Inspection on 22/11/07 for Fairways, The

This inspection was carried out on 22nd November 2007.

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 01/12/06

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 22nd November 2007 12:20 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.V346053.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.V346053.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.V346053.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. As agreed on the 4th September 2006, one named service user, under the age of 65 years can be accommodated. The CSCI must be informed when this service user no longer resides at the home. 1st December 2006 2. 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 but there were 17 residents including one person on respite care at the time of the inspection. The Home consists of two separate houses, the main House and the smaller Feather House. However, Feather House was closed temporarily on the 30th August and the unit’s four residents were transferred into the main building. The Main House has six bedrooms on the ground floor. A lounge with a quiet area and a rear conservatory/dining area. An assisted shower/bathroom/toilet and a separate toilet. There is a small kitchen to the rear of the house and small office. There is a seating area, one double bedroom, a bathroom/toilet, staff sleep-in room and staff toilet on the first floor which can be accessed via stairs, stair-lift or passenger lift. Feather House is located at the end of the garden. There are six single bedrooms, a lounge/diner area, kitchen, en suite bathroom/toilet and separate toilet. Fairways, The DS0000044518.V346053.R01.S.doc Version 5.2 Page 5 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. Fees for the home are £526 per week for a single room and £505 per week for a double room. Fairways, The DS0000044518.V346053.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 12:20 and 5:00pm on 22nd November 2007. The Registered Manager, three care staff and seventeen residents were at the home. During the course of the inspection, the home’s records, documents, policies and procedures were viewed. A tour of the building was undertaken and observations were made. Discussions were held with three care staff members including one Senior. Seven residents were spoken with. The requirements that were made at the last inspection and all key Standards were examined. The Annual Quality Assurance Assessment Part 1: Self Assessment completed by the home, and CSCI service user and staff surveys were considered. The Registered Manager was co-operative and provided appropriate assistance throughout the inspection. What the service does well: The needs of prospective residents are fully assessed prior to admission and separate cultural and religious needs are being met at the home. Personal records were up-to-date and clearly detailed. In particular, care plans were being appropriately drawn up and regularly reviewed. Health and safety checks were satisfactory and reflective of the health, safety and welfare of residents being protected. Care staff members are qualified and receive regular training for meeting the needs of residents. This was confirmed in CSCI surveys that were completed and returned by care staff. People were attractively dressed, well groomed and appeared comfortable and content. Those who were spoken with reported being well treated and added that care staff were ‘kind’ and the quantity and quality of food provided was ‘good’. The majority of people who responded to CSCI surveys indicated overall satisfaction with the standard of care they received. The home was found to be clean, tidy and well maintained. The environment was safe, pleasant and homely. Fairways, The DS0000044518.V346053.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Fairways, The DS0000044518.V346053.R01.S.doc Version 5.2 Page 8 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.V346053.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users’ guide was in place and appropriately detailed. The needs of prospective residents are being appropriately assessed prior to admission. EVIDENCE: The service users guide had been updated and the Registered Manager confirmed that copies had been distributed to residents. The personal files of people who use the service were examined at random. It was evidenced that ‘pre-admission’ assessments based on the home’s ‘Admissions checklist’ were carried out in relation to prospective residents. Fairways, The DS0000044518.V346053.R01.S.doc Version 5.2 Page 10 Social Workers, relevant health care professionals, relatives and prospective residents participated in the process of identifying and determining the suitability of the home in meeting separate personal, healthcare, social and dietary needs. Confirmation that separate assessed needs would be met at the home was included within contracts/statement of terms and conditions. The home does not provide intermediate care. Fairways, The DS0000044518.V346053.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual care plans are being appropriately drawn up and regularly reviewed. Separate healthcare needs are identified within care plans and are being met satisfactorily. Policies and procedures regarding medication are in place. People’s privacy and dignity are being respected. EVIDENCE: The changing personal, healthcare and social needs of residents were reflected within individual care plans and action plans and set goals were put in place. Risk assessments regarding specific activities such as moving and handling had also been undertaken. Fairways, The DS0000044518.V346053.R01.S.doc Version 5.2 Page 12 Care plans and risk assessments were reviewed on a monthly basis or following significant changes. The healthcare needs of residents were identified within care plans. It was indicated that people received access to healthcare professionals as required and were accompanied to medical appointments. Weight and continence charts were in place. The Registered Manager confirmed that none of the residents were being treated for pressure sores at the time of the inspection. Prescribed medication was being administered to all residents. The storage, disposal and administration of medicines were satisfactory. The records indicated that staff training on medication had been delivered. The home’s policy and procedures regarding medication were in place and comprehensive. Care staff members were observed interacting in a respectful manner with people and knocked on bedroom doors prior to entering. Residents that were spoken with confirmed that their privacy and dignity were respected at the home. Fairways, The DS0000044518.V346053.