Inspection on 06/10/05 for Fairways, The

This inspection was carried out on 6th October 2005.

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 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 01/12/06

Fairways, The 07/02/06

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 Pauline Griffin Unannounced Inspection 10:30 6 October 2005 th 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.V251821.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V251821.R01.S.doc Version 5.0 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.V251821.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd September 2004 Brief Description of the Service: The Fairways is an established residential home. The proprietors are Farrington Care Homes Limited who own three other establishments in the area. The Fairways is a converted Edwardian house, which is situated on a road linking Ickenham and 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 two 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 toilet. The second floor can only be accessed by stairs or a stair lift. On the second floor there is a seating area and one double bedroom, a bathroom/toilet, staff sleepover room and staff toilet. All bedrooms in the home have a pedestal sink. 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 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 which serves both Houses. The first floor has four bedrooms and a bathroom and a stairlift has been installed to access the ground to first floors. Fairways, The DS0000044518.V251821.R01.S.doc Version 5.0 Page 5 service users on both floors. The garden between the two houses is mostly laid to lawn with two gazebos and seating areas. Feather House has it’s own small garden which is adjacent to the golf course. Staff have a large shed in the garden that is called the ‘1st tee’’ ‘ and this is used for staff meetings and as a staff room. The staff team consists of the Registered Manager, Assistant Manager, 3 Senior Careworkers and about 27 Careworkers (who work various hours on a rota). There is a Cook and an Assistant Cook and a Laundress. The staff team work across both Houses. Fairways, The DS0000044518.V251821.R01.S.doc Version 5.0 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and was carried out over the course of one day for a total of 6 ½ hours. The Inspector spoke to three Staff members including the Cook and Registered Manager. A Service User’s representative was interviewed and four Service Users. Two Service Users’ files and one Staff file were chosen at random for examination. The records and logs that were examined were found to be in satisfactory order. The home is well managed and the Service Users are well cared for. The Staff work well as a team. Many of the Service Users in the main building were too confused to converse with and the emphasis of the inspection was to assess the type of referrals being accepted in the home and whether these were within the home’s registration. What the service does well: The service provides good care to the Service Users who are clean, well groomed and neatly dressed. The personal care and health related care provided by the home was very good. The food menu is designed to appeal to the Service User group and comprises traditional food that is well balanced and healthy. There are two choices of main meal at lunch time and a three course supper with a hot choice. The home is clean and the bedrooms are comfortable and tidy. Fairways, The DS0000044518.V251821.R01.S.doc Version 5.0 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. Fairways, The DS0000044518.V251821.R01.S.doc Version 5.0 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.V251821.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,5 & 6. New Service Users must only be admitted on the basis of a full assessment with a summary of the Care Management from Health and/or Social Services. Assessments must include the home’s ability to meet needs and take into account the needs of existing Service Users to ensure their needs are not compromised. EVIDENCE: Two files of newly admitted Service Users were examined and both included reference to confusion being present. The Registered Manager said that professionals referred people to the home and were sometimes not providing all the information to enable an informed assessment to be made. The Registered Manager said that more caution would be taken when accepting emergency respite referrals and the needs of the existing Service Users would Fairways, The DS0000044518.V251821.R01.S.doc Version 5.0 Page 10 be considered to ensure their needs were considered and that specialist needs could be catered for by the home. Fairways, The DS0000044518.V251821.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7&9 Service User’s health, personal and social care needs are detailed and reviewed in comprehensive care plans. None of the Service Users manage their own medication. The home’s medication policy, Staff training, recording and administrative systems are satisfactory and provide protection for Service Users. EVIDENCE: Care Plans are detailed, comprehensive and reviewed regularly. The administration of medication in the home is carried out satisfactorily and records were well maintained. Only Staff who have been trained can administer medication and medication rounds are carried out by two staff. The home uses Boots Pharmacy controlled dosage system in individual blister packets. A Boots Pharmacist calls every 3 months to ensure the Boots system is being maintained to their satisfaction. Fairways, The DS0000044518.V251821.R01.S.doc Version 5.0 Page 12 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 & 15. The home puts no restriction on visiting times within core times and Service Users are free to leave the home for shopping, excursions or social occasions as they wish. The food offered by the home is very good. The menus are well balanced with plenty of choice. EVIDENCE: The home encourages visits by the Service Users family and representatives. One visitor was interviewed and she/he spoke positively about the home and the service provided to the person she was visiting. Although the home has entertainers who visit at regular intervals, there is no programme of daily of weekly activities designed to stimulate minds and bodies. The Registered Manager said that it was possible to identify a set time of the day for exercises, games and quizzes and produce a programme for Service Users who wanted them. One Service User spoken to missed the bingo sessions that a volunteer used to hold until having to give up recently. Fairways, The DS0000044518.V251821.R01.S.doc Version 5.0 Page 13 The cook and kitchen was visited on this inspection. The food choice for the luncheon was sampled and was tasty and well cooked. No packet sauces are used and the cook prides herself on offering a selection of home made cakes Two meat choices are offered for the main meal at lunch time and these were minced beef or chicken casserole with creamed potatoes, carrots and green beans on the day of the inspection. The sweet choice was home made treacle sponge or pineapple chunks and custard. The supper choice was hot sausage rolls or tinned spaghetti and potato waffles. The cook said that hot soup was also offered for supper. The menu records were examined and found satisfactory. One Service User said that although Staff came to ask their choice in the evening for the following day, they did not always seem to record it properly and the wrong meal was given. Food storage was satisfactory and the kitchen was hygienic and well managed. Fairways, The DS0000044518.V251821.R01.S.doc Version 5.0 Page 14 Fairways, The DS0000044518.V251821.