather House accommodates 6 service users in single rooms. One of the rooms was previously used as a double room but does not meet the National Minimum Standards size requirements and is currently being used as Fairways, The DS0000044518.V308016.R01.S.doc Version 5.2 Page 5 a single room. The six service users in this unit are more independent and prefer not to join the activities in the Main House. There are two bedrooms and a toilet on the ground floor, which also accommodates the lounge/dining area and the kitchen. The first floor has four bedrooms and a bathroom and a stair-lift has been installed to access the ground to first floors. The garden between the two houses is mostly laid to lawn with seating areas. Feather House has it’s own small garden. There is a large shed in the garden that is called the ‘1st tee’ and this is used for staff meetings and as a staff room3. The staff team consists of the Registered Manager, Assistant Manager, 3 Seniors and 27 Care Assistants. There is a Cook and an Assistant Cook, 2 full time Housekeepers, a Handyman and a Laundress. The staff team work across both Houses. Fairways, The DS0000044518.V308016.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out between 11:00am and 4:00pm on 1st December 2006. The Registered Manager, Deputy Manager, four Care Assistants and 20 service users were present. It was reported by the Registered Manager that one service user had been admitted to hospital. During the course of the inspection, the home’s records, policies, procedures and documents were viewed. A tour of the building was undertaken and observations were made. The Inspector spoke to the Deputy Manager, two Care Assistants, five service users and one visitor. The requirements that were made at the last inspection and all key Standards were examined. The Registered Manager was co-operative and provided appropriate assistance throughout the inspection. As part of this unannounced inspection the quality of information given to people about the care home was looked at. People who use services were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the service user’s guide (sometimes called a brochure or prospectus), statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk. What the service does well: Fairways, The DS0000044518.V308016.R01.S.doc Version 5.2 Page 7 The service users appeared appropriately dressed, well cared for and comfortable within their environment. Those who spoke to the Inspector expressed satisfaction with the standard of care they received at the home and were particularly happy with the quality and quantity of the meals that were being provided. The Inspector spoke to one visitor who reported positively about the health and welfare of a service user who he/she visited on a regular basis and the overall environment of the home. All service users records viewed were accurate, up-to-date and indicated that their best interests were being safeguarded. Care workers received regular appropriate training and were observed being competent and attentive in meeting the needs of the service users. Overall, the home was found to be clean, hygienic and adequately maintained. The atmosphere was calm, pleasant and homely. What has improved since the last inspection? What they could do better: Three requirements were identified at this inspection and related to fire safety issues and the service users guide. Fairways, The DS0000044518.V308016.R01.S.doc Version 5.2 Page 8 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, The DS0000044518.V308016.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fairways, The DS0000044518.V308016.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6. Quality in this outcome area is good. This judgement had been made using available evidence including a visit to this service. Copies of the service user guide have not been supplied to individual service users. Appropriate assessments of needs in relation to prospective service users are being carried out by the home. EVIDENCE: Although appropriately detailed copies of the service user guide and statement of purpose were within a policies folder that was viewed at the time of the inspection, service users that were spoken with reported that they had not received a copy of the service user guide. Copies of initial needs led assessments that were carried out by the home in relation to prospective service users were evidenced on service users files that Fairways, The DS0000044518.V308016.R01.S.doc Version 5.2 Page 11 were inspected at random. It was indicated that a representative from the home visited prospective service users in their own homes or in hospital and that relatives, social workers and medical professionals were involved in a subsequent process of assessing and determining the home’s capacity to meet specific identified needs and aspirations. Related assessments that had been submitted by placing Authorities at the point of referral were also evidenced within service users files. The Registered Manager confirmed that an intermediate care service is not provided at the home. Fairways, The DS0000044518.V308016.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement had been made using available evidence including a visit to this service. Care plans are drawn up appropriately and the health care needs of the service users are being met as required. The home’s policy and procedures on medication are satisfactory. The privacy and dignity of the service users are being upheld. EVIDENCE: All care plans that were viewed at random were appropriately drawn up. Separate personal, social and health care needs had been assessed. Action plans and set goals were put into place. It was evidenced that service users received access to General Practitioners and Physiotherapists as required and were accompanied during hospital appointments. There were regular optical and dental checks. The Chiropodist visited the home every six weeks. Fairways, The DS0000044518.V308016.R01.S.doc Version 5.2 Page 13 Risk assessments, in relation to specific activities identified within care plans such as falls and moving and handling, had been undertaken. All care plans and risk assessments viewed were reviewed on a monthly basis or following specific changes, incidents or accidents such as falls. The home’s policy and procedures relating to medication were in place and the records indicated that refresher medication training had been delivered to the care staff on 14th March 2006. Storage, disposal and administration of medication were satisfactory. The Inspector was informed by the Registered Manager that at the time of the inspection, one service user was self-administering prescribed eye drops. Care workers were observed interacting with service users in a friendly and respectful manner and knocked on bedroom doors prior to entering. Care workers who spoke to the Inspector reported that personal care tasks were carried out in privacy within bedrooms and bathrooms. Service users that were spoken with confirmed that their privacy and dignity were being respected at the home. Fairways, The DS0000044518.V308016.