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Separate cultural and religious needs are been met appropriately. Contact with relatives and/or friends are being maintained. People receive choice in relation to their daily living routines but the home should ensure that everyone is happy with being prepared for bed at a set time each day. Wholesome and nutritional meals are being provided. EVIDENCE: People’s religious, social and cultural needs are identified within their separate care plans. It was indicated that residents were able to receive Holy Communion on a regular basis. The Registered Manager confirmed that a Fairways, The DS0000044518.V346053.R01.S.doc Version 5.2 Page 14 Church of England Service was held at the home on the last Friday in each month. Daily activities include bingo, quizzes, manicures and holistic massages. There are regular visits from a representative from Age Concern. A hairdresser calls each week and karaoke sessions are held fortnightly. The Registered Manager reported that a Christmas party and show had been arranged. People were observed singing along and/or dancing to music in the main lounge at the time of the inspection. The Inspector was informed by a resident of a day trip to Brighton that occurred during the summer. An open visiting policy is in place. Contact between residents and their respective relatives and/or friends are encouraged and facilitated and can occur in people’s bedrooms or communal areas. The Inspector was informed by the Registered Manager that people received choice regarding activities, meals, clothing/hairstyles/make up and in relation to times of retiring at night and getting out of bed on mornings. Residents meeting were also held. Residents were observed resting in bedrooms or being with others in separate communal areas. Individual choices and interests were also reflected in personalised bedrooms. Although people were able to choose times for retiring at night, it was reported that they were routinely made ready for bed at approximately 4:30 pm and prior to tea being served. It was also revealed that residents received less than a week’s written notice prior to being transferred from Feather House to the main building. These issues were discussed with the Registered Manager. The Inspector was advised that discussions were held with people regarding the proposed closure of Feather House in advance of letters being sent out and that residents were able to exercise choice in relation to being undressed for bed. A professional cook is employed at the home and menus are reflective of varied and nutritional meal options being provided. The Registered Manager confirmed and specific cultural choices were also available and that people were able to have meals delivered to their individual bedrooms. Residents that were spoken with expressed overall satisfaction with the quality and quantity of food they received. Fairways, The DS0000044518.V346053.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure is in place and satisfactory. Residents are being protected from abuse. EVIDENCE: The complaints procedure is clearly detailed and accessible to residents, relatives, friends and/or advocates. People who replied to CSCI surveys indicated knowledge about how to make a complaint. Incidents and accidents were being accurately recorded and related reassessments of risk were reflected within care plans. Policies and procedures on the protection of vulnerable adults were in place and the records were indicative of staff training on POVA being delivered. Personal allowances were held in safekeeping by care staff on behalf of residents. No discrepancies were identified in relation to recorded incoming/outgoing expenditure. Fairways, The DS0000044518.V346053.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being well maintained and the environment is pleasant and homely. EVIDENCE: The communal areas at the home are appropriately furnished, spacious and appropriate for shared and/or individual activity. The rear garden was adequately maintained and accessible to residents. There were no issues regarding the laundry. Fairways, The DS0000044518.V346053.R01.S.doc Version 5.2 Page 17 Overall, the home was found to be bright, airy, clean, hygienic and well maintained. The environment was safe, calm and homely. Fairways, The DS0000044518.V346053.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels at the home are adequate and care staff members are suitably trained and qualified for meeting the needs of residents. The policy and procedures on recruitment are satisfactory. EVIDENCE: The Inspector was informed by the Registered Manager that ten care staff are employed at the home and that ancillary workers include one full-time and one part-time cook, a part-time kitchen assistant, two part-time house-keepers and a maintenance person. The rota indicated that three care staff covered duty on both morning and evening shifts and two care staff were on duty in the afternoon. Two waking staff covered duty at night. Staff recruitment files were inspected at random and contained all required documents. Fairways, The DS0000044518.V346053.R01.S.doc Version 5.2 Page 19 Individual training records were viewed. It was reflected that new staff received induction training. It was indicated also, that staff training delivered during 2006/07 included Protection of Vulnerable Adults, Dementia Care Awareness, Administration of Medication and Moving and Handling. Five care staff members had achieved Level 2 NVQ in Health and Social Care and three were receiving NVQ training at the time of the inspection. Staffing levels at the time of the inspection were adequate and care staff members were observed being competent in meeting the practical needs of residents. The rota was reflective of additional staff being on duty during morning and evening peak periods but care staff reported feeling ‘rushed’ due to high demands for personal care and required practical tasks such as laundry, preparing/serving breakfast, supper and teas. It was indicated on CSCI surveys that care staff were not being fairly remunerated and that numbers had been reduced. Specifically, staffing levels were not always appropriate for meeting the individual needs of residents. Staffing levels were adequate at the time of the inspection and care staff members were observed being competent in meeting the practical needs of residents. However, no meaningful interactions between care staff and residents were observed. Fairways, The DS0000044518.V346053.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager is appropriately qualified and experienced. Quality assurance has been satisfactorily undertaken. The health, safety and welfare of residents are being protected. Fairways, The DS0000044518.V346053.R01.S.doc Version 5.2 Page 21 EVIDENCE: The Registered Manager has been in post since 1991 and has obtained the Registered Managers Award. Separate discussions were held with three members of the care staff team. The Registered Manager was unanimously described as being approachable and supportive. She was observed interacting in a friendly manner with staff as well as residents. A copy of the published quality assurance undertaken by the home during 2007 was submitted to the CSCI. The home does not hold overall financial responsibility for any of its residents. All health and safety records viewed were up-to-date. These included checks for fire safety, water temperature, portable appliances and gas maintenance. Tests for Legionnaires were undertaken in June 2007. Fire drills were regularly carried out and clearly detailed. Environmental risk assessments were in place. Staff training on Food Hygiene and Infection Control had been delivered. Fairways, The DS0000044518.V346053.R01.S.doc Version 5.2 Page 22 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 3 X 3 X X N/A 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 2 15 3 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 2 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 3 Fairways, The DS0000044518.V346053.R01.S.doc Version 5.2 Page 23 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 OP14 Regulation 12(2) Requirement The Registered Person must make sure that people are able exercise choice regarding when they are made ready for bed to ensure that they maintain control over their lives. The Registered Person must ensure that staffing levels are appropriate to ensure that the individual needs of residents are being met satisfactorily. Timescale for action 20/12/07 2. OP27 18(1)(a) 30/12/07 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.V346053.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V346053.R01.S.doc Version 5.2 Page 25 - 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. 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