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 The home has a policy on Adult Protection and ‘Whistleblowing’. Training and supervision of Staff emphasise the need for vigilance in order that the practices of the home protect Service Users. EVIDENCE: The home’s Statement of Purpose and Service User’s Guide are kept in the entrance hall of the home and these include details of the home’s complaints procedure. Incidents and accidents in the home are recorded and significant ones are sent to the Commission for Social Care Inspection (CSCI). The recruitment process includes checks with the Criminal Records Bureau, character/professional references and other verifications to ensure that Staff are suitable to work with vulnerable people. The system of keeping the Service Users’ individual money ‘floats’ was examined. Individual records were satisfactory and the cash float (chosen at random) tallied with the recorded amount in the log. Fairways, The DS0000044518.V251821.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 23, 24 and 25. The home is generally well decorated internally and externally and provides a safe, comfortable and well-maintained environment for the Service Users and Staff. Service Users’ bedrooms were inspected and found to be comfortable and clean. EVIDENCE: The programme of maintenance for the home indicated work that had been completed and the Registered Manager said that she put forward proposals for work that needed attention. A tour of the premises was made of both the inside and outside of the property. Although the general upkeep of the home is good, a few shortfalls were identified that fell under the heading of general maintenance. Fairways, The DS0000044518.V251821.R01.S.doc Version 5.0 Page 17 The garden around the Feather House is in need of attention to keep it tidy and attractive. The porch of the Feather House is in need of sweeping away leaf debris and other miscellaneous items that had collected there. There was an old chair in the garden. The food store for tinned goods had two large holes in the Perspex windows. The exterior of the woodwork of the main house conservatory needed attention and had paint that had flaked away and left bare wood. Some of the bedrooms on the ground floor were in need of redecoration. Some of the curtaining around the home had fallen off the rails. The home was clean and hygienic throughout. Fairways, The DS0000044518.V251821.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 & 29 Service Users’ benefit from a well trained Staff team who are well trained and supervised. EVIDENCE: The Registered Manager said that 10 of the 27 Careworkers were currently completing either NVQ Level 2 or 3. The Registered Manager is aware that 50 of the Staff complement need to achieve this in 2005. The Staff file examined (chosen at random) contained all the necessary checks, declarations and verifications. The application forms and interview format are designed to ensure that Service Users are protected. Fairways, The DS0000044518.V251821.R01.S.doc Version 5.0 Page 19 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, 36, 37 & 38. The Registered Manager must ensure that the Service Users and the Staff Team are supported with adequate management arrangements in the home that corresponds with the requirements of the service provision. The service provision must be monitored to ensure an overview is maintained. EVIDENCE: The Registered Manager has both the qualifications and experience required by the Standards. The Registered Manager agreed that she was finding it hard to keep up with all the records, assessments and supervision required of her. Fairways, The DS0000044518.V251821.R01.S.doc Version 5.0 Page 20 Records examined during the inspection were satisfactory but there was evidence of some ‘slippage’ in some areas like supervision, minutes and other recording systems especially in recent weeks. It was noted that the Registered Person (or other nominated representative) had not been making regular monthly visits to the home as required under Regulation 26 of the Care Homes Regulations. Copies of the monthly Regulation 26 reports must be forwarded to the CSCI. Regulation 26 reports play an important part in the monitoring process and provides and overview of how the home is performing. A chart of all training that identified each member of Staff’s record and gave review dates was maintained and confirmed that mandatory training for staff was provided at regular intervals. The Staff file examined included training certificates of courses attended. Records and verifications of checks made on the gas, water, electrical equipment, fire equipment and alarms, emergency equipment, passenger lift, chair lifts, wheelchairs, hoist maintenance and clinical waste collection confirmed that these had been carried out in the past 12 months by accredited organisations. The accident book was examined and it was noted that it was not supplied by the Health and Safety Executive. Weekly fire drills are held in the home and these include the checking of doors and alarms. Fairways, The DS0000044518.V251821.R01.S.doc Version 5.0 Page 21 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 2 x 2 2 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 3 3 x 3 x 3 3 3 x STAFFING Standard No Score 27 x 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x x 2 3 3 Fairways, The DS0000044518.V251821.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3OP6 Regulation 14 (1) Requirement New Service Users must only be admitted on the basis of a full assessment with a summary of the Care Management from Health and/or Social Services. The Registered Manager must ensure that the Service Users and the Staff Team are supported with adequate management arrangements in the home that corresponds with the requirements of the service provision. Timescale for action 28/10/05 2 OP31 18 (1)(a) 30/11/05 3 OP33 4 OP36 Regulation 26 visits must be 28/10/05 carried Register Person (or a representative) every month. These visits should monitor the performance of the home, include interviews with Staff and Service Users and check the premises. Copies of the Regulation 26 visits must be sent to the CSCI. 18(1)(a)(c The Registered Manager must 30/11/05 )(i) ensure that Staff are appropriately supervised both on 26 Fairways, The DS0000044518.V251821.R01.S.doc Version 5.0 Page 23 a day to day and formal basis. 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 Refer to Standard OP12 Good Practice Recommendations A programme of activities (either on a daily or weekly basis) should be produced for those Service Users who wish to take part. This should be designed to provide both physical and mental stimulation. The maintenance issues of the home should be identified and a system devised for prioritising them. Maintenance should be a built in part of the monthly Regulation 26 visits to the home by the Registered Person (or their representative). 2 OP19 Fairways, The DS0000044518.V251821.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST 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.V251821.R01.S.doc Version 5.0 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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