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above 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 and 15. Quality in this outcome area is good. This judgement had been made using available evidence including a visit to this service. Service users are able to independent, participate in activities of their choice and maintain contact with relatives and/or friends. An excellent variety of appealing and nutritional meals are being provided to the service users. Requirements under Standard 12 and 14 relating to activities and choice have been met. EVIDENCE: An Activities Co-ordinator was observed leading a game of bingo with the service users during the afternoon of the inspection. Service users also enjoyed a taped sing-along session and were seen dancing with the Activities Co-ordinator. Various service users were observed resting, reading or watching television in their bedrooms or sitting in small groups in separate lounges. Several spoke to Fairways, The DS0000044518.V308016.R01.S.doc Version 5.2 Page 15 the Inspector and strongly indicated their right to be independent and in choosing to be excluded from shared activities within the main lounge. An activities programme was on display. Birthday celebrations, monthly religious services, karaoke sessions, gardening and day trips were among activities listed. An open visiting policy is in operation at the home and the Registered Manager confirmed that contact with relatives and/or friends are encouraged and facilitated. Two visitors were seen at the home during the course of the inspection. Personal interests and choices were reflected in separate bedrooms and service users made decisions in relation to meals and activities at the time of the inspection. The Registered Manager reported that service users also received choice regarding what they wore, hairstyles, make-up, when they got up in the mornings/retired at night or whether they received meals in their bedrooms. Service users were able to go shopping or put forward ideas and organise various shared activities within the community. Varied and wholesome meals were listed on the menus and appealing and nutritional lunch choices were provided at the time of the inspection. Drinks and snacks were readily available. Service users who spoke to the Inspector expressed satisfaction with quality and quantity of food they received at the home. Fairways, The DS0000044518.V308016.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement had been made using available evidence including a visit to this service. The complaints procedure is satisfactorily detailed and service users are being protected from abuse. EVIDENCE: The complaints procedure was clear, concise and accessible to the service users and/or their relatives. The records were reflective of two complaints being made to the home following the last inspection. These were appropriately investigated and resolved. The home’s policy and procedures and the London Borough of Hillingdon Manual on the Protection of Vulnerable Adults were in place. It was indicated on records viewed that staff training on the Protection of Vulnerable Adults was delivered in May 2006. Service users’ personal allowances are being safeguarded at the home. A number of service users’ financial records were examined at random and no discrepancies were identified. Fairways, The DS0000044518.V308016.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement had been made using available evidence including a visit to this service. The home is being satisfactorily maintained and the environment is safe and homely. EVIDENCE: The communal areas within home are comfortably furnished, attractively decorated, adequately spacious and suitable for shared or individual activity. The garden was well maintained and accessible to the service users. The Inspector was informed by the Registered Manager that refurbishment and redecoration of various areas on the ground floor were in the process of being carried out. There were no issues regarding the laundry. Fairways, The DS0000044518.V308016.R01.S.doc Version 5.2 Page 18 Overall the home was found to be clean, hygienic and adequately maintained. The environment was safe, pleasant and homely. Fairways, The DS0000044518.V308016.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement had been made using available evidence including a visit to this service. Staffing levels are adequate and care workers are appropriately trained for meeting the needs of the service users. The recruitment policy and practices are satisfactory. EVIDENCE: The Registered Manager reported that seventeen care workers, three senior care staff and a Deputy Manager were employed at the home. There were also two cooks, two kitchen assistants, two housekeepers, one laundering person and a maintenance person. It was indicated on the rota that four care workers were on duty during waking hours and there were three waking staff cover at night. All required documents such as CRB disclosure certificates, application forms, references, signed contracts/statement of terms and conditions and photoidentification were within personnel files that were viewed at random. Fairways, The DS0000044518.V308016.R01.S.doc Version 5.2 Page 20 A training programme was in place and it was reflected that new staff members received induction training. Subsequent and refresher training delivered included manual handling, infection control, first aid, medication, dementia and protection of vulnerable adults. The Registered Manager confirmed that nine care staff had achieved level 2 National Vocational Qualification in care and that two care workers had recently commenced NVQ training. Care workers were observed being competent and attentive in meeting the needs of the service users. Fairways, The DS0000044518.V308016.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement had been made using available evidence including a visit to this service. The Registered Manager is suitably qualified. Self-monitoring has been carried out appropriately and the financial interests of the service users are safeguarded. The health and welfare of the service are adequately protected but fire safety checks are not being regularly undertaken at the home. Requirements under Standards 31 and 33 in relation to management and quality assurance have been complied with. Fairways, The DS0000044518.V308016.R01.S.doc Version 5.2 Page 22 EVIDENCE: The Registered Manager has had seventeen years experience in the care profession and has occupied her present position for two years. She has obtained the Registered Managers Award and is currently receiving training on the A1 Assessors Award. Open and friendly interactions were observed between service users and the Registered Manager. However, service users were also able to express feelings of dissatisfaction in relation to decisions made by the Registered Manager that affected them personally. The responses were indicative of service users being heard and their rights respected. Care workers who spoke to Inspector reported that the Registered Manager operated an open door policy and was approachable and supportive. It was evidenced on documents viewed that appropriate quality assurance exercises had been carried out and summaries compiled. These were dated April/May 2006. Individual financial records in relation to service users’ personal allowances were examined and found to be satisfactory. The records were reflective of up-to-date professional tests being carried out in relation to the fire alarm system, gas boiler/water temperature, portable appliances and legionella. However, there were no recorded indicators that regular fire safety checks or fire drills were being undertaken at the home. Fairways, The DS0000044518.V308016.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Fairways, The DS0000044518.V308016.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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 OP1 Regulation 5(2) Requirement The Registered Person must ensure that a copy of the service users guide is provided to each service user. The Registered Person must ensure that fire drills are undertaken at three monthly intervals. The Registered Person must ensure that weekly fire safety checks are carried out. Timescale for action 30/04/07 2 OP38 23(4)(e) 10/01/07 3 OP38 23(4)(v) 10/01/07 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, The DS0000044518.V308016.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection West London Area Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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, The DS0000044518.V308016.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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